DIRECTOR, Department of Medical Assistance Servicessfc.virginia.gov › pdf › Jt Sub HHR Oversight...
34
DMAS UPDATE HEALTH AND HUMAN RESOURCES OVERSIGHT COMMITTEE OCTOBER 21, 2019 KAREN KIMSEY DIRECTOR, Department of Medical Assistance Services
DIRECTOR, Department of Medical Assistance Servicessfc.virginia.gov › pdf › Jt Sub HHR Oversight › 2019... · KAREN KIMSEY DIRECTOR, Department of Medical Assistance Services
Contractsbull MES Connectivitybull COMPASSbull Behavioral Health
Redesign (proposed)
Implement Managed Care Expansion
Continue CorrectionsRefinement
January 2019 - Present
bull During the first full year post- CCC Plus and Medallion 40 implementation plans continue to refine program and correct start-up issues including with community mental health services
bull January 1 2019 -Successfully phased in the Medicaid expansion population
Managed Care Expansion Timeline to Date
Medallion 40 Statewide Implementation
Expanded managed care to remaining fee-for-service populations per requirements in the Appropriations Act
Managed Care Programs
8
90 of Medicaid members are now in managed care
Births vaccinations well child visits sick visits acute care pharmacy ARTS behavioral health services including community mental health rehabilitation services excludes LTSS
Serving infants children pregnant women caretaker adults and newly eligible adults
Medallion 401049300 Members
Commonwealth Coordinated Care Plus (CCC Plus)243400 Members
Full continuum of services (same as Medallion) but also includes long-term services and supports (LTSS) in the community and in nursing facilities and hospice
Serving older adults disabled children disabled adults medically complex newly eligible adults includes individuals with Medicare and Medicaid (full-benefit duals)
Covered Groups
Covered Benefits
DMAS Monthly Enrollment as of October 1 2019
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring ensures MCO operations are consistent with the contract requirements includes working with members and providers to resolve any identified service and care management concerns
Systems and Reporting manages data submissions from the MCOs in accordance with the DMAS Managed Care Technical Manual
Compliance Monitoring Process oversees develops and monitors MCO corrective action plans (CAPS) and sanctions
Quality Performance and Improvement measures MCO performance against standard criteria such as HEDIS PIP PVM and facilitates focused quality projects to improve care for all members including with the DMAS external quality review (EQR) contractor
Financial Oversight monitored in several ways Plans are licensed by the Bureau of Insurance (meet solvency criteria) MCO rates are determined by our actuary are certified as actuarially sound and approved by CMS
Five main oversight functions goal is continuous quality improvement
9
Contract Development and Monitoring Activities
10
Ensure health plans are providing high quality health care through contract monitoring
bull Ensure contract fully supports federal and state requirements and aligns with program needs and expectations
bull Provide close oversight and on-going technical assistance to health plans including care coordinators
bull Work with members and providers to resolve any identified service and care management concerns
bull Conduct on sitedesk reviews of identified agency priority areas and to address any health plan specific concerns
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Contractsbull MES Connectivitybull COMPASSbull Behavioral Health
Redesign (proposed)
Implement Managed Care Expansion
Continue CorrectionsRefinement
January 2019 - Present
bull During the first full year post- CCC Plus and Medallion 40 implementation plans continue to refine program and correct start-up issues including with community mental health services
bull January 1 2019 -Successfully phased in the Medicaid expansion population
Managed Care Expansion Timeline to Date
Medallion 40 Statewide Implementation
Expanded managed care to remaining fee-for-service populations per requirements in the Appropriations Act
Managed Care Programs
8
90 of Medicaid members are now in managed care
Births vaccinations well child visits sick visits acute care pharmacy ARTS behavioral health services including community mental health rehabilitation services excludes LTSS
Serving infants children pregnant women caretaker adults and newly eligible adults
Medallion 401049300 Members
Commonwealth Coordinated Care Plus (CCC Plus)243400 Members
Full continuum of services (same as Medallion) but also includes long-term services and supports (LTSS) in the community and in nursing facilities and hospice
Serving older adults disabled children disabled adults medically complex newly eligible adults includes individuals with Medicare and Medicaid (full-benefit duals)
Covered Groups
Covered Benefits
DMAS Monthly Enrollment as of October 1 2019
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring ensures MCO operations are consistent with the contract requirements includes working with members and providers to resolve any identified service and care management concerns
Systems and Reporting manages data submissions from the MCOs in accordance with the DMAS Managed Care Technical Manual
Compliance Monitoring Process oversees develops and monitors MCO corrective action plans (CAPS) and sanctions
Quality Performance and Improvement measures MCO performance against standard criteria such as HEDIS PIP PVM and facilitates focused quality projects to improve care for all members including with the DMAS external quality review (EQR) contractor
Financial Oversight monitored in several ways Plans are licensed by the Bureau of Insurance (meet solvency criteria) MCO rates are determined by our actuary are certified as actuarially sound and approved by CMS
Five main oversight functions goal is continuous quality improvement
9
Contract Development and Monitoring Activities
10
Ensure health plans are providing high quality health care through contract monitoring
bull Ensure contract fully supports federal and state requirements and aligns with program needs and expectations
bull Provide close oversight and on-going technical assistance to health plans including care coordinators
bull Work with members and providers to resolve any identified service and care management concerns
bull Conduct on sitedesk reviews of identified agency priority areas and to address any health plan specific concerns
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Contractsbull MES Connectivitybull COMPASSbull Behavioral Health
Redesign (proposed)
Implement Managed Care Expansion
Continue CorrectionsRefinement
January 2019 - Present
bull During the first full year post- CCC Plus and Medallion 40 implementation plans continue to refine program and correct start-up issues including with community mental health services
bull January 1 2019 -Successfully phased in the Medicaid expansion population
Managed Care Expansion Timeline to Date
Medallion 40 Statewide Implementation
Expanded managed care to remaining fee-for-service populations per requirements in the Appropriations Act
Managed Care Programs
8
90 of Medicaid members are now in managed care
Births vaccinations well child visits sick visits acute care pharmacy ARTS behavioral health services including community mental health rehabilitation services excludes LTSS
Serving infants children pregnant women caretaker adults and newly eligible adults
Medallion 401049300 Members
Commonwealth Coordinated Care Plus (CCC Plus)243400 Members
Full continuum of services (same as Medallion) but also includes long-term services and supports (LTSS) in the community and in nursing facilities and hospice
Serving older adults disabled children disabled adults medically complex newly eligible adults includes individuals with Medicare and Medicaid (full-benefit duals)
Covered Groups
Covered Benefits
DMAS Monthly Enrollment as of October 1 2019
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring ensures MCO operations are consistent with the contract requirements includes working with members and providers to resolve any identified service and care management concerns
Systems and Reporting manages data submissions from the MCOs in accordance with the DMAS Managed Care Technical Manual
Compliance Monitoring Process oversees develops and monitors MCO corrective action plans (CAPS) and sanctions
Quality Performance and Improvement measures MCO performance against standard criteria such as HEDIS PIP PVM and facilitates focused quality projects to improve care for all members including with the DMAS external quality review (EQR) contractor
Financial Oversight monitored in several ways Plans are licensed by the Bureau of Insurance (meet solvency criteria) MCO rates are determined by our actuary are certified as actuarially sound and approved by CMS
Five main oversight functions goal is continuous quality improvement
9
Contract Development and Monitoring Activities
10
Ensure health plans are providing high quality health care through contract monitoring
bull Ensure contract fully supports federal and state requirements and aligns with program needs and expectations
bull Provide close oversight and on-going technical assistance to health plans including care coordinators
bull Work with members and providers to resolve any identified service and care management concerns
bull Conduct on sitedesk reviews of identified agency priority areas and to address any health plan specific concerns
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Contractsbull MES Connectivitybull COMPASSbull Behavioral Health
Redesign (proposed)
Implement Managed Care Expansion
Continue CorrectionsRefinement
January 2019 - Present
bull During the first full year post- CCC Plus and Medallion 40 implementation plans continue to refine program and correct start-up issues including with community mental health services
bull January 1 2019 -Successfully phased in the Medicaid expansion population
Managed Care Expansion Timeline to Date
Medallion 40 Statewide Implementation
Expanded managed care to remaining fee-for-service populations per requirements in the Appropriations Act
Managed Care Programs
8
90 of Medicaid members are now in managed care
Births vaccinations well child visits sick visits acute care pharmacy ARTS behavioral health services including community mental health rehabilitation services excludes LTSS
Serving infants children pregnant women caretaker adults and newly eligible adults
Medallion 401049300 Members
Commonwealth Coordinated Care Plus (CCC Plus)243400 Members
Full continuum of services (same as Medallion) but also includes long-term services and supports (LTSS) in the community and in nursing facilities and hospice
Serving older adults disabled children disabled adults medically complex newly eligible adults includes individuals with Medicare and Medicaid (full-benefit duals)
Covered Groups
Covered Benefits
DMAS Monthly Enrollment as of October 1 2019
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring ensures MCO operations are consistent with the contract requirements includes working with members and providers to resolve any identified service and care management concerns
Systems and Reporting manages data submissions from the MCOs in accordance with the DMAS Managed Care Technical Manual
Compliance Monitoring Process oversees develops and monitors MCO corrective action plans (CAPS) and sanctions
Quality Performance and Improvement measures MCO performance against standard criteria such as HEDIS PIP PVM and facilitates focused quality projects to improve care for all members including with the DMAS external quality review (EQR) contractor
Financial Oversight monitored in several ways Plans are licensed by the Bureau of Insurance (meet solvency criteria) MCO rates are determined by our actuary are certified as actuarially sound and approved by CMS
Five main oversight functions goal is continuous quality improvement
9
Contract Development and Monitoring Activities
10
Ensure health plans are providing high quality health care through contract monitoring
bull Ensure contract fully supports federal and state requirements and aligns with program needs and expectations
bull Provide close oversight and on-going technical assistance to health plans including care coordinators
bull Work with members and providers to resolve any identified service and care management concerns
bull Conduct on sitedesk reviews of identified agency priority areas and to address any health plan specific concerns
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Contractsbull MES Connectivitybull COMPASSbull Behavioral Health
Redesign (proposed)
Implement Managed Care Expansion
Continue CorrectionsRefinement
January 2019 - Present
bull During the first full year post- CCC Plus and Medallion 40 implementation plans continue to refine program and correct start-up issues including with community mental health services
bull January 1 2019 -Successfully phased in the Medicaid expansion population
Managed Care Expansion Timeline to Date
Medallion 40 Statewide Implementation
Expanded managed care to remaining fee-for-service populations per requirements in the Appropriations Act
Managed Care Programs
8
90 of Medicaid members are now in managed care
Births vaccinations well child visits sick visits acute care pharmacy ARTS behavioral health services including community mental health rehabilitation services excludes LTSS
Serving infants children pregnant women caretaker adults and newly eligible adults
Medallion 401049300 Members
Commonwealth Coordinated Care Plus (CCC Plus)243400 Members
Full continuum of services (same as Medallion) but also includes long-term services and supports (LTSS) in the community and in nursing facilities and hospice
Serving older adults disabled children disabled adults medically complex newly eligible adults includes individuals with Medicare and Medicaid (full-benefit duals)
Covered Groups
Covered Benefits
DMAS Monthly Enrollment as of October 1 2019
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring ensures MCO operations are consistent with the contract requirements includes working with members and providers to resolve any identified service and care management concerns
Systems and Reporting manages data submissions from the MCOs in accordance with the DMAS Managed Care Technical Manual
Compliance Monitoring Process oversees develops and monitors MCO corrective action plans (CAPS) and sanctions
Quality Performance and Improvement measures MCO performance against standard criteria such as HEDIS PIP PVM and facilitates focused quality projects to improve care for all members including with the DMAS external quality review (EQR) contractor
Financial Oversight monitored in several ways Plans are licensed by the Bureau of Insurance (meet solvency criteria) MCO rates are determined by our actuary are certified as actuarially sound and approved by CMS
Five main oversight functions goal is continuous quality improvement
9
Contract Development and Monitoring Activities
10
Ensure health plans are providing high quality health care through contract monitoring
bull Ensure contract fully supports federal and state requirements and aligns with program needs and expectations
bull Provide close oversight and on-going technical assistance to health plans including care coordinators
bull Work with members and providers to resolve any identified service and care management concerns
bull Conduct on sitedesk reviews of identified agency priority areas and to address any health plan specific concerns
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Contractsbull MES Connectivitybull COMPASSbull Behavioral Health
Redesign (proposed)
Implement Managed Care Expansion
Continue CorrectionsRefinement
January 2019 - Present
bull During the first full year post- CCC Plus and Medallion 40 implementation plans continue to refine program and correct start-up issues including with community mental health services
bull January 1 2019 -Successfully phased in the Medicaid expansion population
Managed Care Expansion Timeline to Date
Medallion 40 Statewide Implementation
Expanded managed care to remaining fee-for-service populations per requirements in the Appropriations Act
Managed Care Programs
8
90 of Medicaid members are now in managed care
Births vaccinations well child visits sick visits acute care pharmacy ARTS behavioral health services including community mental health rehabilitation services excludes LTSS
Serving infants children pregnant women caretaker adults and newly eligible adults
Medallion 401049300 Members
Commonwealth Coordinated Care Plus (CCC Plus)243400 Members
Full continuum of services (same as Medallion) but also includes long-term services and supports (LTSS) in the community and in nursing facilities and hospice
Serving older adults disabled children disabled adults medically complex newly eligible adults includes individuals with Medicare and Medicaid (full-benefit duals)
Covered Groups
Covered Benefits
DMAS Monthly Enrollment as of October 1 2019
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring ensures MCO operations are consistent with the contract requirements includes working with members and providers to resolve any identified service and care management concerns
Systems and Reporting manages data submissions from the MCOs in accordance with the DMAS Managed Care Technical Manual
Compliance Monitoring Process oversees develops and monitors MCO corrective action plans (CAPS) and sanctions
Quality Performance and Improvement measures MCO performance against standard criteria such as HEDIS PIP PVM and facilitates focused quality projects to improve care for all members including with the DMAS external quality review (EQR) contractor
Financial Oversight monitored in several ways Plans are licensed by the Bureau of Insurance (meet solvency criteria) MCO rates are determined by our actuary are certified as actuarially sound and approved by CMS
Five main oversight functions goal is continuous quality improvement
9
Contract Development and Monitoring Activities
10
Ensure health plans are providing high quality health care through contract monitoring
bull Ensure contract fully supports federal and state requirements and aligns with program needs and expectations
bull Provide close oversight and on-going technical assistance to health plans including care coordinators
bull Work with members and providers to resolve any identified service and care management concerns
bull Conduct on sitedesk reviews of identified agency priority areas and to address any health plan specific concerns
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Contractsbull MES Connectivitybull COMPASSbull Behavioral Health
Redesign (proposed)
Implement Managed Care Expansion
Continue CorrectionsRefinement
January 2019 - Present
bull During the first full year post- CCC Plus and Medallion 40 implementation plans continue to refine program and correct start-up issues including with community mental health services
bull January 1 2019 -Successfully phased in the Medicaid expansion population
Managed Care Expansion Timeline to Date
Medallion 40 Statewide Implementation
Expanded managed care to remaining fee-for-service populations per requirements in the Appropriations Act
Managed Care Programs
8
90 of Medicaid members are now in managed care
Births vaccinations well child visits sick visits acute care pharmacy ARTS behavioral health services including community mental health rehabilitation services excludes LTSS
Serving infants children pregnant women caretaker adults and newly eligible adults
Medallion 401049300 Members
Commonwealth Coordinated Care Plus (CCC Plus)243400 Members
Full continuum of services (same as Medallion) but also includes long-term services and supports (LTSS) in the community and in nursing facilities and hospice
Serving older adults disabled children disabled adults medically complex newly eligible adults includes individuals with Medicare and Medicaid (full-benefit duals)
Covered Groups
Covered Benefits
DMAS Monthly Enrollment as of October 1 2019
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring ensures MCO operations are consistent with the contract requirements includes working with members and providers to resolve any identified service and care management concerns
Systems and Reporting manages data submissions from the MCOs in accordance with the DMAS Managed Care Technical Manual
Compliance Monitoring Process oversees develops and monitors MCO corrective action plans (CAPS) and sanctions
Quality Performance and Improvement measures MCO performance against standard criteria such as HEDIS PIP PVM and facilitates focused quality projects to improve care for all members including with the DMAS external quality review (EQR) contractor
Financial Oversight monitored in several ways Plans are licensed by the Bureau of Insurance (meet solvency criteria) MCO rates are determined by our actuary are certified as actuarially sound and approved by CMS
Five main oversight functions goal is continuous quality improvement
9
Contract Development and Monitoring Activities
10
Ensure health plans are providing high quality health care through contract monitoring
bull Ensure contract fully supports federal and state requirements and aligns with program needs and expectations
bull Provide close oversight and on-going technical assistance to health plans including care coordinators
bull Work with members and providers to resolve any identified service and care management concerns
bull Conduct on sitedesk reviews of identified agency priority areas and to address any health plan specific concerns
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Managed Care Programs
8
90 of Medicaid members are now in managed care
Births vaccinations well child visits sick visits acute care pharmacy ARTS behavioral health services including community mental health rehabilitation services excludes LTSS
Serving infants children pregnant women caretaker adults and newly eligible adults
Medallion 401049300 Members
Commonwealth Coordinated Care Plus (CCC Plus)243400 Members
Full continuum of services (same as Medallion) but also includes long-term services and supports (LTSS) in the community and in nursing facilities and hospice
Serving older adults disabled children disabled adults medically complex newly eligible adults includes individuals with Medicare and Medicaid (full-benefit duals)
Covered Groups
Covered Benefits
DMAS Monthly Enrollment as of October 1 2019
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring ensures MCO operations are consistent with the contract requirements includes working with members and providers to resolve any identified service and care management concerns
Systems and Reporting manages data submissions from the MCOs in accordance with the DMAS Managed Care Technical Manual
Compliance Monitoring Process oversees develops and monitors MCO corrective action plans (CAPS) and sanctions
Quality Performance and Improvement measures MCO performance against standard criteria such as HEDIS PIP PVM and facilitates focused quality projects to improve care for all members including with the DMAS external quality review (EQR) contractor
Financial Oversight monitored in several ways Plans are licensed by the Bureau of Insurance (meet solvency criteria) MCO rates are determined by our actuary are certified as actuarially sound and approved by CMS
Five main oversight functions goal is continuous quality improvement
9
Contract Development and Monitoring Activities
10
Ensure health plans are providing high quality health care through contract monitoring
bull Ensure contract fully supports federal and state requirements and aligns with program needs and expectations
bull Provide close oversight and on-going technical assistance to health plans including care coordinators
bull Work with members and providers to resolve any identified service and care management concerns
bull Conduct on sitedesk reviews of identified agency priority areas and to address any health plan specific concerns
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring ensures MCO operations are consistent with the contract requirements includes working with members and providers to resolve any identified service and care management concerns
Systems and Reporting manages data submissions from the MCOs in accordance with the DMAS Managed Care Technical Manual
Compliance Monitoring Process oversees develops and monitors MCO corrective action plans (CAPS) and sanctions
Quality Performance and Improvement measures MCO performance against standard criteria such as HEDIS PIP PVM and facilitates focused quality projects to improve care for all members including with the DMAS external quality review (EQR) contractor
Financial Oversight monitored in several ways Plans are licensed by the Bureau of Insurance (meet solvency criteria) MCO rates are determined by our actuary are certified as actuarially sound and approved by CMS
Five main oversight functions goal is continuous quality improvement
9
Contract Development and Monitoring Activities
10
Ensure health plans are providing high quality health care through contract monitoring
bull Ensure contract fully supports federal and state requirements and aligns with program needs and expectations
bull Provide close oversight and on-going technical assistance to health plans including care coordinators
bull Work with members and providers to resolve any identified service and care management concerns
bull Conduct on sitedesk reviews of identified agency priority areas and to address any health plan specific concerns
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
bull Federal Managed Care Regulations bull Federal 1915(b) and 1915(c) Waiver
compliancebull Licensure and Certifications Virginia Department of Health - Managed Care
Health Insurance Plan (MCHIP) Quality Certificate approves geographical coverage areas based on network adequacy
Bureau of Insurance (Financial Solvency) NCQA Accreditation (HEDIS CAHPS and more)
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Systems and Reporting and Compliance Monitoring
Take compliance action such as issuing Corrective Action Plans and financial penalties when needed a health plan is not conforming to one or more contract requirements
11
Continual emphasis on health plan quality accountability and transparency
MCOs are responsible for robust and transparent reporting on critical elementsMCOs submit deliverables as specified in the contract and in the current the Managed Care Technical Manual
DMAS collects reviews and validates contract deliverables based on Technical Manual specificationsGeneration of monthly metrics to review MCO performance in several areas
Implemented encounter process system (EPS) which is used for reporting analysis and (soon) rate setting
Analyze encounter data to determine timeliness completeness accuracy and reasonablenessProvide technical assistance to health plans on identified problem areas
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Quality Improvement Activities
bull NCQA Accreditation includes reporting of Healthcare Effectiveness Data and Information Set (HEDISreg) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data
bull Annual health plan quality rating system (QRS) ldquoscore cardrdquo tool designed to increase health plan transparency and accountability Consumers use this information to help make an informed MCO selection
bull Participation in performance improvement projects (PIPS) and Performance Measurement Validation Activities (with the DMAS external quality review contractor)
bull Participating in either a performance incentive award program (Medallion 40) or quality withhold program (CCC Plus)
bull Value based payment strategies
MCOs complete federal state and DMAS established quality improvement activities including
12
Track and Analyze Trends For
Improvement
Improve Health Outcomes
Metrics
Participate in Subpopulation
Activities
Support Programs
Set Priorities andQuality Strategy
Communicate
VBP is a Powerful Tool to Promote Quality and Efficiency
13
Program Accountability Incentive
Clinical Efficiencies
bull Evaluate levels of preventable utilization (ie ED visits hospital admissions hospital readmissions)
bull Develop performance measures to track MCO-amp hospital-specific performance
2020 Adjust capitation rates
2021 and Beyond MCOs have two-sided risk based on measure performance
Performance Withholds
bull Performance targets for key process and outcome metrics
bull Focus on behavioral health chronic conditions maternity care and prevention
CCC+ 1 capitation withhold beginning in 2019
Medallion 40 1 capitation withhold beginning in SFY 2021
CCC+ Discrete Incentives
bull Support successful sustained transitions of complex nursing facility residents into the community
bull MCOrsquos can earn one-time bonus for each successful transition
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Timeliness of Prenatal Care-Subpopulation race ethnicity
geographic area (Clinical)
Ambulatory Care Emergency Department Visits (Clinical)
Annually the health plans must perform at least one clinical and one non-clinical PIP
Clinical PIPs include projects focusing onbull prevention and care of acute and chronic
conditions bull behavioral health bull long term services and supports bull high-volume services bull high risk services andor high cost services
Non-clinical PIPs include projects focusing onbull availability accessibility bull cultural competency of services bull interpersonal aspects of care bull appeals grievances complaints bull care transitions and continuity bull coordination of care and care management bull member satisfaction
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Financial Oversight with Provider Reimbursement
bull Plans are required to be licensed by the Bureau of Insurance (BOI) a Division of the Virginia State Corporation Commission and meet solvency requirements
bull DMAS reviews the MCO quarterly and annual filings to BOI and annual audits
bull DMAS monitors net profit and medical loss ratios and administrative expense ratios
bull Rates are determined by our actuary certified as actuarially sound and approved by CMS
bull Program staff participate with provider reimbursement in rate setting process and waiver cost effectiveness development process
bull On-going fiscal monitoring and trending
bull 2018 JLARC Report to the General Assembly was submitted reviewing financial and utilization planning for managed care operations including future plans regarding the need for a baseline data collection year given the changing managed care populations
15
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Current MCO Rates Compared to Forecastbull Current rates are slightly below forecastbull DMAS notified Money Committee Chairmen and Department of Planning and
Budget Director in May 31 2019 letter as required by the Budget
16
Fiscal Impact of FY20 Rates Compared to Forecast
Base Medicaid Expansion MedicaidTotal Funds GF Total Funds
Medallion 40 ($14953572) ($7476786) ($88884551)CCC Plus ($14492748) ($7246374) ($5909280)
FY20 PMPM Compared to ForecastForecast Actual
Medallion Base Medicaid $30016 $29817 Medallion Expansion Medicaid $55654 $52889
CCC Plus Base Medicaid $182894 $182331 CCC Plus Expansion Medicaid $177472 $176845 Actuals do not include GA changes
For More Information Managed Care Contracts
CCC Plus - httpwwwdmasvirginiagovcccplusinformation Medallion 40 - httpwwwdmasvirginiagovmed4
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Performance Incentive Awards - httpwwwdmasvirginiagovincentiveawards NCQA Health Plan Ratings for Virginia Medicaid (ratings for other states are also available for
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
PROPOSED BEHAVIORAL HEALTH REDESIGN UPDATE
Advancing Proactive Evidence-Based Solutions
October 21 2019
18
Advancing Behavioral Health Care in Virginia
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Advancing Behavioral Health Care in Virginia
Current Medicaid-Funded Behavioral Health Services
Behavioral Health Redesign Care Continuum
High Acuity
More equitable distribution of services ndash from prevention to acute
Full Continuum
Enhances other BH transformation efforts (STEP-VA FFPSA) and coordinates systems among state agenciesAligned
Proven practices with measurable effectiveness and quality
Evidence-BasedOutdated
From Band-Aids to proactive evidence-based solutions
Imbalanced
19
Proposed
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
20
Behavioral Health Redesign for Virginia
Implement fully integrated behavioral health services that provide a full continuum of care to Medicaid members This comprehensive system will focus on access to services that are
Vision
Quality care from quality providers in community settings
such as home schools and primary care
Proven practices that are preventive and offered in the least
restrictive environment
Better outcomes from best-practice services that acknowledge and address the impact of trauma for individuals
Encourages use of services and delivery
mechanisms that have been shown to reduce cost of care for system
High Quality Evidence-Based Trauma-Informed Cost-Effective
20
Proposed
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Trends in CMHRS
$0
$50
$100
$150
$200
$250
$300
$350
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Mill
ions
Annual Cost of Community Mental Health and Rehabilitation Services
(State Fiscal Year)
Therapeutic Day Treatment Intensive In-Home Mental Health Skill-BuildingCase Management Other CMHRS Services
21
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
BH Redesign and Psychiatric Inpatient Admissions
bull There are approximately 300000 crisis calls statewide each year out of which 90000 calls resulted in face-to-face evaluation only 15-25 were billed to Medicaid
bull Based on our current system - ~25000 individuals are hospitalized due to crisis calls
Lack of alternative crisis services has contributed to the increasing number of temporary detention orders
BH Redesign provides solutions instead of Band-Aids to permanently decrease capacity and reliance on state psychiatric beds
22
Proposed
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Behavioral Health Redesign Current Priorities Explained
Implementation of SIX high-quality high-intensity and evidence-based services that have demonstrated impact and value to patients Services that currently exist and are licensed in Virginia BUT are not covered by Medicaid or the service is not adequately funded through Medicaid
What are our top priorities at this
time
Provides alternatives to state psychiatric admissions and offers step-down resources not currently available in the continuum of care which will assist with the psychiatric bed crisis
Demonstrated cost-efficiency and value in other states
Why BH Redesign for Virginia
Partial Hospitalization Program (PHP)
Program of Assertive Community Treatment
(PACT)
Comprehensive Crisis Services (Mobile Crisis
Intervention Residential 23Hr Observation)
Intensive Outpatient Program (IOP)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
23
Proposed
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Redesign Supports amp Enhances STEP-VA
24
Proposed
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
BH Redesign Efforts since May 2019
Interagency Prioritization
and Alignment Efforts
Mercer Rate Study amp Fiscal
Impact Analysis
Stakeholder Implementation
Workgroups
25
20+ meetings100+ stakeholders5 workgroups (4 service specific)
- Assumptions for rate development- Assumptions for fiscal impact- Input from stakeholder workgroups
- Workforce needs analysis- Alignment with other key
initiatives
Proposed
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Fiscal Impact Summary
FY2021 FY2022
General Fund $8130868 $16708460
Non-General Funds $11082810 $22814805
Subtotal $19213678 $39523265
MEL (2 FTEs) $352361 $352361
TOTAL FUNDS REQUESTED $19566039 $39875626
26
Proposed
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Comparison of Proposed Services
Services Current Costs FY2021 FY 2022Assertive Community Treatment $14819250 $24927362 $29552449Multi-Systemic Therapy NA $2836385 $3178836Functional Family Therapy NA $1366334 $1528993Intensive Outpatient NA $229507 $8040373Partial Hospitalization $429230 $908412 $1518984Crisis Intervention $4761084 $1131528 $7355437Community-Based Crisis Stabilization $21312912 $21833399 $2183339923-Hour Observation NA $355756 $889799Crisis Stabilization Unit NA $6947472 $6947472Grand Total $41322476 $60536154 $80845741Net Increase In Costs $19213678 $39523265
Note Prior impact summary slide displays total costs (medical and administrative costs) this slide shows only medical costs associated with the services
27
Proposed
Summary HHR oversight
Detail HHR oversight
Budget Summary
Detail
AttBYear over year comparison
ampArialRegularamp12DMAS Behavioral Health RedesignPhase I Budget ProjectionsampArialRegularamp12 Confidential
ampArialRegularampP of ampNampArialRegular9182019
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Estimated Expenditures
Percent Change
Service
Level
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
FY 2021
FY 2022
FY 2023
FY 2024
FY 2025
Assertive Community Treatment
Base - Small
$2007242
$3357245
$3357245
$3357245
$3357245
NA
673
00
00
00
Base - Medium
$3775212
$4360755
$3497850
$2619535
$1741220
NA
155
-198
-251
-335
Base - Large
$19144908
$21834449
$20749957
$19651004
$18566512
NA
140
-50
-53
-55
High Fidelity - Small
$0
$0
$0
$0
$0
NA
00
00
00
00
High Fidelity - Medium
$0
$0
$1071842
$2124879
$3196721
NA
00
00
982
504
High Fidelity - Large
$0
$0
$1314593
$2611889
$3926483
NA
00
00
987
503
Multi-Systemic Therapy
Established - Bachelors
$666422
$746883
$837838
$837838
$837838
NA
121
122
00
00
Established - Masters
$2169963
$2431953
$2728116
$2728116
$2728116
NA
121
122
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Functional Family Therapy
Established - Bachelors
$309446
$346285
$388035
$388035
$388035
NA
119
121
00
00
Established - Masters
$1056888
$1182708
$1325304
$1325304
$1325304
NA
119
121
00
00
New - Bachelors
$0
$0
$0
$0
$0
NA
00
00
00
00
New - Masters
$0
$0
$0
$0
$0
NA
00
00
00
00
Intensive Outpatient
Standard
$203774
$7225501
$14238736
$14238736
$14238736
NA
34458
971
00
00
Specialty with OTRecreational Therapy
$25733
$814872
$1595434
$1595434
$1595434
NA
30667
958
00
00
Partial Hospitalization
$908412
$1518984
$2129556
$2740128
$2740128
NA
672
402
287
00
Crisis Intervention
21 (LicensedPeer)
$103690
$673982
$1036896
$1036896
$1036896
NA
5500
538
00
00
21 (LicensedMA)
$112579
$731765
$1125792
$1125792
$1125792
NA
5500
538
00
00
21 (MAMA)
$742291
$4824893
$7422912
$7422912
$7422912
NA
5500
538
00
00
21 (MAPeer)
$97152
$631488
$971520
$971520
$971520
NA
5500
538
00
00
11 (Licensed)
$75816
$493309
$758160
$758160
$758160
NA
5507
537
00
00
Community-Based Crisis Stabilization
21 (LicensedPeer)
$323717
$323717
$323717
$323717
$323717
NA
00
00
00
00
21 (LicensedMA)
$42417
$42417
$42417
$42417
$42417
NA
00
00
00
00
11 (MA)
$18943109
$18943109
$18943109
$18943109
$18943109
NA
00
00
00
00
11 (Licensed)
$2524155
$2524155
$2524155
$2524155
$2524155
NA
00
00
00
00
23-Hour Observation
$355756
$889799
$1423024
$1423024
$1423024
NA
1501
599
00
00
CSU
$6947472
$6947472
$6947472
$6947472
$6947472
NA
00
00
00
00
Total
$60536154
$80845741
$94753680
$95737318
$96160946
NA
335
172
10
04
Note From Mercer
Behavioral Health Redesign Options - SHHR
Initial Proposal
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
1
Assertive Community Treatment
$ 14819250
$24927362
$24927362
$29552449
$29552449
2
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
3
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
4
Intensive Outpatient
$229507
$229507
$8040373
$8040373
5
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
6
Crisis Intervention
$ 4761084
$1131528
$1131528
$7355437
$7355437
7
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$21833399
$21833399
8
23-Hour Observation
$355756
$355756
$889799
$889799
9
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Grand Total
$ 41322476
$ 60536154
$ - 0
$ - 0
$ 60536154
$ 80845741
$ - 0
$ - 0
$ 80845741
Initial Proposal Cost (Savings)
$ 19213678
$ 39523265
Option 1
The whole Enchilada
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$24927362
$ 29552449
$29552449
Multi-Systemic Therapy
$ 2836385
$2836385
$ 3178836
$3178836
Functional Family Therapy
$ 1366334
$1366334
$ 1528993
$1528993
Intensive Outpatient
$ 229507
$229507
$ 8040373
$8040373
Partial Hospitalization
$ 429230
$ 908412
$908412
$ 1518984
$1518984
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 60536154
$ 2989900
$ - 0
$ 63526054
$ 80845741
$ 2989900
$ - 0
$ 83835641
Option 1 Cost (Savings)
$ 22203578
$ 41322476
Option 2
Follow the Data
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ 2836385
$ 2836385
$ 3178836
$ 3178836
Functional Family Therapy
$ 1366334
$ 1366334
$ 1528993
$ 1528993
Intensive Outpatient
$ - 0
$ - 0
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ - 0
$ - 0
$ 355756
$ 355756
CSU
$ - 0
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (400000)
$ (400000)
$ - 0
Grand Total
$ 41322476
$ 29130080
$ 2589900
$ - 0
$ 31719980
$ 74087789
$ 2989900
$ - 0
$ 77077689
Option 2 Cost (Savings)
$ (9602496)
$ 41322476
Option 3
Pinching Pennies
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ - 0
$ - 0
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ 229507
$ 229507
$ 8040373
$ 8040373
Partial Hospitalization
$ 429230
$ 908412
$ 908412
$ 1518984
$ 1518984
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ - 0
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ - 0
23-Hour Observation
$ - 0
$ - 0
$ - 0
CSU
$ - 0
$ - 0
$ - 0
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (637500)
$ (637500)
$ (712000)
$ (712000)
Grand Total
$ 41322476
$ 1137919
$ 2352400
$ - 0
$ 3490319
$ 9559357
$ 2277900
$ - 0
$ 11837257
Option 3 Cost (Savings)
$ (37832157)
$ (29485219)
Option 4
Adult Focus-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$ 24927362
$ 24927362
$ 29552449
$ 29552449
Multi-Systemic Therapy
$ - 0
$ - 0
Functional Family Therapy
$ - 0
$ - 0
Intensive Outpatient
$ - 0
$ - 0
$ - 0
Partial Hospitalization
$ 429230
$ - 0
$ - 0
$ - 0
Crisis Intervention
$ 4761084
$ - 0
$ - 0
$ 1131528
$ 1131528
Community-Based Crisis Stabilization
$ 21312912
$ - 0
$ - 0
$ 21833399
$ 21833399
23-Hour Observation
$ 355756
$ 355756
$ 889799
$ 889799
CSU
$ - 0
$ 6947472
$ 6947472
Workforce Training
$ 2989900
$ 2989900
$ 2989900
$ 2989900
Workforce Training Savings
$ (532000)
$ (532000)
$ (77000)
$ (77000)
Grand Total
$ 41322476
$ 25283118
$ 2457900
$ - 0
$ 27741018
$ 60354647
$ 2912900
$ - 0
$ 63267547
Option 4 Cost (Savings)
$ (13581458)
$ 21945071
Option 5
Child Focused
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 14267185
$ - 0
$ - 0
$ 14267185
Option 5 Cost (Savings)
$ (35981838)
$ (27055291)
Option 6
Breezy-ACT Phased
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$229507
$229507
$8040373
$8040373
Partial Hospitalization
$ 429230
$908412
$908412
$1518984
$1518984
Crisis Intervention
$ 4761084
$0
$0
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$0
$0
CSU
$0
$0
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 5340638
$ - 0
$ - 0
$ 5340638
$ 39194547
$ - 0
$ - 0
$ 39194547
Option 6 Cost (Savings)
$ (35981838)
$ (2127929)
Option 7
National Standards Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$24927362
$24927362
Multi-Systemic Therapy
$2836385
$2836385
$3178836
$3178836
Functional Family Therapy
$1366334
$1366334
$1528993
$1528993
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$0
$1131528
$1131528
Community-Based Crisis Stabilization
$ 21312912
$0
$0
23-Hour Observation
$355756
$355756
$889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$0
$0
$0
$0
Workforce Training Savings
$ - 0
$ - 0
$ - 0
$ - 0
Grand Total
$ 41322476
$ 11505947
$ - 0
$ - 0
$ 11505947
$ 38603989
$ - 0
$ - 0
$ 38603989
Option 7 Cost (Savings)
$ (29816529)
$ (2718487)
Option 8
Crisis Only-Split
Current Costs
FY 2021
FY 2022
Service
DMAS
DMAS
DBHD
Step VA
Total By Service
DMAS
DBHD
Step VA
Total By Service
Assertive Community Treatment
$ 14819250
$0
$0
Multi-Systemic Therapy
$0
$0
Functional Family Therapy
$0
$0
Intensive Outpatient
$0
$0
Partial Hospitalization
$ 429230
$0
$0
Crisis Intervention
$ 4761084
$1131528
$1131528
$ 7355437
$7355437
Community-Based Crisis Stabilization
$ 21312912
$21833399
$21833399
$ 21833399
$21833399
23-Hour Observation
$355756
$355756
$ 889799
$889799
CSU
$6947472
$6947472
$6947472
$6947472
Workforce Training
$ 2989900
$2989900
$ 2989900
$2989900
Grand Total
$ 41322476
$ 30268155
$ 2989900
$ - 0
$ 33258055
$ 37026107
$ 2989900
$ - 0
$ 40016007
Option 8 Cost (Savings)
$ (8064421)
$ (1306469)
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
Med CostMember
FY21
FY22
1
456
0100
1233
GF Dollars
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
2
456
1000
1233
93778
NGF Dollars - Federal
$ 10615557
$ 21836604
$ 29520740
$ 30064200
$ 30298255
$ 30298255
3
456
0978
1233
05107
NGF Dollars - Special
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
4
446
0100
1233
GF Dollars
$ 72772
$ 138331
$ 187009
$ 190452
$ 191935
$ 191935
$ 16708460
5
446
1000
1233
93767
NGF Dollars - Federal
$ 119365
$ 256901
$ 347303
$ 353696
$ 356450
$ 356450
6
466
0100
1233
GF Dollars
$ 36386
$ 69166
$ 93505
$ 95226
$ 95967
$ 95967
7
466
1000
1233
93767
NGF Dollars - Federal
$ 59682
$ 128451
$ 173651
$ 176848
$ 178225
$ 178225
8
499
0100
1233
GF Dollars
$ - 0
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
$ 154051
9
499
1000
1233
93778
NGF Dollars - Federal
$ - 0
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
$ 198310
10
GF Positions
1
1
1
1
1
1
11
NGF Positions
1
1
1
1
1
1
12
Layoffs
13
GF Transfer
14
GF Revenue
15
Additions to Balance
Total GF
$ - 0
$ 8284919
$ 16862511
$ 22742092
$ 23157925
$ 23337014
$ 23337014
Total NGF - Federal
$ - 0
$ 10992915
$ 22420266
$ 30240004
$ 30793055
$ 31031240
$ 31031240
Total NGF - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
Total Funding
$ - 0
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
$ 55190831
Category
Other Spending or Initiatives
93778
$ 10813867
$ 22034914
$ 29719050
$ 30262510
$ 30496564
$ 30496564
Strategic
93767
$ 179047
$ 385352
$ 520954
$ 530545
$ 534675
$ 534675
Link
6020004Number of individuals residing in institutional settings
0978
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
$ 11281120
$ 23013115
$ 31041472
$ 31609277
$ 31853817
$ 31853817
Region
Multiple
Enterprise
Strategy
Behavioral Health
Sub Pgm
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2020 Request
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
FY2026 Request
09
456
0100
1238
GF Dollars
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
$ 22895061
09
456
1000
1238
93778
NGF Dollars - Federal
$ - 0
$ 8021711
$ 16500963
$ 22307528
$ 22718197
$ 22895061
11
456
9780
1239
05107
NGF Dollars - Special
$ - 0
$ 288205
$ 592849
$ 801468
$ 816223
$ 822577
$ 822577
11
456
1000
1239
93778
NGF Dollars - Federal
$ - 0
$ 2593847
$ 5335641
$ 7213213
$ 7346004
$ 7403193
$ 2882052
$ 5928490
$ 8014681
$ 8162226
$ 8225770
10
10
10
10
10
90
90
90
90
90
Behavioral Health Redesign Options - SHHR
Services
Current Costs
FY2021
FY 2022
8741
1
Assertive Community Treatment
$14819250
$24927362
$29552449
7400
2
Multi-Systemic Therapy
NA
$2836385
$3178836
1341
484101
3
Functional Family Therapy
NA
$1366334
$1528993
7400
4
Intensive Outpatient
NA
$229507
$8040373
5
Partial Hospitalization
$429230
$908412
$1518984
3600
6
Crisis Intervention
$4761084
$1131528
$7355437
7
Community-Based Crisis Stabilization
$21312912
$21833399
$21833399
8
23-Hour Observation
NA
$355756
$889799
9
Crisis Stabilization Unit
NA
$6947472
$6947472
Grand Total
$41322476
$60536154
$80845741
Net Increase In Costs
$19213678
$39523265
Discrectionary
15
BH Redesign
Summary of Costs and Positions
Requested funding detail
Program
Fund
Sub Obj Code
Revenue Source Code
Object Type
FY2021 Request
FY2022 Request
FY2023 Request
FY2024 Request
FY2025 Request
8
499
0100
1233
General Funds
$ 8130868
$ 16708460
$ 22588041
$ 23003875
$ 23182963
9
499
1000
1233
93778
Non- General Funds
$ 11082810
$ 22814805
$ 30843162
$ 31410968
$ 31655507
11
Subtotal
$ 19213678
$ 39523265
$ 53431204
$ 54414842
$ 54838470
MEL
$ 352361
$ 352361
$ 352361
$ 352361
$ 352361
Total Funding Request
$ 19566039
$ 39875626
$ 53783565
$ 54767203
$ 55190831
Redesign Brings Alignment Across BH Efforts
Redesign amp Family First Prevention Act Focused on workforce development evidence-based programs prevention-focused investment improving outcomes and trauma-informed principles
Redesign amp Juvenile Justice TransformationSupports sustainability of these services for the provider community particularly in rural settings who have struggled with maintaining caseloads and business models when dependent on DJJ or CSA
Redesign amp Governors Childrens Cabinet on Trauma-Informed Care
BH Redesign continuum is built on trauma-informed principles of prevention and early intervention to address adverse childhood experiences
BH Redesign Leverages Medicaid Dollars to Support Cross-Secretariat Priorities
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
bull DMAS already has sect1115 ARTS waiver which allows Substance Use Disorder (SUD) residential and inpatient treatment and also required implementation of an ASAM Continuum of Care
bull A new CMS SMI 1115 Waiver is available that would infuse new federal dollars replacing GF funds currently used to pay for some TDOrsquos The 1115 waiver would allow federal funds to pay for adult inpatient psychiatric hospitalizations and psychiatric residential treatment benefit creating new capacity and alternatives to TDOs
bull The SMI 1115 is different from ARTS because DMAS must first implement Redesign to demonstrate availability of a comprehensive continuum of evidence-based community mental health services prior to an 1115 waiver application
bull Could result in GF savings - state psychiatric hospitals could bill Medicaid (at 90 federal match10 provider assessment for expansion and 5050 for traditional) instead of using 100 GF dollars
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Redesign Implementation Steps
Once installation plan is clear
engage Federal Government for 1115 SMI Waiver
application
Develop metrics and dashboards with stakeholder
input to report out on implementation
progress and outcomes
cReconvene
regular stakeholder
workgroups for installation
planning
If Authority is Granted to Proceed
INSTALLATION PLANNING
ACCOUNTABILITY 1115 SMI WAIVER
Throughout this process we commit to continued interagency partnership with DBHDS as well as continued alignment efforts with DSS-DOE-DJJ-DOC
bull Systems changes
bull SPA Regulations and Manual Updates
bull Launch statewide workforce training
30
Proposed
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
DMAS ORGANIZATIONAL UPDATE
October 21 2019
31
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
32
Office of the Chief of Staff was created to provide coordinated oversight of all operations and projects within the agency with a particular focus on human resources and workforce development
The Office of Quality amp Population Health and the Office of Value Based Purchasing were created to execute cross-divisional initiatives to ensure high-quality high-value care across delivery systems
The COMPASS Division was created to lead the implementation and monitoring of the 1115 COMPASS demonstration waiver
Reorganization of several divisions resulted in the creation of Health Economics amp Economic Policy Policy Planning and Innovation Division the Division of Federal Reporting and the Office of Community Living to ensure strong oversight over the agencyrsquos data analytics policy development federal reporting and home- and community-based waivers respectively
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
33
DMAS Organizational Chart As of End of FY19
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
Overview of Organizational Changes at DMAS Evolution of Several Divisions to Serve Key Cross-Agency Functions
Slide Number 33
Slide Number 34
bull Restructuring and alignment of managed care divisions to ensure appropriate oversight of managed care contracts and a coordinated delivery system
bull Changes to Finance business processes to ensure external and internal oversight and transparencybull Focus on HR to improve efficiency and ensure positions are filled timely
o Between 712018 ndash 6302019 DMAS filled 119 Classified Positions (with 58 Classified Position Departures) and filled 78 Wage Positions (with 57 Wage Position Departures)
34
Focus on Improving Efficiency Transparency and Oversight
CHCS has found that based on its understanding of Medicaid programs across the country and interactions with DMAS leadership
and staff the current structure of DMAS is consistent with other state Medicaid agencies
ldquoDMAS is very capable of advancing specific strategic priorities with speed and intensity as demonstrated by the successful implementation of Medicaid
expansion The agency is also successful in the ongoing management of a large volume of competing priorities created by the day-to-day demands
involved in administering a state Medicaid programrdquo
Preliminary Centers for Healthcare
Strategies (CHCS) Findings on DMAS
Organizational Structure
DMAS UpdateHealth and Human Resources Oversight committeeOctober 21 2019Karen KimseyDIRECTOR Department of Medical Assistance Services
Slide Number 2
Managed Care Update
Who Does Medicaid Serve
Medicaid Benefits and Covered Services
Slide Number 6
Managed Care Expansion Timeline to Date
Managed Care Programs
Oversight of Managed Care Operations amp Performance
Contract Development and Monitoring Activities
Systems and Reporting and Compliance Monitoring
Quality Improvement Activities
VBP is a Powerful Tool to Promote Quality and Efficiency
Performance Improvement Projects (PIP)
Financial Oversight with Provider Reimbursement
Current MCO Rates Compared to Forecast
For More Information
Proposed behavioral health Redesign UPDATE
Advancing Behavioral Health Care in Virginia
Behavioral Health Redesign for Virginia
Trends in CMHRS
BH Redesign and Psychiatric Inpatient Admissions
Behavioral Health Redesign Current Priorities Explained
