Becoming a Medicaid Provider of Family and Youth Peer Support - CHCS

[Pages:24]Becoming a Medicaid Provider of Family and Youth Peer Support

Considerations for Family Run Organizations

FEBRUARY 2014

Made possible through support from the Centers for Medicare & Medicaid Services

AUTHORS

Jane Kallal Family Involvement Center, Arizona

Jane Walker Maryland Coalition of Families for Children's Mental Health and Family-Run Executive Director Leadership Association

Lisa Conlan Lewis Parent Support Network of Rhode Island

Dayana Simons Center for Health Care Strategies

Jessica Lipper Center for Health Care Strategies

Sheila Pires Human Service Collaborative

ABOUT THE CENTER FOR HEALTH CARE STRATEGIES

The Center for Health Care Strategies (CHCS) is a nonprofit health policy resource center dedicated to improving health care access and quality for low- income Americans and people with chronic illnesses and disabilities. CHCS works with state and federal agencies, health plans, providers, and consumer groups to develop innovative programs that better serve people with complex and high-cost health care needs. Its work focuses on: enhancing access to coverage and services; advancing quality and efficiency through delivery system reform; integrating care for people with complex needs; and building Medicaid leadership and capacity.

EDITOR

Taylor Hendricks Center for Health Care Strategies

Funder Disclaimer

This document was developed under grant CFDA 93.767 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. However, these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal Government.

? 2014 Center for Health Care Strategies

TABLE OF CONTENTS

Getting Started: How to Use This Resource .......................................................................................... 4 Introduction......................................................................................................................................... 5 SECTION 1: Before Becoming a Medicaid Provider ? Weighing the Options .......................................... 7

CONSIDERATION: Mission......................................................................................................................... 7 CONSIDERATION: Funding Diversification and Sustainability................................................................... 7 CONSIDERATION: Financing ...................................................................................................................... 7 CONSIDERATION: Training and Service Delivery....................................................................................... 8 CONSIDERATION: Advocacy Role .............................................................................................................. 8 SECTION 2: Understanding State Medicaid Programs ......................................................................... 10 SECTION 3: Working with State and Local Governments and Provider Systems .................................. 12 SECTION 4: Understanding Key Staffing Considerations...................................................................... 15 SECTION 5: Establishing Medicaid Billing and Rate-Setting Processes ................................................. 17 Conclusion ......................................................................................................................................... 19 APPENDIX A ....................................................................................................................................... 20 APPENDIX B ....................................................................................................................................... 22

3 | Becoming a Medicaid Provider of Family and Youth Peer Support: Considerations for Family Run Organizations

GETTING STARTED: HOW TO USE THIS RESOURCE

This resource provides guidance to family run organizations that are considering whether to become Medicaid providers of family and youth peer support. It uses examples from three states ? Arizona, Maryland, and Rhode Island ? to illustrate key aspects of this decision and process in becoming a Medicaid family and youth peer support provider.

The content is divided into five sections:

1. Before Becoming a Medicaid Provider ? Weighing the Options: Highlights key considerations for family run organizations to explore prior to becoming Medicaid providers, including how this process may impact the mission, funding, service delivery environment, and advocacy role of the organization.

2. Understanding State Medicaid Programs: Outlines considerations for family run organizations concerning the structure and requirements of a state's Medicaid program and how this may impact the delivery of Medicaid-funded family and youth peer support services.

3. Working with State and Local Governments and Provider Systems: Explores how family run organizations can work in partnership with state and local government stakeholders to maintain integrity to core missions, and meet Medicaid provider requirements. Includes subsections on: (1) increasing the prominence of youth/family voice; (2) balancing roles; and (3) developing a practice model, designing training, and hiring staff.

4. Understanding Key Staffing Considerations: Covers key considerations related to staffing for family organizations becoming Medicaid providers of family and youth peer support, including: (1) training needs; (2) hiring and retaining staff; (3) choosing a staffing model; and (4) ensuring staff capacity for meeting Medicaid's federal reporting requirements.

5. Establishing Medicaid Billing and Rate-Setting Processes: Describes how family organizations can establish Medicaid billing procedures and rates for family and youth peer support provision, which also helps organizations to determine staff salaries and benefits.

Readers are encouraged to dip into the sections as needed, rather than reading the resource cover-to- cover. Each section starts with a brief overview to guide readers through the document. Additionally, at the end of this resource, you will find:

An "Agency Readiness Tool" containing questions that can be used to assess whether or not an organization is ready to become a Medicaid provider; and

An at-a-glance list of pros and cons to be weighed by organizations considering becoming Medicaid providers of family and youth peer support services.

4 | Becoming a Medicaid Provider of Family and Youth Peer Support: Considerations for Family Run Organizations

INTRODUCTION

Family run organizations across the country are lead providers of family and youth peer support services. Most are grassroots organizations developed and run by the parents and caregivers of children, youth, and young adults affected by serious emotional, behavioral, and mental health challenges. The mission of most family run organizations includes family support, education, public awareness, and local and state policy advocacy to ensure that an effective and evidence-based service delivery infrastructure is in place. Family run organizations also ensure the family and youth voice is prominent in shaping a state's system of care infrastructure.

The Affordable Care Act (ACA) provides a critical opportunity for family run organizations to expand their scope, achieve sustainable funding, and become established Medicaid providers. An informational bulletin issued by the Centers for Medicare & Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) in May 2013 provided states guidance in designing benefits for children with behavioral health needs. The bulletin identifies parent and youth peer support as a service that significantly enhances positive outcomes for children and youth.i In addition, nearly all of the Psychiatric Residential Treatment Facility waiver demonstrationii states and many state and local system of care initiatives funded by the federal Comprehensive Community Mental Health Services for Children and Their Families Programiii have included peer-to-peer support services for youth with mental health conditions and their parents, guardians, or caregivers. Family run organizations are now ideally positioned to become Medicaid providers that are reimbursed for family and youth peer support services.

What Do Family and Youth Peer Support Providers Do?

Develop and link children, youth, and parents/caregivers with formal and informal supports; Instill confidence; Assist in the development of goals; Serve as advocates, mentors, or facilitators for resolution of issues; Teach skills necessary to improve coping abilities; Help families to secure basic needs, and access health insurance or social service benefits; Provide peer support and system navigation by phone and in person; Increase parent knowledge for meeting their child's educational, and social/emotional health needs; Advocate and promote systems transformation; Provide transportation; Participate in care planning and supporting court ordered concerns; and Ensure the safety, permanency, and well-being of children and youth.

Who Can Serve as Family and Youth Peer Support Providers?

Family and youth peer support providers are typically community members with "lived experience" who have personally faced the challenges of coping with serious mental health conditions, either as a consumer or a caregiver.

This resource provides guidance to family run organizations that are considering whether to become Medicaid providers of family and youth peer support. It uses examples from three states ? Arizona, Maryland, and Rhode Island ? to illustrate key aspects of this decision and process in becoming a Medicaid family and youth peer support provider.

5 | Becoming a Medicaid Provider of Family and Youth Peer Support: Considerations for Family Run Organizations

The Role of Family Run Organizations in Arizona

In Arizona, family run organizations serve many functions in the community in addition to delivering parent and youth peer support, including: Developing parent and youth leaders for system of care committees/workgroups and projects; Participating in the development of the system's practice model; Establishing and coaching family education groups to complement in-person support; Providing input on requests for proposals for the service provider network; Developing and delivering training for family members and the behavioral health workforce; and Participating in quality assurance processes.

For family run organizations already providing peer support services through grant or state funding, becoming a Medicaid provider means the funding source for these services will change, as well as eligibility and reporting requirements. Family run organizations may also encounter limitations on the populations served, length of service, and components of service, in addition to training and credentialing requirements. However, becoming a Medicaid provider does not have to change an organization's identity; rather, an organization can expand its services and promote itself as an enhanced provider, making it eligible for increased funding and allowing for growth.

Culture Shift Family run organizations that are considering becoming Medicaid providers must ask the fundamental question:

Does becoming a Medicaid provider fit with our mission?

For some the answer may be "no" or perhaps "not right now." However, if the answer is "yes," it should be anticipated that becoming a Medicaid provider may require (or create) a significant culture shift for both the board and staff. Across the organization, there must be awareness and understanding of the parameters for billing Medicaid, and how these may limit the frequency or duration of services, as well as the number of families that may be served.

Becoming a Medicaid provider may require an organization to overhaul its existing policies and procedures, as well as modify the services currently provided and the population of families served. Family run organizations that are not currently billing Medicaid may want to consider two important questions:

1. Does becoming a Medicaid provider change how families view the organization and staff? If so, how?

2. How dramatically does becoming a Medicaid provider change or limit the services provided by the organization? Will the organization's primary identity shift from that of a family organization to a provider organization?

Funding Shift If an organization is already providing family and youth peer support services with non-Medicaid funding, the addition of a Medicaid contract expands its capacity to serve additional families or offer a broader array of services. It does not necessarily mean that the organization can no longer provide parent and youth support through grant, foundation, volunteer, or state appropriation funding. An organization's leadership must explore whether becoming a Medicaid-funded provider of peer support services means that other state or grant dollars would go away. In Arizona for example, about 40

6 | Becoming a Medicaid Provider of Family and Youth Peer Support: Considerations for Family Run Organizations

percent of the revenue for its family run organization, the Family Involvement Center, comes from Medicaid provider contracts. The remaining 60 percent comes from other sources and covers system transformation activities, including front line and system leadership training; quality management; and other non-billable family support services.

To become a Medicaid provider, an organization must ensure it has the infrastructure capacity to hire staff for administrative, supervisory, and peer support provider roles. Additionally, the organization must be able to develop, implement, and evaluate its peer support provider program. It will need to seek other funding development opportunities to support the organization's mission and goals, including: (1) public awareness and education; (2) family and youth leadership; (3) system transformation; (4) and policy reform.

SECTION 1: BEFORE BECOMING A MEDICAID PROVIDER ? WEIGHING THE OPTIONS

OVERVIEW

Read this section for a summary of key considerations that family run organizations should explore prior to becoming Medicaid providers, including how this process may impact the mission, funding, service delivery environment, and advocacy role of the organization.

A family run organization must weigh multiple considerations before becoming a Medicaid provider, including how this process may impact the mission, funding, service delivery environment, and advocacy role of the organization. These considerations are outlined below. Also see Appendix A for an Agency Readiness Tool with key questions to address.

CONSIDERATION: Mission Family run organizations across the country have diverse organizational structures and missions. For some, advocacy, training, or coordination of other local family organizations ? rather than direct delivery of peer supports ? are the primary focus. In these instances, becoming a Medicaid provider may not align with the organization's mission. If a key mission, however, is to provide direct services to families, becoming a Medicaid provider may be a good option for sustainability and peer workforce development that cannot be achieved solely through grant or state funding.

CONSIDERATION: Funding Diversification and Sustainability Family run organizations must evaluate the need for funding diversification in the context of sustainability. An organization that is already providing family and youth peer support with non- Medicaid dollars will need to determine whether the current funding sources will still be available if it becomes a Medicaid provider. If not, the organization may be more limited in whom it can serve, as Medicaid services are linked to and offered as part of an individual child's plan of care, and require a specific intake, assessment, and eligibility determination process. In most states, Medicaid funding for peer support is targeted to high-need, multi-system-involved families, so a family run organization must consider whether that consumer focus fits with its current program approaches.

CONSIDERATION: Financing Family run organizations must consider the ebb and flow of funds based on billable hours. Unlike a block or discretionary grant, billing Medicaid under a fee-for-service arrangement does not guarantee a fixed amount of money to the organization each month. The reimbursement amount may fluctuate month-to- month, depending on the caseload and the number of billable hours. Therefore, an organization must

7 | Becoming a Medicaid Provider of Family and Youth Peer Support: Considerations for Family Run Organizations

consider whether it has sufficient funds in reserve to sustain it during the start-up phase of billing, and over the course of a year when Medicaid billing may fluctuate.

Financing for Arizona's Family Involvement Center

Arizona's family run organization ? the Family Involvement Center in Maricopa County ? became a Medicaid provider in 2005, after three years of experience providing family support services with non-Medicaid funding. Funded through the same type of contract as traditional service providers in Maricopa County, the organization receives 12 monthly payments (the "block purchasing" method). This funding structure allows the Center time to build up the base of families it serves throughout the year and reach the total annual service contract amount ? even with fluctuations in referrals for Medicaid reimbursable services. If the organization does not believe it will reach the contract amount, or is exceeding the contract due to demand, it can adjust staffing and other costs, set aside the anticipated funding surplus, and return it to the managed care organization at the end of the contract year.

Like other behavioral health providers in Maricopa County, the Family Involvement Center receives monthly reports from the managed care organization of billable, paid claims, which allows the center to monitor the contract as it would any other contract with set deliverables. Additionally, the center now has a block purchase contract with another managed care organization in Arizona. This grant supports the process of "self-referral," by which the family of a Medicaid eligible child or young adult can contact the Family Involvement Center directly. The Center then works with the intake agencies to obtain the appropriate documentation and authorization to begin providing family support services. This contract also includes a fee-for- service option to provide additional family support-related services not included in its contract with the managed care organization. Dollars for these additional services come from local providers, which simplifies the process of coordination and service planning with families.

Block purchase contracts with managed care organizations help providers manage ongoing expenses by establishing a strong foundation of operating capital. In states with managed care delivery systems, Medicaid agencies and their contracted managed care organizations work with new providers to communicate provider standards related to service delivery, record keeping, reporting, billing, and other requirements through the credentialing process, prior to negotiating a contract.

CONSIDERATION: Training and Service Delivery As a Medicaid provider, the staff responsible for managing and delivering peer support services must be trained on Medicaid rules relating to documentation, administration, and coordination of care across the provider network, including how peer support complements clinical services in a plan of care. Typically, state Medicaid guidelines describe how service providers must work together for the good of the child and family. Family run organizations must work closely with other providers and translate referrals into services for a child's or family's plan of care. The family run organization must become more conscious of different administrative demands, including increased documentation and potentially constrained billable timeframes. An organization must be fully comfortable with this role before deciding to become a Medicaid provider. Such understanding also helps the organization to be a stronger advocate and policy advisor.

CONSIDERATION: Management Information Systems and Electronic Health Records Family run organizations must take into account the capacity of their management information systems and will need to determine whether and how their hardware, software, and data collection, management, and storage processes may need to change in order to meet Medicaid provider and payer reporting requirements. The use of electronic health records (EHRs), which help standardize data, terms, and forms is growing in prevalence and is the basis for health information exchange. EHRs allow for the tracking and reporting of data and outcomes related to care, at both individual and aggregate levels. This capability is desired--and increasingly, required--of providers by managed care organizations and state Medicaid agencies. Electronic record keeping has implications for Medicaid auditing and federal data reporting guidelines (both discussed in other sections of this guide); and moving from paper files to electronic record keeping and reporting will likely be necessary in the short term. Family run

8 | Becoming a Medicaid Provider of Family and Youth Peer Support: Considerations for Family Run Organizations

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