RFA Pre-Release Spells Out Requirements for BH/IDD Tailored Plans

NC DHHS recently published a Request for Application (RFA) pre-release concept paper that outlines the proposed requirements for the BH/IDD Tailored Plans.  Legislation states that opportunities to be BH/IDD Tailored Plans are only available to the LME/MCOs for the first four years after the implementation of the Standard Plan.  Legislation also established that the BH/IDD Tailored Plan will go into effect no earlier than one year after the implementation of the Standard Plan. 

If the tentative start date for the BH/IDD Tailored Plans for July 2021 were to stand, the Standard Plans would have to be implemented no later than July 2020.  The ongoing budget impasse between the NC General Assembly and the NC Governor has left us with an indefinite suspension of the implementation of managed care in physical healthcare and that may require an adjustment of the go-live date for BH/IDD Tailored Plans.  Regardless of the actual start date for the BH/IDD Tailored Plan, NC DHHS is moving forward on the RFA process.  As the concept paper shows, there are a multitude of preparations and processes that must occur prior to the implementation of BH/IDD Tailored Plans.  Dave Richard, Deputy Secretary for Medicaid, noted to legislators recently that it will facilitate ongoing preparation to identify the BH/IDD Tailored Plans and allow for focused work with awardees.    

Basic premises of the RFA:

• The regions are based on the current LME/MCO catchment areas, per recommendations of the NC Association of County Commissioners and others.
• Only the LME/MCO currently serving that region can apply to be the BH/IDD Tailored Plan for that region in this round.
• The first contract period will be for the entire four-year period in which LME/MCOs are the sole contractors (after that time, it will be bid competitively with current BH/IDD Tailored Plans and non-profit Prepaid Health Plans licensed in North Carolina).
• Legislatively, there will be 5-7 BH/IDD Tailored Plans, therefore, there is not a guarantee that every current LME/MCO will be a BH/IDD Tailored Plan.
• The requirements for BH/IDD Tailored Plans not only include those that were used to award the Standard Plan contracts, but include additional requirements based on the high-needs population being served.
• Governance structures such as the LME/MCO Board, the Consumer and Family Advisory Committee (CFAC) and other advisory boards remain in place.
• BH/IDD Tailored Plans will be required to develop and implement a Local Community Collaboration and Engagement Strategy.  In addition, they are required to have or strengthen relationships with the Department of Public Instruction and the Division of Vocational Rehabilitation as well as the NC Housing Finance Agency. 
• The BH/IDD Tailored Plan will subcontract with a PHP licensed in North Carolina and it is not required that the subcontractor already be providing Standard Plan services in that Tailored Plan region. 
• The provider network for the Tailored Plan behavioral health and I/DD services will be closed (as it is now) and the provider network for the Tailored Plan physical health services will be open—any willing Medicaid provider. 
• Network adequacy standards will be in place.  One benefit is to ensure there is choice at the provider level to the greatest extent possible. 
• I/DD and TBI Tailored Plan Care Management is further clarified to allow for the Medicaid beneficiary to choose between the Tailored Plan Care Management or the current care coordination service that the LME/MCO provides. 
  • Care management takes the whole-person approach of coordinating physical, I/DD, TBI, BH, pharmacy and unmet health-related needs. 
  • All eligible Medicaid beneficiaries will be informed of these services and provided options that include care management by an Advanced Medical Home + or a Care Management Agency. 
  • The current Community Navigator service is replaced by the BH/IDD Tailored Plan Care Management and, therefore, will no longer be offered when the Tailored Plans go-live. 

When a Contract isn’t Awarded in a Region: 

• In the event a contract is not awarded to the responding LME/MCO for a region, this will be considered an “empty region”.
• LME/MCOs can answer several supplemental questions in the RFA that will qualify them to be considered to take on counties of an “empty region”.
• Awarding contracts for empty regions is handled according to the following:  “In the event that no Contract is awarded in a Region to the entity currently serving the Region, the Department will, at its discretion, award all or part of the “empty” Region to one or more qualified applicants, using an optional, supplemental questions request”.  The paper further notes that there will only be one BH/IDD Tailored Plan in each county. 
• The BH/IDD Tailored Plan is required to become licensed as a Prepaid Health Plan in North Carolina 90 days before the end of the Contract Year 3 (it will require legislative authority to require this),

Alignment with Standard Plan Requirements:

• Capitation rate-setting methodology will align with the methodology used with the Standard Plans. 
• BH/IDD Tailored Plans, similar to Standard Plans, will have incentives to use savings towards high-impact initiatives on health-related needs of their communities. 
• BH/IDD Tailored Plans must use the same statewide formulary for pharmaceuticals that the Standard Plans will use.
• Similar to Standard Plans, BH/IDD Tailored Plans will be required to have rate floors for provider reimbursement. 
• Quality of services will be based on the Standard Plan requirements and will have additional layers related to the high-needs populations being served under the 1915(c) waiver (Innovations) and the health home requirements.
• NCQA Accreditation is required as it is for the Standard Plans and BH/IDD Tailored Plans must additionally have that accreditation cover long-term services and supports. 

BH/IDD Tailored Plan Solvency and Risk:

• Each Tailored Plan must meet an 88% Medical Loss Ratio (see below for further explanation).
• NC DHHS is considering a shared risk with Tailored Plans in the beginning that are structured through a “risk corridor” that would limit the amount of savings for the Tailored Plan and also limit the amount of financial risk they take on.
• Each BH/IDD Tailored Plan must have a risk reserve from the first day of go-live that is equal to 12.5% of the annual capitation. 

Value-Based Care and Withholds:

• NC DHHS will withhold a portion of the premiums paid to the BH/IDD Tailored Plans which will then be paid to them retrospectively based on meeting performance expectations in various areas. 
• NC DHHS acknowledges the need to move more slowly into value-based contracting with the BH/IDD Tailored Plan population than they have prescribed for the Standard Plan.  Therefore, they are going to begin with a focus on value-based care management under the Tailored Plan. 
• NC DHHS will develop value-based purchasing targets for BH/IDD Tailored Plans that will begin in Contract Year 2. 

Quality:

• Performance measures will be used for NC DHHS to track whether there are improved outcomes for members.  (See pages 19-27 of concept paper for measures).  Contract Year 1, NC DHHS will report the performance based on the measures.
• Priority performance measures will be identified.  Contract Year 2, NC DHHS will begin withholds on specific priority measures. 

In-Reach, Transition and Diversion from Higher Levels of Care:

• NC DHHS will expand the use of in-reach, transition and diversion beyond the Transition to Community Living Initiative to individuals residing in certain institutional settings.
• Individuals who will qualify for in-reach and transition include—
  • Individuals with Severe Mental Illness who are residing in an Adult Care Home or a state psychiatric facility;
  • Individuals residing in an Intermediate Care Facility for Individuals with an Intellectual Disability (ICF-IID) or a state developmental center. 
• Individuals who will qualify for diversion include–
  • Individuals who transitioned from an institutional or correctional setting within the previous six months or are seeking entry into an institutional setting.
  • Individuals with an I/DD or TBI diagnosis whose caregiver is unable to provide interventions before institutionalization, aging or in fragile health.
  • All children and youth with an I/DD diagnosis and complex behavioral health needs. 
• In-reach and transition staff of the BH/IDD Tailored Plans are expected to have competencies in the area of disability of that Medicaid beneficiary.
• In-reach activities include:  informing individuals of their options to live in the community; addressing barriers and challenges to their transition to the community; addressing concerns of consumers and family members about transitioning to the community; creating opportunities for consumers and family members to visit with peers who live and receive services and supports in the communities; supporting facility staff in the transitions.
• Transition activities include:  assisting the consumer and family in planning for community-based services and supports; providing any training or technical assistance to the community-based providers receiving this consumer; addressing barriers to transition; identifying funding options to assist in the transition. 
• Specifics on In-Reach and Transition for Children and Youth–
  • Children and youth who are in state psychiatric hospitals, psychiatric residential treatment facilities (PRTFs) and certain residential treatment levels will receive in-reach and transition services. 
  • Goals are set to reduce the average length of stay, readmissions, and the number of youth in institutional or other out-of-home settings.
  • BH/IDD Tailored Plans will be expected to identify and engage children and youth members in transition services; collaborate with facilities, community providers, and other youth-specific entities or systems; ensure individualized, person-centered transition plans; identify and address barriers to transition; and ensure warm handoffs and linkages to community providers and care managers.
• Diversion activities for all members eligible to move into the community and receive community-based services include:  screening and assessment, education on options and supports available, referral and linkage to services (including supported housing), a Community Integration Plan.

I HAVE A QUESTION OUT WITH KELSI TO CONFIRM THIS TIMELINE

Current Proposed Timeline for Implementing of the BH/IDD Tailored Plan—what we know:

February 21, 2020:  Pre-Release of the BH/IDD Tailored Plan RFA concept paper comments due

Spring 2020:  BH/IDD Tailored Plan RFA is released.  LME/MCOs have 120 days to respond.

Late Summer 2020:  LME/MCO responses to RFA are due.  NC DHHS has certain turnaround time to award contracts? 

Readiness Reviews – Unknown

Late Fall 2020:  NC DHHS awards BH/IDD Tailored Plan contracts.

July 2021:  Tentative go-live of BH/IDD Tailored Plans. 

What is the Medical Loss Ratio? 

General Definition:  Medical Loss Ratio (MLR) is a measure of the percentage of premium dollars that a health plan spends on medical claims and quality improvements, versus administrative costs.

Because NC DHHS is proposing an 88% MLR for the BH/IDD Tailored Plans, each plan will not be able to spend more than 12% of their capitation payments on administrative expenses. 

OPEN MINDS article RFA Pre-Release Puts In Question Number Of North Carolina Tailored Behavioral Health Plans To Be Awarded for which i2i served as an Expert Resource.