Medicaid Managed Care: Recovery Moves to the Mainstream

Medicaid Managed Care: Recovery Moves to the Mainstream

By Briana Gilmore, Director of Public Policy and Advocacy, New York Association of Psychiatric Rehabilitation Services (NYAPRS)

Learn More About the Trends That Will Affect You

Big changes are coming soon to New York’s Medicaid system. Services are being overhauled to emphasize quality and outcomes, and new services are being added to ensure that Medicaid is paying for the most cost-effective and valued treatment. Why is this good news? These changes will be beneficial to all Medicaid consumers who use behavioral health (BH) services. In fact, New York will implement changes in 2015 that emphasize recovery-oriented BH services in unprecedented ways.

This change started in 2011 when Governor Cuomo instituted the Medicaid Redesign Team, a planning system that looked at outcomes of the Medicaid system and made targeted changes. The goal was to build off reforms central to the Affordable Care Act, with the mission of reducing overall cost while improving outcomes and quality care. Policy makers quickly realized that achieving this would be particularly challenging for the BH system.

New York is transitioning the BH system because recovery-focused services not only improve quality and outcomes, but also save money. This plan also raises the bar for providers, many of whom have long been funded based on how often people come to programs rather than demonstrated improvements in people’s lives. In order to achieve this transition, the plan targets social determinants of well-being such as housing, employment, education, and family connections.

DOH, OMH, and OASAS have decided to accomplish this by moving to a system of managed care that will be expected to improve the coordination and impact of care.

Managed care isn’t new, and many who are Medicaid eligible already have physical health and pharmacy services paid for by a Managed Care Organization (MCO). In 2015, every person in New York State who is eligible for Medicaid will also have their mental health and addiction services coordinated and paid for by an MCO.

If you are already enrolled in an MCO, you will receive all of your benefits from the same plan. If you’re not enrolled, you will have to choose an MCO. If you’re not sure about which plan to choose or if you want to switch, you can access an enrollment broker to help you do so.

Medicaid recipients who have used a lot of mental health and addiction in the past will be enrolled in a Health and Recovery Plan (HARP) that will offer and coordinate a greater amount of those services.

Thanks to advocacy from NYAPRS (New York Association of Psychiatric Rehabilitation Services) and other advocacy groups, HARPs are required to offer services that have never been Medicaid funded, including peer services, crisis respite, supported employment and education, family supports, non-medical transportation, and self-directed care.

Some of these services, like crisis respite, will be available as needed. But others will be offered based on goals you express during treatment planning with a care manager, such as transitional employment. This will be a major change for many people; instead of just being offered service options, people in HARPs will be asked what their recovery goals are and what supports they need to get there. It will take time to build a system that understands how to do this, but it will also take time before all community members are able to articulate what their goals and preferences are.

Ideally, that is what care management is all about. Health Homes are established throughout the state to provide care management that excels at helping people access services they really want and need, including community supports like housing and wellness activities. Health Homes are just networks of providers organized by a central agency; they aren’t a place, but have care managers that provide outreach in community settings.

Health Homes are operating with mixed success. Their capabilities depend on the strength of their provider network and ability of staff to truly understand the needs of our community, including cultural norms and preferences. Care Management will be a big part of the way MCOs understand and organize services in the future, particularly through HARPs. MCOs will have to work with Health Homes to ensure each recipient receives the attention that helps them achieve the best life possible in the community.

This historic shift in the way Medicaid is delivered will mean dramatic improvements in the way the community accesses services that truly help people recover. But it won’t happen perfectly all at once, and recipients may have to press for better attention from care managers, more appropriate service access, or demand community-based living and service options. NYAPRS and Medicaid Matters New York, along with other associations, achieved the inclusion of an ombuds program in Medicaid Managed Care; an ombuds is an office that can objectively help resolve complaints and help consumers navigate problems.

Importantly, this shift is just one of many moving toward a more coordinated system. People who need nursing home or long-term care services will also experience changes in services coordination, and eventually everyone in New York State who has Medicare coverage will elect an MCO. Stay updated through community forums for information about how benefits you receive are improving and what you can do to advocate for what you and your peers need.