STATE OF ALASKA DEPARTMENT OF HEALTH AND SOCIAL SERVICES
NOTICE OF PUBLIC COMMENT PROCESS FOR MEDICAID SECTION §1115 BEHAVIORAL HEALTH DEMONSTRATION WAIVER
Public Comment Period Opens: November 28, 2017
Public Comment Period Closes: December 29, 2017 at 5:00 pm AST
Public notice is hereby given that the State of Alaska’s Department of Health and Social Services (DHSS) is seeking public comments on a Section 1115 Behavioral Health Demonstration Waiver application to support the comprehensive reform of Alaska’s Medicaid supported behavioral health system.
Program Summary
DHSS is requesting approval of a Section 1115 Behavioral Health Demonstration Waiver from the Centers for Medicare & Medicaid Services (CMS) to develop a data-driven, integrated behavioral health system of care for children, youth, and adults with serious mental illness, severe emotional disturbance, and/or substance use disorders. The demonstration project also seeks to increase services for at-risk families in order to support the healthy development of children and adults through increased outreach, prevention and early intervention supports.
Program Background
In 2016 the Alaska Legislature passed Senate Bill 74, a multi-dimensional Medicaid reform package that includes 16 separate and significant initiatives including direction to apply for a Section 1115 Medicaid waiver to enable the state to more efficiently manage a comprehensive and integrated behavioral health system. The bill also directs the state to reduce operational barriers, minimize administrative burden, and improve the effectiveness and efficiency of Alaska’s behavioral health system.
In order to proactively address the many goals and expectations of the Alaska legislature and improve the long-term outcomes for Alaskans, DHSS has brought together community members, tribal entities, behavioral health providers, other concerned stakeholders, and contracted with Medicaid experts to develop an 1115 waiver proposal that seeks to address the complex behavioral health needs of Alaskans.
Goals and Objectives
The Alaska 1115 Behavioral Health Demonstration Waiver seeks to provide Alaskans with a comprehensive continuum of cost-effective, high quality behavioral health services designed to ensure access to the right services at the right time in the right setting. The goals and objectives of the application are:
Goal 1: Rebalance the current behavioral health system of care to reduce Alaska’s over-reliance on acute, institutional care and shift to more community or regional-based care.
Objectives:
Decrease use of inpatient hospital and emergency department care episodes.
Decrease use of residential out-of-home placements.
Increase regionally-based capacity for a continuum of intensive outpatient, day treatment, intensive case management, community and recovery support, home-based family, assertive community treatment, and ambulatory withdrawal management services.
Develop community-based, culturally appropriate behavioral health workforce capacity to address existing workforce deficits.
Goal 2: Intervene as early as possible in the lives of Alaskans to address behavioral health symptoms before symptoms cascade into functional impairments.
Objectives:
Provide universal screening to identify symptoms.
Provide brief, solution-focused interventions to prevent acute care.
Provide care as close as possible to the homes or regional-hub communities of Alaskans.
Goal 3: Improve the overall behavioral health system accountability by reforming the existing system of care.
Objectives:
Contract with an Administrative Services Organization (ASO) to manage Alaska’s existing system of behavioral health care.
Improve the consistency of screening, assessment, and service/placement decisions through use of evidence-based and evidence-informed tools.
Standardize and streamline documentation requirements to reduce duplication of effort and facilitate coordination of care across all providers.
Support provider development of infrastructures necessary to coordinate care, report and achieve performance/quality measures, report per capita BH costs, and improve participant outcomes.
Delivery System Changes
Alaska’s proposed Section 1115 Behavioral Health Demonstration Waiver is aimed at a subset of its Medicaid population that is currently covered under the Medicaid State Plan. Individuals who fit into the three target populations will be eligible to receive an enhanced set of services designed to address their clinical and social needs. These three targeted populations of Medicaid recipients include:
1. Children, adolescents and their parents or caretakers with or at risk of mental health and substance-use disorders.
2. Individuals with acute mental health needs.
3. Individuals with substance-use disorders.
As of October 2017, approximately 179,727 individuals were enrolled in Alaska’s Medicaid program. The following table estimates the average annual enrollment of beneficiaries for each year of the demonstration project.
The following table estimates the projected expenditures for the 1115 Behavioral Health Demonstration Waiver by program year.
Please note: This data in these tables were provided by Milliman, Inc. Their full methodology report is attached as an appendix in the Medicaid Section 1115 Behavioral Health Demonstration Application.
There will be no cost sharing requirement with this demonstration.
Strategies and Services
The following are the proposed strategies and evidence-based interventions aimed at more effectively addressing the needs of each of the target populations. New Medicaid-covered services under the waiver will establish a robust continuum of care designed to anticipate and address the range of behavioral health needs of the target populations. There are no proposed changes in Alaska Medicaid eligibility requirements; however each target population has defining criteria for the waiver’s enhanced services.
Targeted Services: Youth At-Risk of Mental Health or Substance Use Disorders
Evidence-based clinical assessments
Standardized mental health and SUD screening
Community-based outpatient services.
Home-based family treatment services
Intensive case management services
Mental health day treatment services
Acute intensive services
Mobile crisis response services
23-hour crisis stabilization services
Therapeutic foster care
Residential treatment services
Community and recovery support services
Targeted Services: Individuals with Acute Mental Health Needs
Standardized screening and assessment
Community-based outpatient treatment options, including the creation and deployment of teams modeled on the Assertive Community Treatment approach
Intensive case management services
Mental health day care treatment
Acute intensive services
23-hour crisis stabilization services
Peer-based crisis stabilization services
Community and recovery support services
Existing crisis residential and stabilization services, including medically-monitored, short-term, residential program in an approved (10-15 bed) facilities that provide 24/7 psychiatric stabilization services
Targeted Services: Individuals with Substance Use Disorders
Standardized screening and assessment
Community and recovery support SUD services
Community-based outpatient SUD treatment and medication services
Medication-Assisted Treatment (MAT) services, including MAT Care Coordination
Intensive SUD case management
Intensive outpatient SUD services
Ambulatory withdrawal management
Acute intensive services will also be made including mobile crisis response services and peer-based crisis services
Adult and youth residential treatment services
Demonstration Project Hypothesis and Evaluation
The State of Alaska will conduct an independent evaluation to measure and monitor the outcomes of the Section 1115 Behavioral Health Demonstration project. The evaluation will focus on five key areas: access, service utilization, quality, costs, and integration of care. The evaluators will assess the impact of providing an enriched continuum of local and regional behavioral health services under the proposed waiver, with particular focus on the waiver’s impacts over time on the utilization of residential treatment beds, emergency department visits, inpatient hospital stays and hospital readmissions rates.
Hypothesis 1: Increased access to sub-acute, community- or regionally-based outpatient treatment services will:
Reduce residential lengths of stay
Reduce avoidable Inpatient hospital use
Reduce avoidable Emergency Department use
Reduce readmissions to Inpatient and residential care
Reduce the number of out-of-state residential placements of Alaska’s children/youth
Hypothesis 2: Alaskans will achieve improved health outcomes as a result of behavioral health Medicaid reform by:
Reducing the % of readmissions after hospitalization for mental illness
Reducing the number of children utilizing residential treatment services
Increasing the number of physical health referrals, treatment and monitoring for children with behavioral health diagnoses
Early identification of symptoms through universal screening for substance use disorders, mental health disorders, or developmental issues impacting on family stability
Hypothesis 3: Increased access to appropriate behavioral health care will reduce Alaska’s average behavioral health Medicaid per capita cost.
Hypothesis 4: Increased access to home-based family treatment and wrap-around services will:
Reduce the number out-of-home placements
Increase the number of family reunifications
Reduce the number of children/youth in Office of Children’s Services custody
Reduce the number of children/youth under Division of Juvenile Justice supervision
Reduce the number of children/youth entering or re-entering foster care
Reduce the number of children in residential care
Hypothesis 5: Increased access to Medication Assisted Treatment Care Coordination services will:
Reduce the % of past month alcohol use
Reduce the % of past month adult binge drinking
Reduce the % of past month opioid use
Decrease mortality rate associated with opioid abuse
Improve physical health care by reducing number of inpatient general hospital visits by MAT participants
Reduce the annual cost of physical and behavioral health care for MAT participants
Proposed Federal Authorities Waived
Proper and Efficient Administration §1902(a)(4)
Rationale: Mandate beneficiaries into a single Administrative Services Organization (ASO).
Comparability §1902(a)(17)
Rationale: This waiver program includes benefits specific to eligibility criteria as described in Section II that will not be available to other Medicaid beneficiaries.
Amount, Duration, and Scope §1902(a)(10)(B)
Rationale: To enable the State to offer a different benefit package to the demonstration participants that varies in amount, duration, and scope from the benefits offered under the State Plan.
Freedom of Choice §1902(a)(23)(A)45
Rationale: Beneficiaries enrolled in the program must receive services through the ASO.
Choice of Coverage §1932(a)(3)
Rationale: To enable the state to assign demonstration participants to ASO based on geography and to permit participant choice of provider, but not plan.
Methods of Administration: Transportation §1902(a)(4), insofar as it incorporates 42 CFR 431.53
Rationale: To enable the state to assure transportation to and from providers for the Demonstration participants.
Eligibility Standards §1902(a)(17)
Rationale: To enable the State to apply different eligibility methodologies and standards to the Demonstration eligible population than are applied under the State Plan.
Residential SUD Treatment Services
Alaska also seeks expenditure authority under Section 1115(a)(2) of the Social Security Act to claim expenditures made by the state for services not otherwise covered or included as expenditures under Section 1903 of the Act, such as services provided to individuals residing in facilities that meet the definition of an Institution for Mental Disease (IMD), and to have those expenditures regarded as expenditures under the State’s Title XIX plan.
Alaska Psychiatric Institute Services
Alaska also seeks expenditure authority under Section 1115(a)(2) of the Social Security Act to claim expenditures made by the state for services not otherwise covered or included as expenditures under Section 1903 of the Act, such as services provided to individuals residing in facilities that meet the definition of an Institution for Mental Disease (IMD), and to have those expenditures regarded as expenditures under the State’s Title XIX plan.
1115 Behavioral Health Demonstration Application
The link to the proposed demonstration application is here:
http://dhss.alaska.gov/HealthyAlaska/Documents/AK1115_Draft_Application-11-2017.pdf
Hard copies of the demonstration application are available at:
Department of Health and Social Services- Office of the Commissioner
3601 C Street, Suite 902, Anchorage, Alaska 99503
Public Comment Process
To submit public comments on the 1115 Waiver, please send them via email to 1115_Public_Comments@alaska.gov or mail them to:
1115 Public Comments
C/O Alaska Mental Health Board/ Advisory Board on Alcoholism and Drug Abuse
PO Box 110608, Juneau, AK 99811-0608
Public comments, FAQ’s and additional information will be posted and updated regularly on the web throughout the duration of the public comment period here:
http://dhss.alaska.gov/HealthyAlaska/Pages/PublicComment/1115waiverComment.aspx
Informational Webinar Schedule
The public is welcome to participate in the following online webinars to learn more about the waiver application and ask questions about the project.
Introductory Webinar: Wednesday, December 6th, 2:00 pm
Please join the webinar by following this link: https://stateofalaska.webex.com/stateofalaska/j.php?MTID=m94e0acce3daadf20e8239eb7585122fa
The telephone conference number will be provided when you sign in.
Webinar- Public Comment Process Update and FAQ’s: Thursday, December 21st, 10:00 am
Please join the webinar by following this link: https://stateofalaska.webex.com/stateofalaska/j.php?MTID=md903694bc98043e98c91e4f72a866b47
The telephone conference number will be provided when you sign in.
Public Meeting Schedule
The public is also welcome to attend or call into the following public meetings to learn more about the waiver application, ask questions, and provide public comment:
Juneau Public Meeting
Friday, December 8th, 4:30 pm
Alaska Office Building (350 Main St.), Conference Room 115
Teleconference #: 1-800-315-6338 , Passcode: 58920#
Fairbanks Public Meeting
Monday, December 11th, 6:00 pm
Noel Wien Library (1215 Cowles St.)
Teleconference #: 1-800-315-6338, Passcode: 58920#
Kenai Public Meeting
Tuesday, December 12th, 6:00 pm
Kenai Chamber of Commerce and Visitors Center (11471 Kenai Spur Hwy.)
Teleconference #: 1-800-315-6338, Passcode: 58920#
Mat-Su Public Meeting
Wednesday, December 13th, 6:00 pm
Wasilla Senior Center (1301 S. Century Circle)
Teleconference #: 1-800-315-6338, Passcode: 58920#
Anchorage Public Meeting
Thursday, December 14th, 6:00 pm
Frontier Building (3601 C. St.), Conference Room 880/890
Teleconference #: 1-800-315-6338, Passcode: 58920#
Individuals with disabilities who require special accommodations in order to attend these public meetings, should contact Beverly Schoonover at 907-465-5114, or email at bev.schoonover@alaska.gov to ensure that any necessary accommodations can be provided.