State Medicaid official-telephone interview

ATTACHMENT E

Baseline Telephone Interview Protocol
state medicaid officials

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baseline telephone Interview questions- state medicaid officials

During Year 1 of the demonstration (September 2017), telephone interviews will be conducted with officials in state Medicaid offices. The interviews will address implementation of the CCBHC model in the state, addressing specific factors that shape CCBHC policies. They will be tailored based on the information already gathered through applications and other sources—or gaps in that information—regarding participating sites’ program characteristics. The interviewer will transfer the information gathered from the interviews into a Debrief Template that organizes data by criteria domain and corresponding research questions. The general template for baseline telephone interviews is presented below.

A. Introduction

1. Please describe your current role/position.

B. Demonstration planning and administration

1. What were the key areas of focus for the state Medicaid office in the demonstration planning process (for example, prospective payment system [PPS] selection, cost reporting system, clinic certification, and so on)?

a. What were the critical concerns of the state Medicaid office during the demonstration planning process?

Probe for the following:

• Payment/billing for CCBHC services (e.g., what services can be billed, etc.)

• CCBHC services and program issues (e.g., what constitutes a CCBHC service, what types of providers participate, child/adolescent vs. adult services, crisis services, etc.)

• Concerns regarding regional differences, rural versus urban settings

b. How did these concerns influence the state’s plans for conducting the demonstration?

c. What was your experience in collaborating with the state office(s) of mental health and substance abuse services during the CCBHC planning process?

Probe on the following:

• How responsibilities/contributions to the CCBHC demonstration planning process were distributed across respective offices/agencies

• Challenges with respect to collaboration between the state Medicaid agency and office(s) of mental health and substance abuse services

• What aspects of the collaboration worked well

2. Were clients (including adults with serious mental illness [SMI] and those with long-term and substance use disorders [SUDs]), family members (including of adults with SMI and children with serious emotional disturbances), providers, and other stakeholders (including American Indian/Alaska Native, and other local and state agencies) involved in developing the demonstration? If so, please describe their role.

a. What were the critical issues they raised, and how did their input influence your plan to conduct the demonstration?

3. How was the state Medicaid office involved in certifying clinics as CCBHCs?

a. What processes are in place to ensure continued compliance with the certification criteria?

C. Staffing and access to care

1. Does the state Medicaid agency monitor the staffing criteria for CCBHCs? If so, how?

a. Have specific issues arisen?

b. Did state regulations or policies need to be changed to allow payment for services provided by CCBHC staff?

2. Did state regulations or policies regarding Medicaid payments need to be altered to accommodate the CCBHC model?

Probe about the following:

• Same-day billing restrictions

• Payment for designated collaborating organizations (DCOs)

• Any other regulations or policies

3. What other programs or policies in your state are intended to increase access to behavioral health services? How do they overlap or interact with CCBHCs’ services?

Probe about the following:

• Crisis services

• SUD services, recovery-oriented care

• Centers for Medicare & Medicaid Services (CMS) or health reform demonstrations

• Health homes

• Behavioral health-related waiver or demonstration activity

• Olmstead

• Medicaid expansion

• Affordable Care Act (ACA)

a. What types of funding sources currently support these efforts (for example, existing grants, county-specific services funded through county taxes, 1115 waivers, general revenue)?

b. Do efforts/funding vary by region within the state?

c. How do these efforts interact with CCBHC efforts?

D. Scope of services and coordination of care

1. Are all services within the CCBHC scope of services reimbursable by Medicaid in your state?

a. Which services required by the CCBHC criteria have not historically been reimbursable?

b. For services required by CCBHC criteria that were reimbursable in the past, how were they reimbursed (for example, block grant, state funding, and so on)?

2. What provisions does your state make for payment for care coordination?

Probe about provisions:

• In general medical care

• In behavioral health

• Targeted to high users of care

a. How do these compare with coverage for care coordination in CCBHCs?

3. Are the care coordination services that CCBHCs offer substantially different from those available from other community mental health centers (CMHCs) in your state?

a. If different, how are they different? What changes were required to meet the CCBHC standard?

b. If not different, how are those services paid for in other settings?

4. Did your state have an assisted outpatient treatment program prior to the CCBHC demonstration?

5. How have CCBHCs established care coordination with community or regional supports and providers?

Probe about the following:

• Schools

• Hospitals (for example, to obtain discharge notifications for inpatient/emergency department [ED] care)

• Child welfare agencies

• Juvenile and criminal justice agencies and facilities (including drug, mental health, and veterans and other specialty courts)

• Active military/U.S. Department of Veterans Affairs (VA) facilities

• Indian Health Service youth regional treatment centers

• State licensed and nationally accredited child placing agencies for therapeutic foster care service

• Federally qualified health centers (FQHCs)

• Other social and human services

6. Does your state have information technology requirements for Medicaid reimbursable providers in general medical or behavioral health care?

7. Are the health IT systems required for CCBHCs generally used in CMHCs in your state?

a. How do CCBHCs compare with other CMHCs in the use of electronic health registries?

b. Was the planning grant used to upgrade electronic health registry capabilities?

8. How are CCBHCs in your state coordinating with hospitals to obtain discharge notifications of inpatient/emergency department visits?

a. Are claims data for inpatient/emergency department encounters (discharge information) shared with CCBHCs?

E. Quality of care

1. How are quality measures data going to be collected during the demonstration?

Probe for the following:

a. CCBHC-reported measures (9 required)

• New clients―days until initial evaluation/percentage of new clients evaluated within 10 days

• Preventive care and screening: body mass index (BMI)

• Preventive care and screening: tobacco

• Preventive care and screening: alcohol

• Weight assessment/nutrition counseling; physical activity for child/adolescent

• Child/adolescent: major depressive disorder (MDD)-suicide risk

• Adult: MDD-suicide risk

• Depression screening and follow-up plan

• Depression remission―12 months

b. State-reported measures (12 required)

• Housing status

• Follow-up after discharge from emergency department for mental health

• Follow-up after discharge from emergency department for substance use disorder

• Plan all-cause readmission rate

• Diabetes screening for individuals with schizophrenia or bipolar disorder using antipsychotic meds

• Adherence to antipsychotic medication for individuals with schizophrenia

• Adult (21+): Follow-up after hospitalization for mental illness

• Child/adolescent: Follow-up after hospitalization for mental illness

• Follow-up for children prescribed attention-deficit/hyperactivity disorder (ADHD) medication

• Antidepressant medication management

• Initiation/engagement of substance use disorder treatment

• Patient/family experience of care (survey measures)

c. Who is responsible for collecting quality data when care is covered by a managed care organization (MCO) or provided by a DCO?

2. How are quality measures data going to be used during the demonstration?

Probe for the following:

• Reporting to CCBHC

• Compliance monitoring

• Quality bonus payment

• Public reporting

• Other benchmarking

3. How has the state Medicaid office evaluated CCBHCs’ capacity to report quality measures?

a. Are quality measures a part of the electronic health record (EHR)?

b. Are there specific populations of interest?

c. Are the validity or timeliness of the data of concern?

d. Does the state have other systems in place for monitoring the quality of behavioral health care?

e. Do you anticipate a need for technical assistance among CCBHCs for reporting to state Medicaid agencies?

4. How will information on CCBHC quality measures be shared among various state agencies and with CCBHCs, consumers, families, and the public?

a. How will CCBHC quality data be shared between clinics, MCOs, state Medicaid offices, and state mental health departments?

5. Please describe the required quality reporting systems for Medicaid in your state.

Probe for the following:

• HEDIS?

• Adult and Child Core sets?

• What are the requirements for mental health?

• What are the requirements for substance abuse treatment?

• How is the information used to contribute to quality improvement?

• What has the state’s experience been with reporting in the past?

• Do you anticipate a need for technical assistance to CCBHCs related to quality reporting?

F. Cost and payment

1. What are current cost reporting requirements for community behavioral health clinics in the state?

a. What is the content of current cost reports?

Probe for the following:

-Cost of the CCBHC demonstration overall by year

b. How do these compare with CCBHC cost reports?

c. If new, what were the challenges in creating cost report templates and cost reporting systems and protocols?

Probe for the following:

• Total cost

• Cost by resource

• Cost per consumer/provider/encounter

d. What did the state or clinics learn during this process?

2. How does the PPS system for CCBHCs differ from existing funding mechanisms for behavioral health care in the state?

a. For example, how does the PPS system differ from existing funding mechanisms for CMHCs?

b. How does the PPS system for CCBHCs differ from existing funding mechanisms for specific types of behavioral health services?

Probe about the following:

• Peer support

• Day treatment/partial hospitalization programs

• Social services for people with serious mental illness

3. Are mental health or substance use disorder services covered by a Medicaid PPS-type system in your state (other than the CCBHC)?

Probe about the following:

• Mental health?

• Substance use disorders?

a. If yes, how does the CCBHC PPS compare with those systems?

4. What data sources were used to calculate the CCBHC prospective payment rates?

a. How were initial rates calculated for payment stratification by patient severity, outlier payments, and quality bonus payments?

b. To what extent was the state Medicaid office involved in the rate calculation process (for example, versus clinic and/or managed care entity involvement)?

c. Were there specific challenges to the rate-setting process?

- Costing the full scope of services?

-Incorporating managed care payments?

-Other challenges?

g. How were the quality bonus payment systems structured?

5. How are cost data being collected for rate setting? 

a. Please describe the cost data reporting requirements for CCBHCs.

b. Do you anticipate that CCBHCs will need further technical assistance on reporting costs?

c. How are outliers being defined and identified (PPS-2 only)? 

6. Do you anticipate any issues that may arise regarding payment of DCOs in your state through the CCBHC PPS?

1. How do the state and clinics handle billing if a client is receives services from more than one DCO in a single day?

7. Do you anticipate any issues that may arise with MCOs regarding payment?

a. How might these issues vary depending on the type of MCO?

b. How might issues vary depending on types of services provided?

c. For patients enrolled with multiple MCOs, how will your state ensure that duplication of MCO services or payments will not occur?

d. How will MCOs know what amount they are to pay to CCBHCs?

e. Have actuarial certification letters been revised or will they be revised to show how much of the capitation payment is associated with CCBHC services?

8. Do you anticipate any issues related to claims or PPS payments for dual enrolled (enrolled in both Medicaid and Medicare) populations? What about recipients of 1915(c) Waivers?

G. Data availability

1. How has your state established reporting requirements for CCBHC encounters?

a. How are CCBHC PPS claims reported and identified in claims data?

b. Is the state encouraging or requiring the use of the modifiers with the designated CCBHC HCPCS codes (T1040 and T1041)?

c. How are encounters recorded?

d. Does the state monitor utilization to identify potential unbundling of care; that is, care that should be covered by the PPS but is billed outside of the PPS?

e. How does the state monitor care provided by DCOs and payments to them?

2. What data are available to capture current consumer and payer spending across multiple providers and settings?

3. What data are available for measuring non-Medicaid or dual enrolled (enrolled in both Medicaid and Medicare) populations?

4. What is the timeline for the availability of claims and encounter data? 

5. What sources are available for comparison data (that is, national surveys)?

a. What populations would be good to use for comparison? For example, should we choose other providers or sites of care for comparison, or focus on other types of consumers?

b. How difficult will it be to identify and measure the comparison populations?

c. What challenges do you anticipate when we try to compare performance among the states? For example, similar services may be coded differently by different states.

d. Are historical data available to use as comparison?

e. Can you provide any good examples of linking multiple data sources to get current information?

f. Can you provide any bad examples of linking data sources to get current information?

H. Interviewee feedback/open discussion

1. What information have we missed? What else do we need to know that we haven’t asked you?

2. Is there anyone else from the state Medicaid office who should be included in these interviews?

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