PROSPECTIVE PAYMENT SYSTEM

Presented by Gabriela Moroney

Illinois Department of Healthcare and Family Services

March 29, 2016

Prospective Payment System

  • The Protecting Access to Medicare Act of 2014
    • Established the Certified Community Behavioral Health Clinic (CCBHC) demonstration program.
    • Requires use of a Prospective Payment System (PPS) to pay selected clinics for CCBHC services provided to Medicaid enrollees.
  • PPS applies to CCBHC services delivered either directly by a CCBHC or through a Designated Collaborating Organization (DCO).

Selected PPS

  • Illinois will implement the Certified Clinic PPS Alternative, also known as PPS-2, a cost-based, per clinic monthly rate.
  • PPS-2 requires at least one visit in a month to trigger a payment.

PPS-2 Required Elements

Monthly rate to reimburse CCBHC for services

  • delivered to Medicaid enrollees.
  • Separate monthly rates to reimburse CCBHC for higher costs associated with providing all services needed to meet needs of clinic users with certain conditions.
  • Cost updates.
  • Outlier payments made in addition to PPS for participant costs in excess of thresholds defined by the state.
  • Quality bonus payments.

Special Populations

  • Illinois will establish monthly PPS rates that vary according to users' clinical conditions.
  • Populations under consideration include (but are not limited to):
    • Individuals with serious mental illness with degree of functional impairment.
    • Individuals with dually diagnosed mental illness and substance use disorder with degree of functional impairment.
    • Individuals with substance use disorder and comorbid complex medical conditions.
  • Input on special populations will be sought from Steering Committee and Information Advisory Council.

Quality Bonus Payments

  • Certain quality measures are required by federal Center for Medicaid Services (CMS), others are optional.
  • Illinois has option and intent to establish some additional quality measures, subject to CMS approval.
  • Input on quality metrics will be sought from Steering Committee and Information Advisory Council.

Cost-Based Rates

  • PPS-2 rates are cost-based.
  • Rates will be established through cost reports.
  • Rates will be updated through Medicare Economic Index and/or rebasing.

Cost-Based Rates

  • PPS-2 rates are cost-based.
  • Rates will be established through cost reports.
  • Rates will be updated through Medicare Economic Index and/or rebasing.

State Cost Report responsibilities

  • Develop cost report template to capture:
    • Costs, visits, and charges associated with demonstration services provided to all clinic users, not only Medicaid enrollees
    • Data to support cost allocation methods
    • Data about special populations
  • Secure federal approval for cost report template.

State Cost Report responsibilities

  • Selected CCBHCs complete cost report using:
    • Population-specific cost data
    • Knowledge of accrual-based accounting
    • Understanding of Medicaid and Medicare cost principles
    • Understanding of how to enumerate visits under PPS-2
  • CCBHC CEO, CFO, Director, or a direct delegate certifies the cost report.
  • Estimations are allowed for initial reporting of costs.

Clinical Capacity to Implement PPS-2

*This is only a sample; Illinois may develop unique template

Technical Assistance Opportunities

  • State receiving ongoing technical assistance from CMS.
  • State anticipates providing ongoing technical assistance to select CCBHCs to ensure straightforward implementation of PPS.

Summary of CCBHC Data Collection and Reporting Expectations

CCBHC States must demonstrate the capacity to collect and report data in two categories.

  • PPS claims and encounter data.
  • Quality Measure Data.
  • 17 CCBHC Required Quality Measures
  • 15 State Required Quality Measures
  • States must also Participate in National CCBHC Evaluation.

DATA & REPORTING

Summary of CCBHC Data Collection and Reporting Expectations

  • Tables containing required quality measures are provided in Appendix A (p.65) of the SAMHSA CCBHC RFA (SM-16-001).
  • Need for further information regarding quality measure operational definitions and reporting specifications.
  • It is expected that national evaluation contractor will be identified in January 2017.

Questions?

  • RFI Due 12:00pm April 6th
  • Questions