DMAS UPDATE ONGAP PROGRAM

Cindi B. Jones, Director, DMASHouse Appropriations Committee

September 18, 2017

Bridging the Mental Health Coverage GAP

The Governor’s Access Plan 1 of a 10 point action plan

toward A Healthy Virginia A targeted benefit package

for uninsured, low income Virginians with a SMI diagnosis

Provides basic medical and behavioral health care services through an integrated and coordinated delivery model

GAP Demonstration Goals To improve access to health

care for a segment of the uninsured population in Virginia who have significant behavioral and medical needs;

To improve health and behavioral health outcomes of demonstration participants; and,

To serve as a bridge to closing the insurance coverage gap for uninsured Virginians.

GAP’s Inception

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Bridging the Mental Health Coverage GAPEligibility & Enrollment

Requirements

Ages 21 through 64

U.S. Citizen or lawfully residing immigrant

Not eligible for any existing entitlement program

Resident of VA

Income below 80%* of Federal Poverty Level (FPL) (*80% + 5% disregard)Effective 10/1/2017, Income below 100%* of FPL (*100% + 5% disregard)

Uninsured

Does not reside in long term care facility, mental health facility or penal institution

Screened and meet GAP SMI criteria

GAP application is a two step process:• Financial/non-financial determination with Cover

Virginia• GAP SMI determination with Magellan

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GAP Enrollment12,338 (266 localities represented)

16,329 Enrolled since 1/12/2015

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GAP Enrollment

5

202

708 784 997

1,822 2,249

2,426

3,150

0

500

1000

1500

2000

2500

3000

3500

Eastern Valley Southside Northern West Central Southwest Central HamptonRoads

GAP Members of the Commonwealth by Regions

GAP Enrollment by Gender and Age Group

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Who are our GAP members?

0

500

1000

1500

2000

2500

3000

3500

21 - 30 31 - 40 41 - 50 51 - 60 61 - 65

11581546

18991421

135

1450

16851573

1076

90

GAP Members by Gender and Age Group

MaleFemale

Primary Diagnosis of GAP Members

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Service Authorizations

8

0

20

40

60

80

100

120

140

Bipolar Disorders Major DepressiveDisorders

Panic Disorderw/h Agorabphobia

Panic Disorderwithout

Agoraphobia

PosttraumaticStress

PsychoticDisorders

Schizophrenia

Community MH Rehab Service/(Crisis Intervention) Community MH Rehab Service/(Crisis Stabilization)

Community MH Rehab Service/(Psychosocial Rehab) GAP Case Management

Substance Abuse Day Treatment for Pregnant Women Traditional Outpatient/(Psychotherapy, 45-mins)

Enrollment & ProjectionsHow are we doing?

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

1/1/

2015

2/1/

2015

3/1/

2015

4/1/

2015

5/1/

2015

6/1/

2015

7/1/

2015

8/1/

2015

9/1/

2015

10/1

/201

5

11/1

/201

5

12/1

/201

5

1/1/

2016

2/1/

2016

3/1/

2016

4/1/

2016

5/1/

2016

6/1/

2016

7/1/

2016

8/1/

2016

9/1/

2016

10/1

/201

6

11/1

/201

6

12/1

/201

6

1/1/

2017

2/1/

2017

3/1/

2017

4/1/

2017

5/1/

2017

6/1/

2017

7/1/

2017

8/1/

2017

9/1/

2017

10/1

/201

7

11/1

/201

7

Actual GAP Enrollment

Adjusted Projection GAPEnrollment

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Monthly Calls Received at the Cover Virginia E&E Customer Service Unit

0

500

1000

1500

2000

2500

3000

3500

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

2016

2017

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June Total: 1,902 Calls

July Total: 1,999 Calls

Monthly GAP Applications Received by Cover Virginia

0

200

400

600

800

1000

1200

Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

2016

2017

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June Total: 668 Applications

JulyTotal:778 Applications

0

500

1000

1500

2000

2500

3000

QTR 12017

QTR 12016

QTR 22017

QTR 22016

QTR 32017

QTR 32016

QTR 42017

QTR 42016

# Rec'd

Approved

Denied

Rejected

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Monthly SMI ScreeningsProcessed by Magellan

June Total: Received- 970Approved- 693Denied- 87Rejected- 152

July Total: Received- 809Approved- 551Denied- 82Rejected- 112

GAP Service Utilization

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Medical Services

12033

7831 8205

0

2000

4000

6000

8000

10000

12000

14000

Total enrollment Members who accessed Medical Services(June)

Members who accessed Medical Services(July)

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Pharmacy Information-Project Total

2016

2017

Magellan Recovery NavigatorsEnrollment (as of 07/31/2017)

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For the month of June, there were 117members receiving Recovery Navigation, of which:

• 25 were new enrollees• The average days in program = 146• 46 are homeless or at risk of

homelessness• 2 ER visit reported this month

For the month of July, there were 125members receiving Recovery Navigation, of which:

• 26 were new enrollees• The average days in program = 143• 44 are homeless or at risk of

homelessness.• 4 ER visits reported this month

88

125

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Not Enrolled in Rec. Nav. Supports(unreachable or declined)

Current Rec. Nav. Enrollment

Previously Enrolled, now D/C'd

Magellan Recovery NavigatorsSupports Delivered (as of 07/31/2017)

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Members received the following supports from Recovery Navigators:• Emotional- Recovery navigator

demonstrates empathy, caring or concern to bolster members’ self-esteem and confidence

• Affiliation- Facilitating contacts with other people to promote learning skills, create community and acquire a sense of belonging

• Informational- Sharing knowledge and information and/or providing life or vocational skills training

• Instrumental- Providing concrete assistance to help members accomplish tasks

0

10

20

30

40

50

60

70

80

Support Type -EMOTIONAL

Support Type -AFFILIATIONAL

Support Type -INFORMATIONAL

Support Type -INSTRUMENTAL

76

8

64

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GAP Update- Recovery Navigators

A 50 year old GAP member with a diagnosis of Major Depressive Disorder was referred for recovery navigation following crisis stabilization. The member had four previous suicide attempts in his life and has an extensive family history of suicide, with eight family members having committed suicide.

At the time of referral, he reported that he didn’t have any goals for himself and that he isolates. Over the next several months, the member engaged in Recovery Navigation, GAP Care Coordination, behavioral health services and medical services. He began attending NAMI meetings and has taken on leadership roles within his local NAMI chapter.

In December, the member was approved for disability and has transitioned out of GAP coverage. In March 2017, he applied and was accepted to participate in the DBHDS Peer Recovery Specialist training. He successfully completed the 72 hour training course and is able to provide support for others. He now reports seeing work as a possibility for himself.

Success Story from the Navigator’s Eyes

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Outreach Challenges DMAS is partnering with BHSA to enhance the

Tracfone care message program to send text messages with reminders of benefit renewal as well as recovery and resiliency messaging to GAP members .

DMAS GAP staff have been participating in HB2183 workgroup to address barriers and plan to increase Medicaid and GAP benefit upon release for incarcerated individuals.

DMAS GAP staff are working with ARTS staff to train Virginia Hospital and Healthcare Association members on ARTS/GAP and changes to covered services.

DMAS GAP staff are working closely with Community Services Boards and Federally Qualified Health Centers regarding SMI screenings and service delivery for GAP members.

Comprehensive care coordination for GAP members due to: Transient and highly mobile population Reluctance to engage in service

delivery BHSA limited familiarity with medical

service delivery system Medical FFS provider network lack of

familiarity with GAP and covered benefits.

CMS requires an independent external evaluation which will be challenging due to resources.

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GAP Outreach Activities

GAP staff attended House Bill 2183 Workgroup meetings in May, June, July. On 7/25/2017, the workgroup reviewed draft recommendations: drafting a screening form for jail intake staff to identify potential Medicaid applicants, create a electronic data match.

DJJ/DOC/Compensation board and developing communication process to notify local agencies when member is incarcerated. The Workgroup discussed using COVER VA as a central processing location for applications and discussed how this has worked well for GAP members. The Workgroup discussed the decreased administrative burden of billing for hospital procedures and finding DSS staff who are knowledgeable about this population if recommendations move forward.

Increased awareness in the community and extensive outreach to Jails/DOC

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Collaboration with Department of Corrections (DOC) and Jails

GAP Outreach Activities

No computers to access GAP application

Cannot estimate volume for CSBs to perform screenings

Only 40% CSBs have contracts with jails to provide services; screening may not be part of it

CSBs are primary screeners but are challenged to have the resources to hire qualified personnel

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Challenges with Jails and Department of Corrections (DOC)

Legislative Updates

GAP Regulations were revised to account for program changes mandated by the 2017 General Assembly.

Program changes include increasing the eligibility from 80 – 100% of the Federal Poverty Level; adding partial day hospitalization and residential treatment services for substance use disorder, and; modifying Recovery Navigation, provided by the BHSA, adding Peer Support Services provided by licensed private providers.

The Final proposed regulation package has now been submitted to the Office of the Attorney General for review.

The 2017 General Assembly passed significant funding measures to strengthen the mental health care system including $2 million in new funding to expand the GAP household income allowance to 100% of the FPL and to include Addiction, Recovery and Treatment Services’ residential and partial hospitalization services in the demonstration waiver. Both items are effective for GAP member beginning October 1, 2017.

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Bridging the Mental Health Coverage GAP

Integrating care coordination, primary care, specialty care, pharmacy and behavioral health services

Outpatient MedicalOutpatientBehavioral

Health

Magellan Only Services

Substance Abuse Services

Primary & Specialty Care GAP Case Management Care Coordination;Community Wellness/CommunityConnection

• Screening Brief Intervention and Referral to Treatment

• Intensive Outpatient• Outpatient

Laboratory Psychiatric Evaluation, Management and Treatment

Crisis Line available 24/7 Opioid Treatment Programs

Pharmacy Crisis Intervention andStabilization

Recovery Navigation Office Based Opioid Treatment

Diagnostic Services• Physician’s office• Outpatient hospital coverage limited to:

diagnostic ultrasound, diagnostic radiology (including MRI and CAT) and EKG including stress

PsychosocialRehabilitation

Effective 7/1/2017MH and ARTS Peer Supports

Effective 10/1/2017Partial Hospitalization, Residential and Inpatient Psychiatric Services

Diabetic Supplies Outpatient Psych

GAP Benefits

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For more information, please contact:

BridgetheGAP@dmas.virginia.gov

http://www.dmas.virginia.gov/Content_pgs/gap.aspx