Children's DRAFT Network Standards (Rev 2/1/16)

Children´s Health and Behavioral Health MRT Feedback Request

• Standards also available in Portable Document Format (PDF, 335KB)

Please review the attached network standards which are in development for the children´s service system that will transition to Medicaid Managed Care. Feedback should be returned by Friday, February 19, 2016 to Rachel.Fitzpatrick@omh.ny.gov.

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Network Standards

(From model contract section 21.19 Mental Health and Substance Use Disorder Services)

"a) The Contractor will include a full array of mental health, Substance Use Disorder Services, health providers for medically fragile children and foster care providers OR combined licensure/designation providers in its networks, in sufficient numbers to assure accessibility to Benefit Package services for both children and adults, using either individual, appropriately licensed practitioners or New York State Office of Mental Health (OMH), Office of Children and Family Services (OCFS), Department of Health (DOH) and Office of Alcohol and Substance Abuse Services (OASAS) licensed programs and clinics,.

b) The State defines mental health and Substance Use Disorder Services providers to include the following: Individual Practitioners, Psychiatrists, Psychologists, Psychiatric Nurse Practitioners, Psychiatric Clinical Nurse Specialists, Licensed Certified Social Workers, Licensed Mental Health Counselors, Licensed Family and Marriage Counselors, OMH and OASAS Programs and Clinics, and providers of mental health and/or Substance Use Disorder Services certified or licensed pursuant to Article 31 or 32 of the Mental Hygiene Law, as appropriate."

Minimum network standards for each service type are shown in Table 1.

Table 1. Minimum Network Standards by Service Type

Note: In many areas, these minimum standards will not be adequate to meet members' needs for access.

Service	Urban Counties	Rural Counties1
OMH
Outpatient Clinic – licensed to serve children and adolescents	The higher of 50% of all licensed clinics or minimum of 2 per county	The higher of 50% of all licensed clinics or minimum of 2 per county
Outpatient Clinic – licensed for children only	The higher of 50% of all licensed clinics or minimum of 2 per county	The higher of 50% of all licensed clinics or minimum of 2 per county
State Operated Outpatient Programs	All in county	All in region
Article 28 Hospitals – licensed for children only	All in county (if none in county, then in neighboring county)	All in region
Partial Hospitalization	2 per county where available	All in region where available
State Psychiatric Centers - licensed for children only	All in region	All in region
Residential Treatment Facility	All in region	All in region
Day Treatment and IPRT serving youth	50% of Day Treatment/IPRT, contracting with IPRT first	50% of Day Treatment/IPRT, contracting with IPRT first
Comprehensive Psychiatric Emergency Program & 9.39 ERs – child specific	All per county	All per region
OASAS
Opioid Treatment Programs	All per county and	All per region
for NYC – all in the City
Inpatient Treatment	2 per county	2 per region
Detoxification (including Inpatient Hospital Detoxification, Inpatient Medically Supervised Detoxification, and Medically Supervised Outpatient Withdrawal	2 per county	2 per region
Outpatient Clinic	The higher of 50% of all licensed clinics or minimum of 2 per county	The higher of 50% of all licensed clinics or minimum of 2 per county
Rehabilitation services for residential SUD treatment supports (RRSY)	All per county	All per region
Buprenorphine prescribers	All licensed prescribers serving Medicaid patients	All licensed prescribers serving Medicaid patients
Cross Agency – State Plan Services	Urban	Rural
Crisis Intervention	All per county	All per region
Community Psychiatric Supports and Treatment (CPST)	2 per county	2 per region
Other Licensed Practitioner	2 designated agencies per county	2 designated agencies per region
Family Peer Support Services	50% OR 2 per county where available	2 per region where available
Youth Peer Advocacy and Training	50% OR 2 per county where available	2 per region where available
Psychosocial Rehabilitation	2 per county	2 per region
Cross Agency - HCBS Services	Urban	Rural
HCBS Care Coordination (for children who may not meet Health Home criteria)	50% OR 2 per county	2 per region
Caregiver/Family Supports and Services	2 per county	2 per region
Skill Building	2 per county	2 per region
Crisis Respite	2 per county	2 per region
Planned Respite	2 per county	2 per region
Prevocational Services	2 per county	2 per region
Supported Employment	2 per county	2 per region
Community Advocacy and Support	2 per county	2 per region
Habilitation	2 per county	2 per region
Adaptive and Assistive Equipment and Accessibility Modifications	2 Fiscal Intermediaries per county	2+A33:C37 Fiscal Intermediaries per region

Appointment Availability

The Contractor shall comply with the appointment availability standards and definitions in the model contract. These are general standards and are not intended to supersede sound clinical judgment as to the necessity for care and services on a more expedient basis, when judged clinically necessary and appropriate. Table 2 illustrates how appointment availability standards apply to each BH service type.

Table 2. Appointment Availability Standard by BH Service Type

Service Type	Emergency	Urgent	Non-urgent MH/SUD	BH Specialist	Follow-up to emergency or hospital discharge	Follow-up to residential services or detention discharge	Foster Care
MH Outpatient Clinic		Within 24 hrs	Within 1 wk		Within 5 days of request	Within 5 days of request
Day Treatment and IPRT that serve children				2-4 wks
Partial Hospitalization					Within 5 days of request
Inpatient Psychiatric Services	Upon presentation
CPEP	Upon presentation
OASAS Outpatient Clinic		Within 24 hrs	Within 1 wk of request		Within 5 days of request	Within 5 days of request
Detoxification	Upon presentation
SUD Inpatient Rehab	Upon presentation	Within 24 hrs
Opioid Treatment Program		Within 24 hrs	Within 1 week of request		Within 5 days of request	Within 5 days of request
Residential Rehabilitation Services for Youth (RRSY)	Upon presentation	Within 24 hours		2-4 wks	Within 5 days of request	Within 5 days of request
Cross Agency - State Plan Services
Crisis Intervention	Within 1 hour				Within 24 hrs of MCI response		within 1 hour
Community Psychiatric Supports and Treatment (CPST) – intake/assessment/treatment plan within 72 hrs		Within 24 hrs (for intensive in home and crisis response services under definition) 5 days for adults	Within 7 days of intake 2 weeks for adults		Within 72 hours of discharge 5 days for adults	Within 72 hrs 5 days for adults	Within 72 hrs
Other Licensed Practitioner		Within 24 hrs of request	Within 7 days of intake	Within 7 days of request	Within 72 hours of request	Within 72 hrs of request	Within 72 hrs of request
Family Peer Support Services			Within 1 weeks of request		Within 72 hours days of request 5 days for adults	Within 72 hrs of request 5 days for adults
Youth Peer Advocacy and Training		Within 24 hrs of request	Within 1 week of request		Within 72 hours of request 5 days for adults	Within 72 hrs of request 5 days for adults
Psychosocial Rehabilitation		Within 5 days of request	Within 1 week of request 2 weeks for adults	Within 1 week of request 2 weeks for adults	Within 72 hours of request 5 days for adults	Within 72 hours of request 5 days for adults	Within 72 hours of request 5 days for adults
Cross Agency HCBS Services
HCBS Care Coordination (for children who may not meet Health Home criteria)	Within 24 hrs	Within 72 hrs	Within 7 days		Within 72 hrs(or discharge from residential)	Within 72 hrs (header in column not appropriate for children – juv deten)	Within 24 hrs
Caregiver/Family Supports and Services			Within 1 week of request		Within 5 days of request	Within 5 days of request	Within 5 days of request
Skill Building			Within 1 week of request Adults are 2 weeks	Within 1 week of request Adults are 2 weeks
Crisis Respite	Within 24 hrs of request	Within 24 hrs of request			Within 24 hrs of request	Within 24 hrs of request	Within 24 hrs of request
Planned Respite			Within 7 days of request	Within 7 days of request	7 days of request	Within 7 days of request	Within 72 hours of request
Prevocational Services			Within 2 weeks of request	Within 2 weeks of request
Supported Employment			Within 2 weeks of request	Within 2 weeks of request
Community Self-Advocacy and Support			Within 5 days of request	Within 5 days of request
Habilitation			Within 2 weeks	Within 2 weeks
Adaptive and Assistive Equipment			Within 2 weeks of request	Within 2 weeks of request
Accessibility Modifications			Within 2 weeks of request	Within 2 weeks of request

Travel Time Standards

Plans must conduct geographic access analyses per the standards in Section 15.5.c of the MCO Model Contract specific to each BH category of service. Travel time/distance to specialty care, hospitals, and behavioral health providers shall not exceed thirty (30) minutes/thirty (30) miles from the member´s residence.

Transport time and distance in rural areas to specialty care, hospitals, and mental health providers may be greater than thirty (30) minutes/thirty (30) miles from the member's residence if based on the community standard for accessing care or if by member´s choice.

Initial Network Development in Rural Counties (from Adult BH Policy Guidance to MMC Plans)

1. Rural County Definition
   For the purpose of network development, a rural county is defined as one with a population of fewer than 200,000 inhabitants.
   
   Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Montgomery, Ontario, Orleans, Oswego, Otsego, Putnam, Rensselaer, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington, Wayne, Wyoming, and Yates are rural counties.
2. Region Definition
   For the purpose of determining the adequacy of the Contractor's network in rural counties and for Essential Community Behavioral Health Providers, a region is defined as the catchment area beyond the border of a county, which includes the other counties of the State designated Regional Planning Consortium (RPC) region.
   
   

   Regional Planning Consortium Regions
   Western NY	Allegany, Cattaraugus, Chautauqua, Erie, Niagara, Orleans, Genesee, Wyoming
   Finger Lakes	Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates
   Southern Tier	Broome, Chenango, Delaware, Tioga, Tompkins
   Central NY	Cayuga, Cortland, Madison, Oneida, Onondaga, Oswego
   Mohawk Valley	Fulton, Herkimer, Montgomery, Otsego, Schoharie
   North Country	Clinton, Essex, Franklin, Hamilton, Warren, Washington
   Tug Hill Seaway	Jefferson, Lewis, St. Lawrence
   Capital Region	Albany, Columbia, Greene, Saratoga, Schenectady, Rensselaer
   Mid-Hudson	Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester
   Long Island	Nassau, Suffolk
   New York City	Kings, Queens, Richmond, Bronx, New York

3. Meeting Network Requirements in the Case of Insufficient County Providers
   If the providers in the county are insufficient to meet network requirements, MCOs must first contract with providers in neighboring counties to meet network requirements. If this is still insufficient, the MCO must then contract with providers within the RPC region. Consistent with current DOH approval processes, if the providers in the RPC region are insufficient to meet the minimum network requirement for the service, or the demand in the service area, the MCO must contract with providers in the next contiguous service area. For example, if an MCO service area includes Rensselaer County, and the Capital Region RPC has an insufficient number of Opioid Treatment Programs to meet the demand of the enrollees, then the MCO must contract with providers from the Mohawk Valley Region, North Country Region or Mid-Hudson Region, or any combination of regions, to build a sufficient network.
4. Reimbursement of Non-Participating Providers in the Case of Inadequate Network
   MCOs whose networks are inadequate, whether due to an insufficient number of contracts or an insufficient number of available appointments, will be required, upon enrollee request, to permit enrollees eligible for services to receive services at a non-participating provider and reimburse those providers at no less than the Medicaid Fee for Service (FFS) rate.

Glossary

"BH Specialist"- An individual with an advanced degree in the mental health or addictions field who holds an active, unrestricted license to practice independently or an individual with an associate´s degree or higher in nursing who is a registered nurse with three years of experience in a mental health or addictions setting. Throughout the request for qualifications, the BHP will be specified as either a New York State or U.S. BHP. When specified as a New York State BHP, the individual must hold an active, unrestricted license to practice independently in New York State or be a registered nurse in New York State. When specified as a U.S. BHP, the individual may meet the licensure requirement with an active, unrestricted license to practice independently or be a registered nurse in any state in the U.S.

"Emergency Services" means health care procedures, treatments or services needed to evaluate or stabilize an Emergency Medical Condition including psychiatric stabilization and medical detoxification from drugs or alcohol

"Urgently Needed Services" means covered services that are not Emergency Services as defined in this Section, provided when an Enrollee is temporarily absent from the Contractor´s service area, when the services are medically necessary and immediately required: (1) as a result of an unforeseen illness, injury, or condition; and (2) it was not reasonable given the circumstances to obtain the services through the Contractor's MMC or FHPlus Participating Provider.

"Non-Urgent Services" Do not present an immediate need but are clinically indicated as necessary such as "sick" visits, routine appointments, preventative appointments, or other non-emergent health care visits made allowing access to appropriate care.

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^{1. NYS public health law defines a rural county as any county having a population of less than 200,000.1}