Plans are obligated to have a network sufficient to meet enrollee needs. The following provisions apply to all MAP Plans regardless of size and enrollment numbers unless otherwise specified.

A. All MAP Plans must:

1. Contracting Requirements
   1. Contract with clinics holding a State Article 31 and Article 32 license1 for the full range of services available pursuant to that license.
   2. Offer contracts with all BH crisis intervention programs2 within the MAP Plan service area.
   3. Offer contracts to all BH providers seeing five or more of their enrollees in the Plan's service area based on the initial list provided by the State and continue to monitor out of network single case agreements to identify any additional providers seeing five or more of their enrollees and offer contracts as appropriate for 24 months.
   4. Ensure individuals enrolled beginning January 1, 2023, and after can continue to see their BH provider for a continuous episode of care3 for up to 24 months. This includes allowing HARP eligible enrollees to continue accessing the same Health Home provider and not requiring enrollees to change Health Homes at the time of the transition.
   5. Accept the State-issued CORE designation in place of, and not in addition to, any MAP Plan credentialing process for individual employees, subcontractors, or agents of such providers when credentialing Community Oriented Recovery and Empowerment (CORE) Service providers. The MAP Plan shall still collect and accept program integrity related information from these providers and shall require that such providers not employ or contract with any employee, subcontractor or agent who has been debarred or suspended by the federal or state government, or otherwise excluded from participation in the Medicare or Medicaid program.
   6. Accept OMH and OASAS licenses, operation, designation, and certifications in place of, and not in addition to, any Contractor credentialing process for individual employees, subcontractors, or agents of such providers when credentialing OMH-licensed, OMH-operated, OMH-designated, or OASAS-certified providers, the MAP Plan shall. The MAP Plan shall still collect and accept program integrity related information from these providers and shall require that such providers not employ or contract with any employee, subcontractor or agent who has been debarred or suspended by the federal or state government, or otherwise excluded from participation in Medicare or Medicaid.
   7. Offer contracts to all OASAS Opioid Treatment Program providers within the counties in the MAP Plan's service area.
   8. Update and maintain their provider manual to include all relevant information on BH services and BH-specific provider requirements as applicable to the MAP product line. New York State will provide guidance for this requirement at a later date.
2. Reimbursement Requirements
   1. Reimburse non-participating Comprehensive Psychiatric Emergency Program (CPEP) providers at the same rate as participating providers. CPEP is an emergency service; MAP Plans may not require prior authorization for CPEP.
   2. Reimburse any BH crisis intervention program, regardless of network status. Payment for crisis intervention services by non-participating providers will be at the same rate as for participating providers.
   3. Reimburse participating and non-participating OMH-licensed, OASAS-certified, and OMH and/or OASAS designated BH providers at the Medicaid government rate or higher for Medicaid-only reimbursable services. The government rate reimbursement floor is mandated until March 31, 2027, pending further extension.
   • Continuous ongoing Medicaid-only services of care must be reimbursed at the Medicaid rate or higher (i.e., "the government rate").

B. MAP Plans without an affiliated Mainstream/HARP product must also:

1. Conduct provider training for newly contracted BH providers to ensure they have appropriate knowledge, skills, and expertise, and receive technical assistance to comply with managed care requirements. This includes, but is not limited to, training on:
1. Billing (including claims testing), coding, data interfaces and claiming resources/contacts, in alignment with the NYS Medicaid Advantage Plus Plans Behavioral Health Billing and Coding Manual.
2. UM requirements and documentation requirements.
3. Evidence-based/promising practices and recovery principles.

C. BH Network Standards for MAP Plans with More Than 1,000 Enrollees

MAP Plans with more than 1,000 enrollees must meet all network and appointment availability standards for benefits listed in the table below. At least fifty percent (50%) of the network standards for each service must be met by January 1, 2023. It is expected MAP Plans will meet 100 percent of network requirements by January 1, 2024. MAP Plans must execute Single Case Agreements with any providers where there are network gaps for services between January 1, 2023, through January 1, 2024. These requirements apply to the MAP Plan's service area.

MAP Plans with fewer than 1,000 enrollees must monitor their enrollment. At such time that enrollment exceeds 1,000 enrollees the MAP Plan must meet network adequacy requirements described in section 1.0 A within six months.

MAP Plans must manage the BH benefits and meet the needs of enrollees with serious mental illness, substance use issues, and/or co-occurring physical health challenges. MAP Plans must therefore submit materials to NYS demonstrating they have the personnel and structural capacity to ensure the delivery of effective BH care. The following provisions apply to all MAP Plans regardless of size and enrollment numbers unless otherwise specified.

1. MAP Plans must comply with Contract Personnel Sections 3.3 A, D, H, and M of the New York Request for Qualifications (RFQ) for Adult Behavioral Health Benefit Administration: Managed Care Organizations and Health and Recovery Plans.
2. MAP Plans must meet BH Staffing Requirements as follows:
   1. Health Plans offering MAP that also have an existing Mainstream MMCO, HARP and/or HIV-Special Needs Plan must attest the MMCO and/or HARP BH Key and Managerial Personnel will manage all MAP enrollee BH services. MAP Plans must submit a narrative describing how staff will collaborate across business lines to address MAP enrollee BH needs. If the MAP Plan intends to meet the below requirements in sections 2 and 3 in a different way than outlined above, the MAP Plan must provide a narrative describing their method of managing BH personnel.
   2. Health Plans offering MAP that do not have an affiliated MMCP, HARP or HIV- Special Needs Plan, or those not using existing health plan staff, with more than 4,000 enrollees meeting HARP target criteria and risk factors11 must:
      1. Employ the following Personnel at a 1.0 FTE dedicated to MAP:
         1. BH Medical Director
         2. BH Clinical Director
         3. Manager(s) to fulfill BH Care Management (CM) and BH Utilization Management UM functions defined below in BH Personnel Requirements.
      2. Submit BH Medical Director and BH Clinical Director résumés to ensure appropriate experience and license requirements are met as defined below in BH Personnel Requirements.
      3. In addition to RFQ requirements regarding personnel vacancies, MAP Plans must notify NYS of key BH CM and/or UM personnel changes or if positions(s) become vacant within seven calendar days. MAP Plans must direct these notifications to:
         • Office of Mental Health BHO Mailbox: BHO@omh.ny.gov
         • Office of Addiction Services and Supports BH MMC Mailbox: OASAS.SM.BehavioralHealthMMC@oasas.ny.gov, and
         • MLTC Plan Managers
      4. MAP Plans without an affiliated MMCP, HARP or HIV- Special Needs Plan, with fewer than 4,000 enrollees meeting HARP target criteria and risk factors can either comply with #2 above or submit an alternate staffing plan detailing how the MAP Plan will address BH CM and UM requirements defined below in BH Personnel Requirements.
         1. MAP Plans must notify NYS when a State-approved alternate staffing plan is revised, including changes to, or vacancies in, key BH CM and/or UM personnel. Notifications should be directed to:
         • Office of Mental Health BHO Mailbox: BHO@omh.ny.gov
         • Office of Addiction Services and Supports BH MMC Mailbox: OASAS.SM.BehavioralHealthMMC@oasas.ny.gov, and
         • MLTC Plan Managers
3. MAP Plans must submit organizational chart(s) clearly outlining how BH staff will be integrated into existing organizational structures.
4. MAP Plans must explain how BH expertise12 is incorporated into the Interdisciplinary Care Team to demonstrate coordination with physical health and long-term care management.
5. MAP Plans must ensure staff are trained in accordance with the MAP Plan Staff Training Requirements on page 14.

BH Personnel Requirements:

1. BH Medical Director: This individual must hold a NYS license as a physician and shall have a minimum of five years of experience working in BH managed care settings or BH clinical settings (at least two years must be in a clinical setting). The Plan BH Medical Director shall have appropriate training and expertise in general psychiatry and/or addiction disorders (e.g., board certification in general psychiatry and certification in addiction medicine or certification in the subspecialty of addiction psychiatry). This individual must be located in NYS.
2. BH Clinical Director: This position must be reflected in the Plan's organizational chart and the identified individual must have appropriate managerial experience. The individual shall hold a NYS license as a BH professional2 and have at least seven years of experience in a BH managed care setting or BH clinical setting, including at least two years of managed care experience (preferably Medicaid managed care). This individual must be located in NYS.
3. The BH Medical Director and Clinical Director shall be involved in the following functions:
   1. Development, implementation, and interpretation of clinical-medical policies and procedures specific to BH or which can be expected to impact the health and recovery of BH consumers.
   2. Ensuring strong collaboration and coordination between physical and BH care.
   3. Clinical peer review recruitment and supervision.
   4. Provider recruitment, education, training, and orientation.
   5. Decision-making process for BH provider credentialing decisions.
   6. BH provider quality profile design and data interpretation.
   7. Development and implementation of the BH sections of the Quality Management (QM)/Utilization Management (UM) Plan, including having the BH medical director participate in QM committees.
   8. Administration of all BH QM/UM and performance improvement activities, including grievances and appeals.
   9. Attendance at regular (at least quarterly) Plan leadership and medical director meetings designated by the State BH contract manager.
4. BH Care Management and BH Utilization Management Managerial Positions:
   1. BH care management: Plans shall provide CM to individuals with Serious Mental Illness (SMI), Substance Use Disorder (SUD), co-occurring physical health, co-occurring disorders of MH and SUD, and co-occurring MH and/or SUD disorders and Intellectual and Developmental Disability (I/DD) in collaboration with Health Homes when appropriate. This individual must be a U.S. based BH professional with experience working in a BH managed care setting or BH clinical setting and must work at sites located in NYS.
   2. BH utilization management: Plans shall provide UM to individuals with SMI, SUD, co-occurring physical health, co-occurring disorders of MH and SUD, and co-occurring MH and/or SUD disorders and I/DD. This individual must be a U.S. BH professional with experience working in a BH managed care setting or BH clinical setting and knowledge of BH rehabilitation and recovery services. This position may work at sites located outside NYS.
   3. The BH CM and UM managerial positions above must comply with the following requirements:
      1. Mental Health Services: All managerial staff must demonstrate knowledge (or describe a plan to recruit individuals with knowledge) of the full range of NYS MH services, programs, and requirements. Ideally, the Plan should employ manager(s) with experience working in NYS BH settings that provide recovery-oriented services to individuals with serious BH conditions (e.g., Personalized Recovery Oriented Services, peer services, housing supports, Assertive Community Treatment, and supported employment). Managers should have knowledge of or experience with delivering research-based and evidence-based practices (EBP) for adults in clinical and/or recovery-oriented settings.
      2. Addictions Services: Plans shall demonstrate managerial knowledge (or describe a plan to recruit individuals with knowledge) of the full range of SUD services available to NYS Medicaid enrollees in one or more of the departments listed below. Ideally, the Plan should employ an individual at the manager level who meets the requirements for a Credentialed Alcoholism and Substance Abuse Counselor (CASAC) in good standing with OASAS and who has at least three years of experience in BH and a Master's degree. Additionally, expertise is required in the special needs of adults with a serious SUD with or without co-occurring mental illness. Managers should have knowledge of or experience with delivering research based and EBP for adults in clinical and/or recovery-oriented settings.

MAP Plans must:

1. Comply with the following sections of the New York Request for Qualifications (RFQ)for Adult Behavioral Health Benefit Administration: Managed Care Organizations andHealth and Recovery Plans:
   1. Utilization Management - Section 3.9 A-P, with the following exceptions:
      1. Section 3.9 B: The Table 1 referenced in 3.9 B is outdated. Please refer to the Utilization Management section of the OMH BHO Policy Guidance webpage and the Medicaid Managed Care Crisis Intervention webpage for the list of BH services covered by MAP Plans.
      2. Section 3.9 O: The Section 3.3 requirements referenced in 3.9 O do not apply to MAP Plans. This is superseded by the MAP BH Staffing Requirements in section 2.0 of this packet.
   2. Clinical Management - Section 3.10 B-G, with the following exception:
   1. Section 3.10 E: The referenced requirement for BH Medical Director participation is only applicable to a Health Plans that offers MAP as well as a Mainstream Medicaid Managed Care Plan, Health and Recovery Plan and/or HIV Special Needs Plan, or MAP-only Plans with more than 4,000 enrollees meeting HARP target criteria and risk factors13.
2. Comply with State-issued guidance for BH service administration, including future State-issued Crisis Stabilization Center guidance, pending Centers for Medicare and Medicaid Services approval.
3. Plans may use NYS approved UM protocols, in compliance with parity laws and NYS policy, to review duration and intensity of an episode of care.
   1. These may be applied to the newly carved-in BH services that do have previously issued NYS utilization review criteria guidance after the first 90 days following the inclusion of BH benefits to MAP Plans.
   2. These may be applied after the first 90 days post new enrollment, following the inclusion of BH benefits to MAP Plans for a period of 24 months.
4. MAP Plan will integrate BH services and BH considerations into the existing MAP Plan care management structure. This must encompass:
   1. Inclusion of BH services in MAP Plan care management responsibilities, including referral, assistance in or coordination of services for an enrollee to obtain needed BH services, irrespective of whether the needed services are included in the MAP Benefit Package.
   2. Process for enhanced coordination between specialty BH staff and primary care physicians and long-term care providers serving patients living with serious mental illness, addiction, and co-occurring physical health/long term care needs. This process must include the ability for BH CM and UM managers to access an enrollee's BH, physical health, and long-term care records and service usage, as necessary to meet the enrollee's needs to the extent allowed by law and regulation.
   3. Process for cross-training specialty BH, physical health and long-term care staff in treatment approaches and illness progression, enabling all staff to receive training outside their specialties.
   4. Training and support for long term care providers serving individuals with BH needs, including those with Serious Mental Illness (SMI) and Substance Use Disorder (SUD).
   5. Coordination of all enrollee care management activities, including internal care management, Health Home, and any other service care managers, to reduce redundancy and assure accurate information sharing.
   6. Process to ensure enrollees with Assisted Outpatient Treatment (AOT) court orders are easily identified in the MAP Plan's electronic record by UM and CM staff and the treatment aspects of the Court Order are addressed in the enrollees Plan of Care. Plans are expected to coordinate care with AOT court ordered service providers.
   7. Process to ensure that enrollee plans of care (POCs) include BH need and use a whole-person oriented, person-centered planning approach with health education/health promotion services in accordance with section 10.13 of the MAP Model Contract.
   8. Process to notify enrollees newly eligible to receive CORE Services upon meeting HARP target criteria and risk factors.
5. Adopt, disseminate, and implement the clinical practice guidelines listed below as well as nationally recognized clinical practice guidelines and other evidence-based and promising practices.
   1. Substance Abuse and Mental Health Services Administration (SAMHSA)'s ACT
   2. SAMHSA's Illness Management and Recovery
   3. SAMHSA's Integrated Dual Disorder Treatment for Co-occurring Disorders
   4. SAMHSA's Family Psychoeducation
   5. Tobacco cessation
   6. OMH First Episode Psychosis practice guidelines
   7. Seeking Safety
   8. Motivational Enhancement Therapy
   9. Twelve- Step Facilitation
   10. Cognitive Behavioral Therapy for SUD
   11. Medication Assisted Treatment for SUD
   12. Other SUD EBP as recognized by SAMHSA
6. Develop and implement a system to enable UM/CM staff to identify high-risk enrollees. UM/CM staff must address high-risk enrollees BH and social determinants of health needs through care coordination.
   1. At minimum, the system should include the following criteria to identify high-risk enrollees:
      1. Enrollees meeting HARP target criteria and risk factors identified by an RRE code
      2. Enrollees with a current or expired (within the prior five years) AOT order
      3. Discharge from a State Psychiatric Hospital, State Community Residence, or Adult Home
      4. New onset psychosis
      5. Homelessness
      6. Homebound
      7. Frequent psychiatric inpatient or detox usage
      8. Discharge from psychiatric inpatient unit at a general hospital
      9. Discharge from an emergency department for a BH-related condition
      10. Use of a BH crisis service
      11. History of suicide attempt
      12. Other criteria determined to indicate high risk

Combined Medicare Advantage and Medicaid Advantage Plus Benefit Package for Mental Health Services

Combined Medicare Advantage and Medicaid Advantage Plus Benefit Package for Substance Use Disorder Services

Combined Medicare Advantage and Medicaid Advantage Plus Benefit Package for Behavioral Health Services with Joint OMH and OASAS Oversight

NYS has partnered with the Managed Care Technical Assistance Center (MCTAC) to host webinars related to this transition. The behavioral health services carving into the MAP benefit package are described in the webinars listed below, along with additional information for MAP Plans.

Behavioral Health Carve-In to Medicaid Advantage Plus (MAP):

• Overview
• MCO Readiness
• Medical Necessity Criteria Review for MAP Plans
• Updated Guidance & Readiness Review Process

Questions related to this document may be sent to BHO@omh.ny.gov, and/or OASAS.SM.BehavioralHealthMMC@oasas.ny.gov, and MLTC Plan Managers