December 6, 2023
Good afternoon,
First, here’s some information direct from OMH related to school-based mental health clinic reimbursement changes for providers that operate these services:
Commercial insurers are required to add School Based Mental Health clinic services to their benefits beginning when the insurance plan (held by the beneficiary) renews on or after January 1, 2024. This means that some plans will cover the service beginning on January 1, if the plan renews at the beginning of the year, but others that renew at different points in the year will add the coverage later. So, the effective date of the provision is dependent upon the renewal of the member’s policy and therefore the APG rate requirement may become effective at a later date for out-of-network SBMHC services. That being said, OMH understands it is likely that most individual policies do renew on a Calendar Year (CY) basis. The implications are different depending on whether the provider is already participating in a plan network or not.
On the date that the law becomes applicable:
- For providers that are already participating in a plan’s network, the rate is the prior negotiated rate unless/until the provider renegotiates the provider agreement or stops participating with the plan.
- For providers that are not participating in a plan network, the plan must pay at the Medicaid rate (unless/until negotiation is finalized).
It’s also important to note that this law is applicable to NYS, fully insured plans. Self-funded plans are not required to comply with state laws. (One note – the Empire Plan is self-funded, but has voluntarily decided to comply with the law.) Also, if a New York resident is covered under a plan that is sold under another state, their plan would not be required to comply with our NY law because it is subject to the laws of the state where it was issued.
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Next, here’s some information on state budget-related OMH initiatives that we discussed with OMH leaders on one of our Thursday morning calls back in September. The specific topic was the Office’s plans to invest $20M (potentially grossing up to $40M with federal participation) to address and increase Article 31 Outpatient Clinic access to care, to reduce waiting lists, and put more money in the system. These funds were appropriated as part of the 22-23 enacted state budget. NOTE: The black ink is my note regarding the specific action to be taken by OMH, and the purple ink is an update on the status of the action described as of mid-November:
Regarding Clinic Start Up and Expansion Proposals
Item #1: Increase Article 31 Clinic Services availability with particular emphasis on hard to reach and underserved areas of state: Total investment between $2-3M with RFP going out December or January. Ten awards at $250k each. OMH is willing to entertain proposals that include capital expenditures although these funds are not designated as capital dollars. Will try to be flexible.
UPDATE: OMH is working on this RFA and thinkS the timeline is on track with what was stated in September (December or January). All the opportunities are being published with release dates: https://omh.ny.gov/omhweb/rfp/
Item #2: Another $4M (total) breaking down to about $50k per provider for @ 80 providers, to expand existing clinic capacity. RFA could come as early as October. Modest awards to many providers.
UPDATE: This RFA was released in Mid-October: https://omh.ny.gov/omhweb/rfp/2023/ceg/index.html
Quality Improvement Program (QIP)
- Currently about 80-90% of Article 31 providers are participating in the QIP and they are receiving a rate increase of just under 4% for their participation. Here, OMH would bump up the rate increase for participating providers to close to 6% with intentions to increase again in ’24-’25 to around 7%.
- At present time, @85% of all Article 31 Outpatient Clinic providers participate in the QIP. OMH intends to open this Program up to hospital-based clinics in hopes of increasing participation rates. (Hospitals involved in a different QIP at present time.)
- OMH will soon issue a Federal Participation Notice (FPN) to preserve (with CMS) its intention to implement this initiative.
UPDATE: The Federal Participation Notice (FPN) to raise the QI enhancement to 5.7% and expand the enhancement to hospital-based MHOTRS was published on 9/27/23. The SPA is on track to be submitted to CMS the last week of December 2023. Rates are moving through the approval process (can’t give you a date certain but the effective dates are preserved).
Paying More for Group Therapy services in Article 31 Clinics
· Intention is to pay more for Group Therapy services in Article 31 Clinics in hopes of reducing waiting lists/serving more individuals. Would include Group Therapy delivered by clinicians as well as group therapy by qualified peers.
· This proposal would increase the WEIGHT assigned to Group Therapy code by 50% (not the rate) but this results in increased reimbursement.
· OMHs experience is that making changes to the APG billing system is quite intricate and happens at certain times of the year and so (for expediency) OMH is exploring other ways to push this out other than via APG government rates.
UPDATE: OMH is on track to increase the weight for group services (both psychotherapy group and peer support services group) by 50% on 1/1/2024 for OMH providers using OMH MHOTRS rate codes. While the effective date is 1/1/24, keep in mind that managed care plans will be afforded time to program their systems. MCOs that use the 3M APG product will begin processing claims at this increased rate as soon as the update is made available by 3M which takes the form of a monthly download.
Crisis / Complex Services
· Hoping for an October implementation, however OMH is exploring ways to push these changes out through alternative vehicles other than via APG government rates since this takes time and could delay implementation.
· One of the goals is to simplify requirements to bill for Complex Care service.
UPDATE: OMH is increasing the number of units allowed in the 3M APG grouper for Collaborative Care from (4) 5-min units totaling 20 minutes to (18) 5-min units totaling 1 ½ hours. OMH is also working to eliminate the requirement of a psychotherapy/crisis/medication treatment service within 2 weeks prior to the complex care service for OMH providers using OMH MHOTRS rate codes. Finally, OMH is working on the provisions to allow crisis per diem and crisis – complex to be provided prior to admission to the MHOTRS program and evaluating potential regulatory amendments associated with such a change.
EBPs and Specialty Services
· Intention is to add funds to encourage use of evidence-based practices including DBT where reimbursement (at the present time ) does not cover additional groups.
· Office also intends to increase reimbursement for Neuropsychological Services.
· OMH recognition that providers need funds to train on use of EBPs. Specific information regarding % of increases here TBD.
UPDATE: Will get you an update on this one in the near future.———————————————
ICYMI: The Legislature has released their calendar for this coming year’s session. Find it here: https://nyassembly.gov/write/upload/leg/session_cal/session_calendar_2024.pdf
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Regarding the State Education Department – Office of the Professions forward movement on the new Diagnostic Privilege:
The regulation was proposed on 11/29 (we sent it to all members on the day it came out). There is a 45 day comment period. The NYS Council will issue formal comments.
See page 17 of the document at the link here:
https://dos.ny.gov/system/files/documents/2023/11/112923.pdf
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The Office of Mental Health held a Town Hall last week.
The slides from the event are attached for your reference and the recording is available here.
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