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.


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