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Office of Mental Health

Policy and Guidance for Plans and Providers

Medicaid Managed Care Model Contract and Provider Agreements

New York State Department of Health Information for Medicaid Managed Care Plans Leaving OMH site

Please note that the revisions to the Medicaid Managed Care Model Contract related to the behavioral health transition are pending CMS approval, and are therefore not reflected in the version currently posted on the DOH website.

Health Home and Medicaid Managed Care Contracting

Health Home Administrative Agreement PDF DocumentLeaving OMH site - October 2015
Health Homes and Medicaid Managed Care Organizations can use this document to enter into Contractual Agreements.

Health Home Standards Document PDF DocumentLeaving OMH site - October 5, 2015
Explains and clarifies the roles and responsibilities of Lead Health Homes, downstream Care Management providers and Medicaid Managed Care Organizations (MCOs) for the provision of Health Home services. It also explains the care management services in the Medicaid Managed Care benefit package.

Behavioral Health Transition Guidance

Implementation Policy Paper Transition of Behavioral Health Benefits into Medicaid Managed Care and Health and Recovery Program Implementation. PDF DocumentLeaving OMH site - October 2015.

Addresses HARP eligibility and enrollment, Behavioral Health Home and Community Based Services (BH HCBS), behavioral health network and contracting, transition monitoring reporting, utilization management, finance and reimbursement, managed care plan staffing requirements, and Regional Planning Consortiums.

Medicaid Pharmacy Changes for Behavioral Health PDF Document - October 1, 2015
Guidance on the elimination of course limitations on smoking cessation medications and access through both pharmacy and medical benefits to atypical long-acting injectable medications.

Transition Monitoring Reports: Service Access, Use and Denials Reporting
Guidance for Medicaid Managed Care Plans on measures to monitor service access and use, denials, and timeliness of payment as behavioral health services transition to Medicaid Managed Care. The State will create transition monitoring reports summarizing data extracted from available Medicaid claims and encounter data. Medicaid Managed Care Plans are required to submit data on inpatient and ambulatory service denials on a scheduled basis.

Discharge Planning: Outpatient Appointment Requirements PDF Document - December 10, 2014
Provides OMH policies for scheduling outpatient appointments within five days of discharge for individuals being discharged from psychiatric in patient care.

Smoking Cessation
Smoking cessation is a target initiative as New York State transitions to an integrated system of care. The Office of Mental Health is committed to reducing rates of tobacco use among individuals with Serious Mental Illness.

Utilization Management

Updated prior and concurrent authorization cover memo PDF Document clarifies expectations for utilization management of routine behavioral health outpatient office and clinic care - August 21, 2015

Clarification Regarding Utilization Management for Mental Health Clinics PDF Document - October 15, 2015
Addresses continuity of care and utilization management requirements for OMH clinic services. Applies to Medicaid Managed Care Plans, Health and Recovery Plans (HARPs) and HIV Special Needs Plans.

Detailed requirements: prior authorization and concurrent review for ambulatory behavioral health services.PDF Document

Assertive Community Treatment (ACT) and Personalized Recovery Oriented Services (PROS)
This page provides detailed descriptions of ACT and PROS, two specialty behavioral health services that have transitioned into Medicaid Managed Care.

Behavioral Health Home and Community Based Services (BH HCBS) for Adults PDF Document - December 2, 2016
Provides a framework for discussion to support a collaborative review process among all participants, including BH HCBS providers, Medicaid Managed Care Plans, Health Home Care Managers and enrollees.

Adult BH HCBS Prior and/or Continuing Authorization Request Form.PDF DocumentLeaving OMH site

Long-Stay Article 28 Inpatient Units PDF Document - September 30, 2015
Outlines a modified utilization approach for long stay hospital inpatient units at New York Presbyterian Hospital, Westchester and St. Joseph’s Medical Center, Yonkers.

New Behavioral Health Services in Medicaid Managed Care

Licensed Behavioral Health Practitioner Services Effective October 15, 2016. This benefit permits Medicaid Mainstream Managed Care Organizations (MMCOs) and Health and Recovery Plans (HARPs) to reimburse Clinic Treatment Programs licensed by the NYS Office of Mental Health for the provision of services at locations other than the clinic’s main site(s) or satellite locations.

FAQs for the LBHP benefit

NYS Behavioral Health Home and Community Based Services (BH HCBS) Provider ManualPDF Document Describes the basic requirements for any entity interested in providing BH HCBS services. Includes service definitions, provider qualifications, eligibility criteria, limitations and exclusions, permissible modes of service provision, practitioner credentials, information on which BH HCBS may be provided together, and sample attestation forms.

Possible ACCES-VR Opportunities for Adult BH HCBS ParticipantsPDF Document

Requirements to Co-mingle PROS/Clubhouses/Psychosocial Clubs with BH HCBSPDF Document

Grievances and Appeals

Overview of Grievance and Appeals Processes in Medicaid Managed Care - October 16, 2015 New York State is expanding the behavioral health benefits administered by Medicaid Managed Care plans to include the majority of mental health and Substance Use Disorder benefits available in the Medicaid program. Providers, enrollees, and enrollees’ authorized representatives may file complaints and appeals related to these expanded behavioral health benefits with their Medicaid Managed Care plans and with the State.

Health and Recovery Plans

Health and Recovery Plans (HARPs) PDF Document
Assisting Eligible Individuals with HARP Enrollment

Serving Special Populations

Assisting Individuals Experiencing First Episode Psychosis PDF Document - April 30, 2015
Provides a summary of State standards and requirements for Medicaid Managed Care plans for serving individuals with first episode psychosis (FEP), as well as resources to assist plans in meeting those requirements.

Planning Resources

The County Capacity and Utilization Data Book (2013 – 2014), available on the OMH website, describes inpatient and community-based psychiatric service utilization and capacity statistics at statewide and county levels. Inpatient and outpatient service capacity and utilization are displayed for the adult (18 and older) and child (under 18) populations where appropriate. Other measures reported include psychiatric residential, licensed outpatient, emergency, and support program capacity and utilization by county and program type.

Information from this Data Book can support a range of managed care, DSRIP and Health Home service delivery planning activities.

Information for Consumers

Resources for Consumers on the OMH Website include educational and training materials, and information about Health and Recovery Plans (HARPs).

Notices Sent by New York State to Consumers Eligible for HARP Enrollment
View sample HARP Notices. HARP notices inform people that they are eligible, and explain their options.