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Department of Insurance to provide information and linkage to the appropriate sources to encourage providers who are not currently enrolled in Medicaid to do so.

E. Program Integrity

Block Grant Application Instructions: The Affordable Care Act directs the Secretary of HHS to define EHBs. Non-grandfathered plans in the individual and small group markets both inside and outside of the Marketplace, Medicaid benchmark and benchmark-equivalent plans, and basic health programs must cover these EHBs beginning in 2014. On December 16, 2011, HHS released a bulletin indicating the Secretary’s intent to propose that EHBs be defined by

benchmarks selected by each state. The selected benchmark plan would serve as a reference plan, reflecting both the scope of services and any limits offered by a “typical employer plan” in that state as required by the Affordable Care Act.

SMHAs and SSAs should now be focused on two main areas related to EHBs: monitoring what is covered and aligning Block Grant and state funds to compensate for what is not covered. There are various activities that will ensure that mental and substance use disorder services are covered. These include: (1) appropriately directing complaints and appeals requests to ensure that QHPs and Medicaid programs are including EHBs as per the state benchmark; (2) ensuring that individuals are aware of the covered mental health and substance abuse benefits; (3)

ensuring that consumers of substance abuse and mental health services have full confidence in the confidentiality of their medical information; and (4) monitoring utilization of behavioral health benefits in light of utilization review, medical necessity, etc.

States traditionally have employed a variety of strategies to procure and pay for behavioral health services funded by the SABG and MHBG. State systems for procurement, contract management, financial reporting, and audit vary significantly. SAMHSA expects states to implement policies and procedures that are designed to ensure that Block Grant funds are used in accordance with the four priority categories identified above. Consequently, states may have to reevaluate their current management and oversight strategies to accommodate the new priorities. They may also be required to become more proactive in ensuring that state-funded providers are enrolled in the Medicaid program and have the ability to determine if clients are enrolled or eligible to enroll in Medicaid. Additionally, compliance review and audit protocols may need to be revised to provide for increased tests of client eligibility and enrollment.

States should describe their efforts to ensure that Block Grant funds are expended efficiently and effectively in accordance with program goals. In particular, states should address how they will accomplish the following:

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1. Does the state have a program integrity plan regarding the SABG and MHBG?

The state Division of Mental Health and Addiction (DMHA) is a division of the Indiana Family and Social Services Administration (FSSA), which has a specific internal agency, FSSA Audit Services, who is responsible for fiscal auditing of FSSA programs and agencies. In addition, the State Board of Accounts (SBA) provides oversight and monitoring of Federal funds across Indiana state agencies.

2. Does the state have a specific staff person that is responsible for the state agency‘s program integrity activities?

No. Program Integrity is comprised of multiple components with checks and balances.

3. What program integrity activities does the state specifically have for monitoring the appropriate use of Block Grant funds? Please indicate if the state utilizes any of the following monitoring and oversight practices:

a. Budget review;

DMHA does not currently review provider budgets. b. Claims/payment adjudication;

DMHA’s funding distribution is based on allocation of funds to support individuals and services not covered by other funding sources, not specific services or individuals. Therefore, there is not a claims adjudication system on client or service level currently in place. However, to ensure compliance and good stewardship of Block Grant funds, FSSA and DMHA both have a contract and claims management tracking system with protocols for claim tracking and approval. Contract scopes of work (SOWs) are written with concrete measureable objectives and deliverables tied to funding. Claims are approved based on deliverables being completed. Multiple checks and reviews of deliverables and fiscal stewardship are in place. Quarterly meetings are used to review status and for monitoring expenditures and utilization. As noted in section e. below, a performance- based payment system is in place to ensure accountability for process and qualitative outcomes.

c. Expenditure report analysis;

DMHA does not currently review provider expenditure reports. d. Compliance reviews;

As noted above, DMHA contracts include scopes of work with specific deliverables which are monitored when claims are submitted. FSSA Audit Services and the State Board of Accounts audit for compliance. FSSA Audit Services also monitors provider independent audits for compliance and conducts further audits as determined necessary. DMHA also requires all providers receiving federal or state funds to maintain separate accreditation by a national accreditation organization approved by DMHA (Joint

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Commission, Commission on Accreditation of Rehabilitation Facilities, etc…). In addition, DMHA staff conducts site visits and desk reviews to monitor compliance with certification and contracting program standards. An external vendor is contracted to provide in-depth reviews of compliance specific to checking onsite records for consistency with data reporting and standard compliance.

e. Encounter/utilization/performance analysis; and

Indiana has a relatively mature process for monitoring performance of the mental health and addiction community-based system across the state. This process includes the monitoring of access/capacity (number of persons receiving services each month), employment/education, and criminal/juvenile justice involvement from the National Outcome Measures along with overall improvement in assessed needs and strengths and reduced substance use. This formal system ties a portion of Block Grant funds () to a pay-for-performance contract. Perception of care is also being monitored for both mental health and addiction services through the Mental Health Statistics Improvement Program survey and the Youth Services Survey for Families. Encounter data and utilization data are required reporting at the client level from all contracted providers for all clients (those with serious mental illness, or SMI; serious emotional disturbance, or SED; or substance use disorders, or SUD). These data are used to monitor stability in housing, social connectedness, retention, and use of evidence-based practices. Plans for 2014 -2015 include matching mortality data from the state health department to the mental health and addiction database in order to establish a mortality baseline from which to measure the effects of future programs such as integrated primary and behavioral health care. f. Audits.

As noted above, DMHA contracts include scopes of work with specific deliverables which are monitored when claims are submitted. FSSA Audit Services and the State Board of Accounts audit for compliance. FSSA Audit Services also monitors provider independent audits for compliance, and conduct further audits as determined necessary. 4. How does the state ensure that the payment methodologies used to disburse funds are

reasonable and appropriate for the type and quantity of services delivered?

Indiana uses a complex formula to allocate funds from all sources to providers who have contracts with DMHA for service delivery. DMHA contracts with community mental health centers, specialty addiction treatment providers, and networks of community mental health centers and addiction treatment providers. The allocation formula is applied to the specific providers (not the network). This formula includes several variables including census data, number of persons served data, and level of need distribution for the numbers served. Allocations are calculated at the fund center level (that is, Block Grant funds are separate from state general revenue funds, etc...) and the population level (for SMI, SED, and SUD). The CMHCs are required by Indiana Code (IC 12-7-40.6) and by contract to provide a

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defined continuum of care. Continuum of care means a range of services, the provision of which is assured by a community mental health center or a contracted addiction treatment provider. The term includes the following:

• Individualized treatment planning to increase patient coping skills and symptom management, which may include any combination of the services listed under this section.

• Twenty-four (24) hour a day crisis intervention.

• Case management to fulfill individual patient needs, including assertive case management when indicated.

• Outpatient services, including intensive outpatient services, substance abuse services, and treatment.

• Acute stabilization services including detoxification services. • Residential services.

• Day treatment. • Family support.

• Medication evaluation and monitoring.

• Services to prevent unnecessary and inappropriate treatment and hospitalization and the deprivation of a person’s liberty.

5. How does the state assist providers in adopting practices that promote compliance with program requirements, including quality and safety standards?

DMHA requires all providers receiving federal or state funds to maintain separate accreditation by a national accreditation organization approved by DMHA (Joint Commission, Commission on Accreditation of Rehabilitation Facilities, etc…). These organizations require providers to meet many standards including quality, health, and safety standards.

6. How will the state ensure that Block Grant funds and state dollars are used to pay for

individuals who are uninsured and services that are not covered by private insurance and/or Medicaid?

The state will work collaboratively with the Mental Health and Addiction Planning and Advisory Council to review and discuss Block Grant priorities to ensure Block Grant funds are spent appropriately per requirements. Each Block Grant priority workgroup will submit recommendations to DMHA leadership and the full planning council on key priority

components to direct Block Grant funds in order to achieve priority area goals.

Recommendations will be used in the decision making process to ensure Block Grant dollars are used to meet the identified priority needs and fill identified gaps for which other funding is not available.

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SAMHSA will review this information to assess the progress that states have made in addressing program integrity issues and determine if additional guidance and/or technical assistance is appropriate.