Primary Care and Behavioral Health Technical Assistance Webinar Summary
This webinar, scheduled for August 28th, 2023, focuses on recent statutory and regulatory changes impacting Primary Care and Behavioral Health (PCBH) data collection and payment allocation. Kyle McGourty-Holland, a Health Policy & Data Analyst, will lead discussions on the updates in service types and categories, including Mental Health and Substance Use Disorders. The Massachusetts Chapter 177 Act charges CHIA with monitoring behavioral health costs, quality, and utilization, with various subcategories identified for data collection. Attendees will learn about the submission requirements and due date for files related to PCBH.
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PRIMARY CARE AND BEHAVIORAL HEALTH TECHNICAL ASSISTANCE WEBINAR August 28th, 2023 10:00 11:00am ET CENTER FOR HEALTH INFORMATION AND ANALYSIS
Agenda Discuss recent impactful statutory/regulatory changes Review overview of changes to Primary Care and Behavioral Health (PCBH) data collection materials Discuss changes to medical claims payment allocation methodology Review additional changes to data submission Primary Care and Behavioral Health Technical Assistance Webinar| Kyle McGourty-Holland, Health Policy & Data Analyst | 2 08/28/2023
Massachusetts Chapter 177 An Act 2022 statute charges CHIA with monitoring behavioral health costs, cost trends, price, quality and utilization Statute identifies several subcategories for data collection Subcategories include, but are not limited to: Mental health Substance use disorder Outpatient Inpatient Services for adults Services for children Provider types Primary Care and Behavioral Health Technical Assistance Webinar| Kyle McGourty-Holland, Health Policy & Data Analyst | 3 08/28/2023
Overview of Changes Topic Service Types and Categories Change Service Types to include Mental Health (MH) and Substance Use Disorders (SUD), which combined represent Behavioral Health (BH). Service Categories to include PC Behavioral Health Screening, MH Outpatient PC, MH Outpatient Non-PC, SUD Outpatient PC, SUD Outpatient Non-PC. Updated Service Type and Service Category indicators. Codes Updated code lists to capture primary care, mental health, and SUD spending. BH taxonomy no longer required, except when identifying BH in primary care. Updated diagnoses code list to remove unspecified dementia, without behavioral health disturbance (F03.90). Primary Care and Behavioral Health Technical Assistance Webinar| Kyle McGourty-Holland, Health Policy & Data Analyst | 4 08/28/2023
Overview of Changes (contd) Topic Change Demographic Removed Pediatric Indicator. New Age Group column. Cost Information Updated incurred and member cost-sharing definitions to clarify allocation of CSR subsidies for ConnectorCare members. Updated clarification of capturing facility claim expenditures. Primary Care and Behavioral Health Technical Assistance Webinar| Kyle McGourty-Holland, Health Policy & Data Analyst | 5 08/28/2023
Submission Files and Due Date All files due October 18th, 2023 Submission Files Required CY 2022 Final PCBH Requested CY 2021 Final PCBH according to current data specifications to capture new spending breakouts CY 2020 Final PCBH according to current data specifications to capture new spending breakouts Primary Care and Behavioral Health Technical Assistance Webinar| Kyle McGourty-Holland, Health Policy & Data Analyst | 6 08/28/2023
PAYMENT ALLOCATION METHODOLOGY MEDICAL CLAIMS
Step 1: Identify Claims with a Principal Mental Health Diagnosis Identify claims with a principal mental health diagnosis Based on ICD- 10 diagnosis code in excel reference file Allocate spending for the claim sequentially through the Mental Health specific service categories based on code sets/logic in Appendices B & D: MH MH Outpatient Non-PC MH MH ED/ Observation Outpatient PC Inpatient Changes: MH claims broken out from aggregate SUD claims Outpatient claims associated with a principal MH diagnosis are now split between outpatient primary care and non-primary care Impact: CHIA can quantify mental health payments separately from aggregate SUD payments CHIA can quantify outpatient MH primary care payments Primary Care and Behavioral Health Technical Assistance Webinar| Mary Jo Condon, Principal Consultant, Freedman HealthCare | 08/28/2023 8
Step 2: Identify Claims with a Principal Substance Use Disorder Diagnosis Identify claims with a principal SUD diagnosis Based on ICD-10 diagnosis code in excel reference file Allocate spending for the claim sequentially through the SUD specific service categories based on code sets/logic in Appendices B & D: SUD SUD SUD ED/ Observations Outpatient Non-PC SUD Inpatient Outpatient PC Changes: Aggregate SUD claims broken out from MH claims Outpatient claims associated with a principal SUD diagnosis are now split between outpatient primary care and non-primary care Impact: CHIA can quantify aggregate SUD payments separately from MH payments CHIA can quantify outpatient SUD primary care payments Primary Care and Behavioral Health Technical Assistance Webinar| Mary Jo Condon, Principal Consultant, Freedman HealthCare | 08/28/2023 9
Step 3: Identify Primary Care Claims Spending Claims Spending not previously allocated above, plus claims without a principal MH or SUD diagnosis Allocate spending for the claim sequentially through the Primary Care specific service categories based on code sets/logic in Appendices B & D: PC PC Office Visit PC BH Screening PC PC Other Primary Care Visit PC PC Home/Nursing Facility Visit Preventive Visit Obstetrical Visit Immunization and Injection Change: Adds PC BH Screening Category Impact: PC BH Screening Category can be summed with MH Outpatient PC and SUD Outpatient PC to calculate BH claims spending in PC Primary Care and Behavioral Health Technical Assistance Webinar| Mary Jo Condon, Principal Consultant, Freedman HealthCare | 08/28/2023 10
Step 4: Identify All Other Claims Spending All Claims Spending not previously allocated above to Mental Health, SUD, or Primary Care Allocate spending for the claim sequentially into Other Medical: Other Medical Change: No change Impact: n/a Primary Care and Behavioral Health Technical Assistance Webinar| Mary Jo Condon, Principal Consultant, Freedman HealthCare | 08/28/2023 11
Step 5: Allocate Non-Claims Spending Non-Claims Payments Allocate non-claims payments into the categories below by service type. Use the Other service type for non-claims payments not related to Behavioral Health or Primary Care. Payers may apportion payments into the primary care and behavioral health service types for payments related to both. Do not double count. Non-Claims: Risk Settlement Non-Claims: Incentive Payments Non-Claims: Other Non-Claims: Management Non-Claims: Capitation Changes: SUD non-claims broken out from MH non-claims Impact: CHIA can quantify SUD and MH non-claims payments separately Primary Care and Behavioral Health Technical Assistance Webinar| Mary Jo Condon, Principal Consultant, Freedman HealthCare | 08/28/2023 12
Code Set Updates Other code set updates Taxonomy Adjustments include: Services: MH and SUD: Two G codes added related to prescribing PC: Most codes added related to vaccines, care management Diagnoses: Dementia without behavioral health disturbance removed NDC: Methadone removed Lucemyra included BH taxonomy no longer required, except for identifying BH in primary care Behavioral health services no longer need to be performed by a behavioral health provider to be considered behavioral health Behavioral services in primary care must be performed by a primary care provider Primary Care and Behavioral Health Technical Assistance Webinar| Kyle McGourty-Holland, Health Policy & Data Analyst | 14 08/28/2023
Replace Pediatric Indicator with Age Group Column Pediatric indicator did not support identifying services provided to children as now required by law Costs associated with children who visited family medicine providers were not captured as pediatric Older teens and young adults' costs captured as Pediatric because they continued to see pediatric providers New age groups offer a simple approach to identifying spending for children, adults and older adults Age Group Definition 0-17 18-64 65+ 1 2 3 Primary Care and Behavioral Health Technical Assistance Webinar| Kyle McGourty-Holland, Health Policy & Data Analyst | 15 08/28/2023
Cost Information Allocation of spending should be distinct and mutually exclusive. Facility Claim Expenditures CSR Subsidies Clarified use of Facility Claims: Clarified allocation of Cost Sharing Reductions (CSR) subsidies for ConnectorCare members: Facility Claims with appropriate revenue codes should be used to report: CSR subsidies should be included in Expenditures: Incurred Expenses (Payer Liability) Inpatient; Facility Emergency Department/ Observation; Facility Outpatient Facility Non-PC Primary Care and Behavioral Health Technical Assistance Webinar| Kyle McGourty-Holland, Health Policy & Data Analyst | 16 08/28/2023
Contact Slide For questions, please contact: Erin Bonney, Director of Health Informatics and Reporting Erin.Bonney@chiamass.gov Primary Care and Behavioral Health Technical Assistance Webinar| Kyle McGourty-Holland, Health Policy & Data Analyst | 17 08/28/2023
