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Agenda Item
ASR
Control 23-000870 |
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MEETING
DATE: |
05/07/24 |
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legal entity taking action: |
Board
of Supervisors |
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board of supervisors district(s): |
All
Districts |
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SUBMITTING Agency/Department: |
Health
Care Agency (Approved) |
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Department contact person(s): |
Annette
Mugrditchian (714) 834-5026 |
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Veronica
Kelley (714) 834-7024 |
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Subject: Renewal for Contract for
Administrative Services Organization
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ceo CONCUR |
County Counsel Review |
Clerk of the Board |
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Concur |
Approved
Agreement to Form |
Discussion |
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3
Votes Board Majority |
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Budgeted: N/A |
Current Year
Cost: N/A |
Annual Cost: FY 2024-25 $12,201,230 |
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Staffing Impact: |
No |
# of Positions: |
Sole Source: No |
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Current Fiscal Year Revenue: N/A
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Prior Board Action: 5/23/2023 #17, 11/29/2022 #41,
5/25/2021 #39 |
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RECOMMENDED
ACTION(S):
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1. |
Approve Amendment No. 6 to renew
Contract with Carelon Behavioral Health of California, Inc., for provision of
Administrative Services Organization for Specialty Mental Health and Drug
Medi-Cal Substance Abuse Services, for the term of July 1, 2024, through June
30, 2025, for an increased amount not to exceed $12,201,230, for a revised
cumulative contract total amount not to exceed $45,092,719, renewable for one
additional one-year term. |
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2. |
Authorize the County Procurement Officer
or Deputized designee to execute Amendment No. 6 to the contract with Carelon
Behavioral Health of California, Inc., as referenced in the Recommended
Action above. |
SUMMARY:
Approval of the Amendment to renew
the Contract with Carelon Behavioral Health of California, Inc. will provide
ongoing support of a provider network, adjudication and payment processing of
provider claims, operation of a 24 hours per day, seven days per week telephone
access line, and utilization management of acute inpatient hospital services
for Medi-Cal beneficiaries in the form of concurrent review per Department of
Health Care Services requirements.
BACKGROUND
INFORMATION:
On May 25, 2021, your Honorable Board of
Supervisors (Board) approved the Contract with Carelon Behavioral Health of
California, Inc. (Carelon) to provide Administrative Services Organization
(ASO) for the Specialty Mental Health Plan (MHP) and Substance Abuse Services
and the below actions have been executed pursuant to appropriate authorities.
The Orange County Preference Policy is not applicable to this amendment.
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Board
Date |
Contract/Amendment |
Action |
Term |
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May 25, 2021 |
Contract |
Board Approved Contract |
July 1, 2021-June 30, 2023 |
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N/A |
Amendment No. 1 |
Deputy Purchasing Agent (DPA)
Administrative Amendment: Correct DUNS number, revised Tax ID, and modified
Budget line items |
July 1, 2021-June 30, 2023 |
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N/A |
Amendment No. 2 |
DPA Administrative Amendment: Modified
payment amounts |
July 1, 2021-June 30, 2023 |
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November 29, 2022 |
Amendment No. 3 |
Board Approved Term Renewal |
November 29, 2022- June 30, 2023 |
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May 23, 2023 |
Amendment No. 4 |
Board Approved Renewal |
July 1, 2023-June 30, 2024 |
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N/A |
Amendment No. 5 |
DPA Administrative Amendment: Modified
Period payments amounts |
July 1, 2023-June 30, 2024 |
The proposed increase will allow Carelon
to increase staffing to cover increased responsibilities for concurrent review
first level appeal processes. Additional concurrent review staff were added to
improve the workflow between Carelon and hospitals prior to TAR denials and
reviews by HCA. Carelon will also be adding an auditor and staffing to review
paid and denied mental health claims. Additional staff will improve and ensure
Mental Health Claims are processed accurately and not billed to the State in error.
Additionally, salary adjustments will contribute to Carelon being able to
recruit and retain staff in a very competitive job market and maintain
consistent service levels for Orange County's beneficiaries.
Scope
of Services
Through this contract, Carelon acts as the
Orange County MHPs third-party ASO for both Specialty Mental Health and Drug
Medi-Cal (DMC) Substance Abuse Services and performs services on behalf of the
MHP that are required by the California Department of Health Care Services
(DHCS). The state required services consist of administrative and specialty
mental health service components, including:
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Operating a toll-free 24 hour per day,
seven day per week (24/7) Telephone Beneficiary Access Line for both the MHP
and the Drug Medi-Cal Organized Delivery System (DMC ODS) as required by DHCS
to screen and link |
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Maintaining of an outpatient and inpatient
ASO Provider Network, including credentialing, training, and contracting of
licensed clinical providers, such as licensed therapists and psychiatrists,
to ensure the MHP maintains network adequacy in compliance with DHCS
requirements. |
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Processing and adjudicating Mental
Health (MH) Claims for payment on behalf of the MHP from both outpatient ASO
Network Providers and psychiatrists providing services at acute inpatient
psychiatric hospitals and long-term care facilities. |
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Utilizing management of acute inpatient
psychiatric hospital services in the form of initial and concurrent review
per DHCS regulations for all Orange County Medi-Cal beneficiaries accessing
this high level of care throughout California. This amendment includes
language to add on increased responsibilities for the concurrent review first
level appeal processes. |
The above-described services are highly
regulated and monitored by DHCS and the MHP in the form of ongoing routine
reports provided to DHCS, and multiple audits completed on a yearly basis. DHCS
audits include but are not limited to, the DHCS Triennial Audit and separate
Medi-Cal Specialty Behavioral Health External Quality Reviews of the MHP and of
the DMC ODS.
Performance
Outcomes
The chart below reflects the performance
outcomes utilized to measure the volume and timeliness of accessing services
provided by the ASO telephone access line. The 24/7 telephone access line is
highly monitored by DHCS and the MHP through the reporting of the outcome
measures below on a recurring basis, as well as quarterly random audits
conducted in the form of test calls. The 24/7 telephone access line is required
by DHCS and this contract to: 1) track call volume and provide access to
specialty mental health and substance abuse services; 2) answer 95 percent of
the member calls within 30 seconds; 3) provide treatment authorization within
14 days; and 4) ensure abandoned calls are one percent or less of total monthly
calls.
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Contract
Outcome Measures |
FY
2022-23 |
FY
2023-24 through
end of February |
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Total Member Calls |
8,370 |
5,813 |
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Answer 95% of incoming member calls
within 30 seconds |
98% |
98% |
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100% Treatment Authorizations within 14
Days |
99% |
99% |
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Abandoned Calls are one % or less of
total monthly calls |
3.5% |
2.4% |
Treatment Authorizations completed within
14 days by the ASO Access Line do not meet the 100 percent performance
objective for these fiscal years due to client volume at times exceeding
available appointment times when clinics and outpatient providers experience
short staffing. More commonly, clients may be dropped and do not answer call
backs or are offered to stay on the line while making the intake appointment
and they request a call-back with the appointment time. In some instances,
clients may not answer the phone despite multiple call-backs by the ASO line to
schedule the follow-up appointment. HCA is continually working with Carelon to
improve the access line call scripts in an ongoing effort to improve
efficiencies for screenings and scheduling appointments for the caller.
Providing appointment times as soon as possible will help reduce the instances
of dropped calls and call-back requests.
HCA requests the Board approve Amendment
No. 6 with Carelon for provision of Administrative Services Organization for
Specialty Mental Health and Drug Medi-Cal Substance Abuse Services as
referenced in the Recommended Action.
The contractor is performing
satisfactorily in all areas of performance outcome measures.
HCA has verified there are no concerns
that must be addressed with respect to Contractor's ownership/name, litigation
status or conflicts with County interests.
The Contract has subcontracts with network
providers who will provide authorized specialty mental health services. See
Attachment B for information regarding subcontractors and Contract Summary
Form.
FINANCIAL
IMPACT:
Appropriations
for this Contract will be included in Budget Control 042 FY 2024-25 Budget.
Funding
Sources
Fed: 5% (Substance Abuse Prevention and
Treatment Block Grant)
State: 79% (Mental Health Realignment and
2011 Realignment)
Fees/Other: 16% (Medi-Cal Federal
Financial Participation)
The Contract includes provisions allowing
HCA to terminate the Contract, reduce the level of services, and/or renegotiate
the levels of services provided, as necessary. This includes a notice that
allows HCA adequate time to transition or terminate service to clients, if
necessary.
STAFFING
IMPACT:
N/A
ATTACHMENT(S):
Attachment
A - Amendment No. 6 to Contract MA-042-21011458 for Administrative Services
Organization for Specialty Mental Health and Drug Medi-Cal Substance Abuse
Services with Carelon Behavioral Health of California, Inc.
Attachment B - Contract Summary Form
Attachment C - Redline Version to Attachment A