As policymakers rethink how best to help Nevadans grappling with mental health issues, substance use disorders, homelessness and the foster care system, Medicaid is preparing to ask the federal government to allow it to provide additional services to some of the state’s most vulnerable residents.

The three requests — two waivers of federal rules and a so-called state plan option — would allow the state Medicaid program to expand an existing model of providing behavioral and primary health care, offer housing support to those with behavioral health issues and rethink the way it pays for specialized foster care. Though the requests are separate, state officials say that, collectively, they will go a long way toward providing continuity of care for residents living on the margins.

In a recent interview, Deputy Medicaid Administrator DuAne Young said it was the “perfect time” to pair supportive housing changes, which he is overseeing, with what the Division of Child and Family Services is trying to achieve with its waiver for specialized foster care, which will help children with serious mental or behavioral health needs.

“As a result of homelessness, people, young children, who get out of the foster care system don’t necessarily have a place to go, and they enter that housing market and they don’t know how to live in that housing market,” Young said. “When you’re dealing with a substance use disorder, and those are comorbid with a severe mental illness, it’s having that advocacy and support on your side to help you maintain your housing.”

Medicaid officials are at various stages of drafting the requests to submit to the federal Centers for Medicare and Medicaid Services, or CMS. State officials plan to submit one waiver to expand a behavioral health clinic program by May to begin onboarding new clinics by October and implement the supportive housing expansion by Jan. 1, 2020.

But even with federal approval, whether Nevada is actually able to put these programs into practice depends on lawmakers, who hold the purse strings of the state’s budget. Members of the human services budget committee recently heard the details of Medicaid’s budget, including funding to back many of these requests.

As legislators continue piecing together the details of the state’s budget, here’s a look at the three requests and what impact state officials anticipate they will have on health care in Nevada.

Waiver for behavioral health care

One of the three requests Nevada Medicaid plans to submit would allow the state to expand its so-called Certified Community Behavioral Health Clinic, or CCBHC, program. Nevada is one of eight states that was chosen by the federal government to participate in a two-year demonstration program to explore the efficacy of the CCBHC model starting in June 2017.

CCBHCs are required to provide an expansive array of mental health and addiction services, basic primary care screenings and coordination with primary care providers. In exchange for providing that robust suite of services, they receive an enhanced Medicaid payment rate based on the anticipated costs of care.

That means that whether it provides one service or six services in a day, the clinic still receives one daily rate to care for that patient.

“What it does is it compels them to provide the most appropriate level of care for someone without needing to feel like they have to cut back on services for any one reason,” said Dr. Stephanie Woodard, a clinical psychologist who oversees the CCBHC program.

Additionally, the clinics are supposed to respond to individuals in crisis 24 hours a day, seven days a week, and all new patients are supposed to be seen within 10 days, on average, between the time they call for an appointment and when they go in for an initial evaluation.

Nevada initially had five clinics participating in the demonstration program: two in Las Vegas, one in Reno, one in Elko and one in Fallon. Two of those clinics, both operated by WestCare in Reno and Las Vegas, closed last year after struggling to provide the demanding list of services required of CCBHCs.

Despite those closures, state officials say the three remaining clinics have been successful and are now looking to expand the CCBHC program to 10 clinics through a waiver of federal Medicaid rules. Under the waiver, the state will have another five years to expand and demonstrate the effectiveness of its CCBHC program.

Medicaid officials anticipate submitting the waiver to CMS by May, though they expect the process to move quickly because the federal agency has issued guidance encouraging the growth of CCBHC programs. If approved, the clinics would begin the onboarding process in October.

“There's motivation on both sides to have this move much more quickly than other demonstration projects would move,” said Cody Phinney, deputy administrator for Medicaid.

But the CCBHC expansion is dependent on Medicaid receiving $740,000 in state general fund dollars over the two-year budget cycle. Marta Jensen, a former Medicaid administrator and now a spokeswoman for the agency, said the additional funding would allow the state to expand the services it provides, not just shift Medicaid patients from another provider to the CCBHC model.

“Fundamentally, the goal is to have more people,” Phinney said. “We know we have gaps in this portion, in this capacity to serve people. So, fundamentally, the goal is to reach more people with a more successful product.”

This time around, the state is also planning to spend $200,000 assisting new clinics with setting up their CCBHC programs out of the federal mental health block grant dollars it receives. The funding, split between six clinics, will help the facilities onboard new staff, conduct training and establish data collection programs; Vitality Unlimited, which currently operates the CCBHC in Elko, received a $2 million federal grant to broaden its operations and open the seventh CCBHC expansion clinic in Carson City.

In addition to the CCBHC component of the waiver, Medicaid is planning on asking the federal government to allow it to provide for the treatment of substance use disorders through so-called institutions of mental disease. Right now, Medicaid cannot pay for substance use disorder treatment provided in a freestanding treatment facility with more than 16 beds.

“That's a lot of leverage that could be influenced if those rules were changed, and this waiver would allow Nevada to change those rules. That's a pretty big shift in the landscape of substance use treatment,” Phinney said.

So-called institutions of mental disease, or IMDs, have been excluded from Medicaid coverage since the program was created in the 1960s. The provision was initially intended to ensure that states, rather than the federal government, were responsible for providing inpatient psychiatric services. But as the way those services are provided has shifted in recent years, particularly in the wake of the Affordable Care Act’s Medicaid expansion, the exclusion has created barriers to accessing care.

Without that coverage, Nevadans on Medicaid are required to receive substance use disorder treatment through other means, such as through federal mental health funding provided to the Division of Public and Behavioral Health. By covering the treatment through Medicaid, those dollars will be freed up for other kinds of mental health services, Phinney said.

While states were technically previously able to apply for waivers to cover substance use disorder treatment in IMDs, Medicaid officials said that the Trump administration streamlined the process for doing so in guidance it issued late last year.

“I think the big difference in clarity is CMS, under this administration, has encouraged states to do this by making the process a little bit easier for states,” Young said. “Nevada had always looked at it, but it's a cumbersome lift.”

Though Medicaid is requesting the waiver, funding to cover substance use disorder treatment through institutions of mental disease isn’t funded in the governor’s budget. That means that while Medicaid will have the authority to cover this kind of treatment in the future, it won’t immediately have the funding to do so.

“We're always looking for opportunities to make sure we're using the funds that are available to us to the benefit of the people. Certainly people are asking questions, there are discussions, and we're providing information and details when those are requested, but … it's not in the current proposal,” Phinney said.

The CMS guidance also for the first time encouraged states to apply to have treatment of serious mental illness and severe emotional disturbance covered at IMDs as well, something that was previously not allowed. However, Medicaid officials said they won’t be applying to have those treatments covered through this waiver because they still don’t have enough detail from CMS.

“Because nobody has an approved one yet in another state, that's a whole other animal,” Woodard said. “We didn't want to put the cart before the horse and try to include it in this first round of applications, because it would probably significantly delay our timeline.”

Supportive housing

Medicaid, as a health insurance provider, isn’t allowed to pay for rent. It can, however, pay for assistance to help some of the state’s more vulnerable residents secure housing and ensure that they are able to stay in it, something that state officials say is likely to lead to better overall health outcomes.

That’s what Medicaid is hoping to accomplish through this state plan option, which Young described as a technically less onerous process than a waiver. Young said that the state has been looking at how to expand the way it supports patients with housing needs for several years, but that this state plan option evolved out of the regional behavioral health boards, which were created during the 2017 legislative session.

If Medicaid approves it, the change would create a new provider type and allow community agencies to be reimbursed for providing housing assistance. Young said that while there are a lot of community providers currently offering this service, they cannot be reimbursed by Medicaid for it.

“They do it because they believe in their clients and they want to see them achieve, but that gives them very minimal reach,” Young said. “So paying for this through a mechanism through Medicaid allows us to expand those services to the most vulnerable populations and target that to where it's really going to be effective.”

Medicaid hopes to be able to provide housing support to 1,600 Nevadans who fall into two middle tiers of a vulnerability index — those who aren’t vulnerable enough to require extensive treatment, such as skilled nursing, but need more help than just basic assistance to locate new housing.

“When you're dealing with something else in your life — physical or mental health — it's very hard to focus on, ‘I have to find an apartment, I have to negotiate my lease, how do I deal with a landlord?’” Young said. “When I started in the field, it's what I did. I had clients who were severely mentally ill, and so I would go to their landlord and have the talk with the client and say, ‘You can't really do this because you have neighbors,’ and helped them keep them in their housing because if they lost their housing, that meant another hospitalization or that meant health issues.”

Young said that Nevada has had its eye on supportive housing for several years, but increasing housing shortages and rapid gentrification have increasingly displaced some of the state’s most vulnerable.

The governor’s recommended budget includes $1.9 million in state funding over the two-year budget cycle to reimburse community agencies for providing these supportive housing services. Young said that Medicaid will work with the Division of Public and Behavioral Health to establish qualifications and standards for organizations planning on providing those services.

If CMS approves the program, Medicaid plans to have the program up and running on Jan. 1, 2020. When asked by lawmakers during a recent budging hearing how Medicaid would know if the program is successful or not, Young said the goal is to keep individuals in an apartment for six months.

“The clearest objective is — are they staying in their homes and are they successfully paying their rent?” Young said.

Specialized foster care

Medicaid, in conjunction with the Division of Child and Family Services, is also developing a waiver that would allow the state to standardize the way it pays for specialized foster care services, which are provided to children with a high level of behavioral health needs.

Ross Armstrong, the division’s administrator, said that there are currently several streams of funding, including state dollars and federal Title IV-E money, that flow into child welfare. Medicaid officials described the proposal as a “revamping” of how specialized foster care services are paid for and said it will not require extra dollars in the state’s budget.

“We kind of had a uniqueness in the fragmentation in the way that different agencies were approaching the funding,” Armstrong said. “This was really our way to get everyone on the same page.”

The overall goal of the waiver, Armstrong said, is to ensure all kids are receiving the specialized foster care services they need, whether that’s crisis stabilization or support for specialized foster caregivers.

Armstrong said the waiver is still in the early phases of development so the specific services the waiver will cover haven’t been delineated yet. But he said the agencies plan to submit the waiver toward late spring.

“These are our highest need kids and they’re in foster care so you want to make sure they’re safe number one, and you’re trying to help them stabilize so they can be reunited with their biological family or if they’re free for adoption,” Armstrong said.