CMS GC Investment Goal: Provide public health approaches and other innovative programs to improve the health outcomes, health status and quality of life for uninsured, underinsured and Medicaid-eligible individuals in Vermont

Background on IFS: The initial IFS implementation site in Addison County began on July 1, 2012, and the second pilot region in Franklin/Grand Isle counties began on April 1, 2014. These pilots included consolidation of over 30 state and federal funding streams into one unified whole through one AHS Master Grant agreement. The State created an annual aggregate spending cap for two providers in Addison County (the Designated Agency and the Parent Child Center) and one in Franklin/Grand Isle (this provider is both the Designated Agency and Parent Child Center). This has created a seamless system of care to ensure no duplication of services for children and families. The overarching goal of IFS was to ensure families received support.

*Due to ongoing issues with transition to Electronic Health Records data available for reporting is based on fiscal year rather than calendar year.

IFS offers families an expanded array of service domains, including; mental and behavioral health, developmental disabilities, and substance use.  Services include the following Medicaid State Plan and Demonstration services: Section 1115 Demonstration Services: specialized mental health services for children under 22 with a severe emotional disturbance; specialized developmental disability services for individuals under 18. State Plan Services: mental health clinic services including mental health outpatient therapy, targeted case management, specialized rehabilitation services (early childhood development and mental health), intensive family-based services, extended nursing visits for pregnant and postpartum women.

Moving Forward: On January 1, 2019, the IFS sites became aligned with larger payment reform efforts occurring across AHS including having incentives tied to them in alignment with statewide implementation. At the same time, IFS regions have additional requirements for performance measurement in accordance with the broader scope of services included in those regions.

Goals of IFS: The goals of IFS are: a) to improve the delivery of services and ultimately the health and well-being of pregnant/postpartum women, infants, children and young adults and b) advance maternal and child health and safety, family stability, and optimal healthy development through the transition to adulthood.  This is achieved by:

• Providing flexible funding that allows service providers to meet family needs as they become known.
• Bringing children’s, youth and family services together in an integrated and seamless continuum.
• Offering families supports and services based on need rather than program eligibility criteria.
• Shifting the focus from counting clients and service units to measuring the impact of those services.

IFS propels individuals, organizations and systems at the state and community level to work together more collaboratively, use resources more flexibly, and make supports and services more family-friendly so children, youth and families are better off as a result of their interaction with AHS and its community partners.

How we do it: The Integrating Family Services (IFS) bundled payment model supports Medicaid services for pregnant women and children birth through age 21 across service domains, including: mental and behavioral health, developmental disabilities, and substance use. Services reach across the continuum of prevention, diagnosis, and treatment.

The bundled rate allows IFS providers to bill once a month for Medicaid services after a single unit of service. That single payment supports services regardless of how frequently or intensively services occurred in a month for an individual. The bundled rate further supports IFS delivery of service in the most natural setting for the child and family, including in the home, and allows the provider to focus on the plan of care and supporting individuals in meeting goals. A unique case rate is established for each provider. The provider case rate represents reimbursement for specific Medicaid-covered services to the target population (pregnant women and children age 0 through 21 years). The specific Medicaid services within each IFS provider’s case rate differ, based on the array of services provided by that provider.

IFS providers are expected to serve a minimum caseload for the target population each year.

Should the IFS provider incur verifiable service costs that, because of the pilot, are not reimbursable, but would be reimbursable under practices in place for non-pilot sites at the time the services were provided, they may request a review and payment by the State. The request must be accompanied by documentation of the expense, the services delivered, and the reason the costs are above and beyond the IFS aggregate annual cap and/or the case rate. All IFS-related revenue and expense detail is reported by the provider to the State monthly through an electronic financial reporting system. In moving from a fee-for-service, or uncapped payment model, to a bundled model, the grantee incurs risk in exchange for administrative streamlining and delivery system flexibility. However, grantees must continue to meet EPSDT mandates and fulfill other contractual expectations within this cap.

Providers are required to electronically submit encounter data to the State for all services delivered using the Department of Mental Health Monthly Service Report (MSR). Minimum required encounter data elements include: Medicaid ID, date of referral, date of first contact, date of service, place of service, type of service, and person delivering service. Ad hoc reports are developed by the State to examine demographic, program and/or policy trends that may be reflected in service delivery data.  IFS is a service delivery and payment reform model that uses the same terms of performance and rate setting methodology for all providers. Rather than the previous fee-for-service model utilized for these services, a Results-Based Accountability approach is used to determine if children, youth and families are improving. This model allows for flexibility of service that focuses on providing the right amount of service and support being tied to accountability through specific performance measures and progress monitoring, which all providers are subject to. Performance measures are used to monitor quality of care, but results are not considered when developing the case rate or annual budget. IFS grantees are required to reach 90% of their target caseload to draw down their full allocation. If they do not hit their caseload targets or provide the required services, they would not get reimbursed. 

Special Note related to COVID Pandemic:  On March 24, 2020 Governor Scott issued a “Stay Home, Stay Safe” order that ordered Vermonters to restrict and minimize activities outside of the home and directed non-essential businesses and non—profits to cease in person operations. These orders have had a tremendous impact on the service delivery of mental health services throughout Vermont in all community-based settings and inpatient facilities.