Testimony from Natalie Cuddahee, LMSW, Director of Case Management Services, Family & Children's Service of Niagara

My name is Natalie Cuddahee, and I am the Director of Case Management Services for Family & Children's Service of Niagara, Inc. Through contracts with the Niagara County Department of Mental Health, our agency provides a Supportive Case Management Program (with 15 SCM slots) and an Adult Intensive Case Management Program (with 5 ICM slots), as well as other mental health programs. For over 25 years, in partnership with the New York State Office of Mental Health (OMH) and the Niagara County Department of Mental Health, we have served individuals with the most serious and persistent mental illness. We have helped many people with mental illness to function in the community, and to avoid hospitalization and living in an institutional setting. We are on the "front lines" in this effort on a day to day basis, and our results prove that we are making a positive difference for the people we serve.

I am here today to "sound an alarm" regarding the viability of the current fiscal model as it effects the survival of our ICM Program. The ICM Program is almost fully supported by Medicaid billing with only a small amount of State Aid. A change was made in our fiscal model by the NYS Office of Mental Health in 2005. This new model increased the mount of Medicaid billing required by the provider and decreased the amount of State Aid provided by the OMH. As a result, more pressure has been placed on the ICM Program to have caseloads with enough Medicaid eligible clients that are willing to be seen four times a month, and who can be successfully billed to Medicaid. We have caseloads of 12 clients per worker, and the required level of Medicaid eligible clients in our ICM Program is 66.7% of the total caseload. Currently, 65%of our ICM clients are Medicaid eligible. This fact alone means we can not bill enough Medicaid to support our ICM program, even if every Medicaid eligible client was successfully billed. Considering the population that we are serving, it is not realistic to bill every Medicaid eligible client successfully.

In the new fiscal model, both OMH ICM and SCM programs face many challenges in successfully billing the Medicaid eligible clients on the caseloads. In past years, our SCM Program (with caseloads in excess of 30 per worker) was able to "bail out" the shortfall in ICM revenue, but now SCM is impacted by these same trends and must work hard just to support itself. In addition to an inadequate percentage of Medicaid eligible clients, the following issues impact revenue generation under the current ICM model:

• Clients Not Complying with Service
  The percentage of clients who are not interested in ICM service has increased over the last few years. Clients are referred through Niagara County's Single Point of Access (SPOA) Committee. Many clients who are non-compliant are dually diagnosed individuals, particularly MICA clients. Our current ICM is 25% MICA clients. Many of these clients are not willing to be seen four times a month by their assigned Intensive Case Manager (as required for billing). The case manager spends a great deal of time that is not reimbursed attempting to complete visits. If a client is disinterested in service on any particular day, he or she can simply "not answer the door" when their case manager arrives for a visit. In addition, MICA clients often do not cooperate with a referral to substance abuse treatment services, and do not comply consistently with other mental health treatment providers, such as mental health therapists and psychiatrists, particularly when their substance abuse or dependence is addressed.
• Clients Not Maintaining Medicaid Eligibility
  ICM clients have been non-compliant in keeping their Medicaid status active. Clients with a serious mental health diagnosis or dual diagnosis are often unable to maintain their active Medicaid coverage. Many of them are aware that they will receive ICM service regardless of their commitment to maintain active Medicaid status. In addition, MICA clients are frequently incarcerated. Currently, Medicaid eligibility is cancelled by incarceration, and a process of reapplication must take place upon release from jail. We are aware that there are current efforts to help with this incarceration issue.
• Clients Receiving SSD
  Many ICM clients are receiving Social Security Disability (SSD). This system requires that clients make a "spend down" of their "out-of-pocket" funds to pay for their medical services each month before the ICM Program can bill Medicaid for services. Often, clients do not choose to make this "spend down". As a result, ICM Programs can not bill Medicaid for the services we are mandated to provide.
• Rapid Stepping Down of Service Provision
  In recent years, the mental health service system has placed more pressure on providers to "step down" ICM clients to lower levels of service as soon as possible. The clear benefit is that this makes room on the ICM caseloads for new referrals, and that Medicaid does not have to pay for a level of service that is unnecessary. However, we often disenroll clients who are compliant with ICM service requirements and are Medicaid eligible, and we replace them with new clients who are non-compliant with service requirements and are inactive with Medicaid.

In summary, it is our belief that Intensive Case Management Programs across New York State need increased state aid in order to survive. ICM can not survive on Medicaid billing alone, as indicated by the facts that I presented here today. Without immediate action on this issue, many ICM Programs, including ours, can not survive much longer. The system is broken, and we want to work with you to develop a constructive solution. The ICM fiscal model and the ICM service standards are working against each other. Thank you for the opportunity to present this testimony and for your anticipated attention to this matter, as we all work together to help the seriously and persistently mentally ill residents of our State.

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