NC Medicaid MCT Transition of Care Crossover Series 9192019 - PDF document

1 NC Medicaid | MCT Transition of Care Cr
NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 NC Department of Health and Human Services NC’s Transition to Medicaid Managed Care: The Crossover Education SeriesTrish Farnham, Senior Health Policy Analyst Garrick ProkosProject ManagementQuality and Population HealthZaye Brewer,Business AnalystBusiness Technology Resource TeamSeptember 19, 2019 NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Summary Overview of NC’s Transition to Managed CareTransition of Care “Crossover” ConceptOverview Activities Underway to Support Mem

2 bers and Providers through CrossoverPrev
bers and Providers through CrossoverPreview of Resources in DevelopmentToday’s Session: What’s CoveredWhat’s Not CoveredSpecific guidance on how to enroll in PHP network Specific guidance on PHP benefitsPlease see resource links for all items not coveredOngoing Transition of CareINFORMATION PROVIDED IS CURRENT AS OF THIS PRESENTATION. TRAINING MAY BE AMENDED TO PROVIDE ADDITIONAL INFORMATION OR CLARIFICATION. NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 FFS: FeeforServiceThe service based reimbursement model NC Medicaid currently operates. M

3 CL: Managed Care Launch The date managed
CL: Managed Care Launch The date managed care goes “live” in a particular region. Often referred to as member’s “Managed Care Effective Date.”PHPs: Prepaid Health PlansFive managed care organizations under NC Medicaid Managed CareAlso referred to as “Standard Plans”PA: Prior AuthorizationA request submitted in advance of services starting for a provider to be authorized to provide service, aka “service authorization”UM Vendor: Utilization Management vendorThe entity that reviews and processes the PA request.Terms Used in this Presen

4 tation NC Medicaid | MCT Transition of
tation NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 OVERVIEW OF NC’S TRANSITION TO STANDARD PLANS UNDER NC MEDICAID MANAGED CARE NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Introduction In 2015, the NC General Assembly enacted Session Law 2015245, directing the transition of Medicaid and NC Health Choice from predominantly feeforservice (FFS) to managed care. Since then, the North Carolina Department of Health and Human Services (DHHS) has collaborated extensively with clinicians, hospitals, beneficiaries, counties, health plans,

5 elected officials, advocates, and other
elected officials, advocates, and other stakeholders to shape the program, and is committed to ensuring Medicaid managed care plans:Deliver wholeperson care through coordinated physical health, behavioral health, intellectual/developmental disability and pharmacy products and care modelsAddress the full set of factors that impact health, uniting communities and health care systemsPerform localized care management at the site of care, in the home or communityMaintain broad provider participation by mitigating provider administrative burden NC Medicaid | MCT Transition of Care Cr

6 ossover Series| 9/19/2019 Medicaid Trans
ossover Series| 9/19/2019 Medicaid Transformation Vision “To improve the health of North Carolinians through an innovative, wholeperson centered, and wellcoordinated system of care which addresses both medical and nonmedical drivers of health.” NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 ��7&#x/BBo;&#xx [2;.49;ˆ 4;S.0;
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7 p; /F;&#xoote;&#xr /T;&#xype ;&#x/Pa
p; /F;&#xoote;&#xr /T;&#xype ;&#x/Pag;&#xinat;&#xion ;What do some of the terms mean? New name for our current Medicaid program.Feeservice + LMEMCOs (or PACE)What everyone on Medicaid has now NC Medicaid Direct The term used reference the five “prepaid health plans” or “PHPs” or “health plan”Also called “Standard Plan” or “Standard Plan Option.”Launch date (2/1/2020) is referenced as “Managed Care Launch (MCL),” “Managed Care Effective Date” or “Standard Plan Effective Date” NC Medicaid Managed

8 Care Specialized plans for members with
Care Specialized plans for members with significant behavioral health needs and intellectual/developmental disabilities What the LMEMCOs will become in a few yearsNOT the focus of today’s training session. Tailored Plan NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 ��8&#x/BBo;&#xx [7;&#x.238; 44;.69;c 6;6.7;2 ;Ҕ.;坷&#x ]/S;&#xubty;&#xpe /;oot;r /;&#xType;&#x /Pa;&#xgina;&#xtion;&#x 000;&#x/BBo;&#xx [7;&#x.238; 44;.69;c 6;6.7;2 ;Ҕ.;坷&#x ]/S;&#xubty;&#xpe /;oot;r /;&#xType

9 ;&#x /Pa;&#xgina;&#xtion;&#x 000;PHPs fo
;&#x /Pa;&#xgina;&#xtion;&#x 000;PHPs for NC Medicaid Managed CareStatewide ContractsAmeriHealth Caritas North Carolina, Inc.Blue Cross and Blue Shield of North Carolina, Inc.UnitedHealthcare of North Carolina, Inc.WellCare of North Carolina, Inc. Regional Contract Regions 3 & 5Carolina Complete Health, Inc. NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 NC Medicaid Managed Care Regions NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 NOTICE: NC Medicaid Managed Care will now Launch Statewide on February 1, 2020Managed care will now launch in

10 one phase. Open enrollment will be exte
one phase. Open enrollment will be extended for the 27 counties in Regions 2 and 4 until December 13,2019. Nothing changes for the remaining 73 counties. As planned, open enrollment will begin for those 73 counties on October 14, 2019 and run through December 13, 2019. All stakeholders should continue to work towards the February 1, 2020 implementation date. It is critical that the managed care companies (PHPs) and doctors and health systems continue to work together on contracting. The 27 counties where open enrollment will be extended include: Alamance, Alleghany, Ashe,

11 Caswell, Chatham, Durham, Davidson, Davi
Caswell, Chatham, Durham, Davidson, Davie, Forsyth, Franklin, Granville, Guilford, Johnston, Nash, Orange, Person, Randolph, Rockingham, Stokes, Surry, Vance, Wake, Warren, Watauga, Wilkes, Wilson and Yadkin countiesFrom NC DHHS Communication about Open Enrollment ExtensionNote: Resource materials may still contain earlier launch date information NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Revised Enrollment and Launch Timeframe Note: LTSS members may change plans at any time. AUTO ASSIGNMENT MidDecember(12/16/2019) OPEN ENROLLMENT CONTINUES NC Medicaid T

12 ransformation: Key Crossover Activities
ransformation: Key Crossover Activities September OctoberDecember January February MarchMay, 2020 MANAGED CARE LAUNCH (MCL) Phase I: 2/1/2020Enrolled Member May Change PHP without cause for 90 days after MCL.LTSS Members May Change Any Time Crossover Education and CommunicationDecember: claims, encounter and PA data transfer begins. Crossover Education and Communication1/2020: Members can begin reserving postLaunch transportation appointments through PHP call line. PHPs conduct follow along to high need members. PHP responsible for NEMT services for Enrolled MembersNew PAs

13 submitted to Member’s PHP PHP must
submitted to Member’s PHP PHP must honor open FFS PAs for no less than 90 days.Non participating provider requirements in effect. CrossoverEducation and Communication Begins FEBRUARY 1, 2020: LAUNCH NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 DHHS Vision for Transition of CareAs beneficiaries move between delivery systems, the Department intends to maintain continuity of care for each beneficiary and minimize the burden on providers during the transition. NC Department of Health and Human Services (NC DHHS) NC Medicaid | MCT Transition of Care Crossov

14 er Series| 9/19/2019 Transition of Care:
er Series| 9/19/2019 Transition of Care: Two Distinct Phases Crossover to MCL Transition of CareOne time crossover of beneficiaries eligible for NC Medicaid Managed Care on November 1, 2019 or February, 1 2020 (“Managed Care Implementation” or “MCL”) OngoingTransition of CareOngoing transition of care for beneficiaries moving between PHPs, between PHPs and FFS, between FFS/LMEMCOs and PHPsNOTE: TRANSITIONS BETWEEN SETTINGS ARE RELATED BUT IDENTIFIED IN SEPARATE PROTOCOLS AND NOT FOCUS OF THIS PRESENTATION NC Medicaid | MCT Transition of Care Crossover Serie

15 s| 9/19/2019 NC’s TRANSITION TO MAN
s| 9/19/2019 NC’s TRANSITION TO MANAGED CARE: THE CROSSOVER DESIGN NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 ��MEDICAID TRANSFORMATION LEADERSHIP MEETING | JANUARY 16, 2018 Our Crossover Policy Direction PHPs have the necessary data to ensure effective service continuity for transitioning beneficiaries. As beneficiaries move between delivery systems, the Department intends to maintain continuity of care for each beneficiary and minimize the burden on providers during the transition. Highneed beneficiaries have additional “high tou

16 ch” support to ensure service conti
ch” support to ensure service continuity and reassurance through the transition. PHPs maintain service continuity by implementing DHHS requirements related to prior authorizations, non participating providers, appeal rights and identified services. PHPs, LMEMCOs and FFS vendors establish mechanisms that facilitate the effective data and knowledge transfer. The Department ensures effective oversight through quality communication, reporting and other oversight mechanisms. Providers facilitate service continuity by being effectively informed on Crossoverspecific requiremen

17 ts such as PA submissions. The Departmen
ts such as PA submissions. The Department’s Crossover direction is enhanced by the insight and contribution of stakeholders. NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Key Components of NC DHHS Crossover Design Supporting Continuity of Care Through Data Transfer Establishing Additional Safeguards for High Need Members Member and Provider Education Clear and Organized Communication Between Entities Facilitating Uninterrupted Service Coverage NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 24 months of paid and denied claims/encount

18 er history for all services. Claims and
er history for all services. Claims and Encounter Open and recently closed PAs (60 days) Open and Recently Closed Prior Authorizations (PAs) Care Plans from CCNC and identified LMEMCO members receiving care coordination.PCS Care Plans/Assessments from PCS Vendor.All other treatment plans accessed from providers as Identified Care Plans Data Transfer at Crossover: Key Data NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Provider Impact: None anticipated. Data will be transferred by NC TRACKS Claims and Encounter Provider Impact: Minimal. PHPs may seek clarifi

19 cation on a detail on PA . Open and Rece
cation on a detail on PA . Open and Recently Closed Prior Authorizations (PAs) Provider Impact: PHPs may seek care/service plans for transitioning members if not otherwise included in the file transfer. Identified Care Plans Data Transfer at Crossover: Provider Impact NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 GDIT and other UM Vendors will continue to process Prior Authorization requests through January 31, 2020 as usual.Open and recently closed Prior Authorizations will be transferred to Member’s PHP to help ensure continuity of care.PHPs are requir

20 ed to honor open PAs up to 90 days after
ed to honor open PAs up to 90 days after launch.If PHP ends open PA after 90 days, it must provide appeal rights. Prior Authorization Requests for DOS Prior to Managed Care Date NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Member’s Managed Care Date (or Managed Care Launch=MCL) Member Covered by FFS (Medicaid Direct) Member Covered by PHPScenario A: Provider submits PA request prior to MC effective date for member transitioning to PHP. UM Vendor authorizes services as clinically indicated. Authorization will be transferred to PHPs as part of increment

21 al PA transfer file.Scenario A. PHP hon
al PA transfer file.Scenario A. PHP honors open FFS PA authorization for first 90 days. If Authorization extends beyond 90 days and the PHP terminates or reduces, it must issue appeal rights.Scenario B: Provider submits retroactive PA request for Dates of Service (DOS) prior to MC effective date for a member formerly enrolled in Medicaid Direct, now enrolled in PHP. Vendor may only authorize for DOS prior to Managed Care effective date. Scenario B Scenario A: FFS UM Vendor generated PA received prior to MCLScenario B: Provider may submit separate PA request directly to P

22 HP. Prior Authorization Requests for DOS
HP. Prior Authorization Requests for DOS Prior to Managed Care DateRetroactive PANote about Scenario B: Most retro active PA requests will be processed as outlined here.UM Vendorspecific guidance may apply. NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Ensure providers know about PA submission requirements.Ensure providers have information needed to resubmit PA request to proper PHP. Intensive Provider Education If a provider attempts to enter information for a member who is now enrolled in NC Managed Care, it will see banner message instructing where to

23 get additional information. Notificatio
get additional information. Notification: AutoInformation Message UM call center staff will be informed on how to guide both members and providers. InformedCall Center Staff Stop Lights for Attempted PA Request Submissions after Managed Care Effective Date NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 If a provider attempts to enter member who is now enrolled in Managed Care, it will see banner message instructing where to get additional information. Notification: AutoInformation Message Stop Lights for Attempted PA Request Submissions after Managed Care E

24 ffective Date SAMPLE NC Medicaid | MCT
ffective Date SAMPLE NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 PA Requests at Crossover: Guidance in Development Webresource, providing PHP specific PA submission contact information and instruction. NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Be Clear on When PA is Submitted and on Dates CoveredAfter 2/1/2020, Be Clear if Member has Transitioned to PHP/Standard PlanKey populations will be carved out of Standard Plans, including dually eligible (Medicaid and Medicare) members.Identify Member’s Managed Care Status and PHP Informa

25 tionFor Provider Portal Guidance: See J
tionFor Provider Portal Guidance: See Job Aid PHP Eligibility/Enrollment for Providers in NC Tracks Provider Portal To submit Service Auth/ Request to PHP on or after 2/1/2020Follow instructions provided directly by the PHPComing Soon! All PHP instructions in one place https://medicaid.ncdhhs.gov/providers . PA Requests at Crossover: What Providers Need to Know NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Any PHP termination of open PA after 90 days post MC effective date (2/1/2020) triggers appeal rights.Generally, adverse determination process and appeal

26 rights will be processed as usual.Member
rights will be processed as usual.Members appealing initial service request denials will be instructed on option to submit new request to PHP.PHPs will be required to honor Continuation of Benefits/Maintenance of Service on covered benefits until can reassess and either approve ongoing services or issue appeal rights.EPSDT still requirements apply. Appeals at Crossover NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Claims for dates of service prior to the member’s Managed Care effective date should continue to be submitted to NCTracksor applicable entity

27 (e.g. LMEMCO).Claims for dates of servic
(e.g. LMEMCO).Claims for dates of service afterthe member’s Managed Care effective date should be submitted to the member’s PHP following applicable PHP protocol as provided in provider enrollment materials.Note: PHPs are required to treat claims for nonparticipating providers with dates of service on or after managed care effective date equal to that of enrolled providers until the completion of the episode of care or 60 days, whichever is less.* * N.C. Gen. Stat. 88(d)(g) still in effect. What Providers Need to Know: Processing Payment at Crossover NC Medicaid | MCT

28 Transition of Care Crossover Series| 9
Transition of Care Crossover Series| 9/19/2019 TransitionRelated Safeguards for HighNeed Members Data File Transfer at CrossoverClaims/Encounter DataPA ExtractCare Plans (As Applicable) Targeted Follow Up For HighNeed MembersPHPs perform timesensitive follow up to High Need Members Warm HandoffIndividualized knowledge transfer sessions for members identified by DHHS, LMEMCOs, CCNC. PHPs may also initiate.Applies to All Transitioning BeneficiariesSee High Need Member DefinitionComplex Treatment/Service Circumstances NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2

29 019 “ High Need” Members inclu
019 “ High Need” Members include High need subset of members receiving inhome longterm services and supports/High need subset of members receiving behavioral health servicesExempt members who elect to enroll in PHP.Members identified by CCNC, an LMEMCO or the Department who have complex treatment circumstances or multiple service interventions and necessitate a “warm handoff.”NEMT users with repeated or multiple appointments.Members with Inborn Errors of Metabolism Managed Care Launch Date��Pre MCL, PHP identify and prioritize “High Need&#

30 148; members based on criteria and infor
148; members based on criteria and information providedFollow Up (reported weekly to DHHS):Direct contact between PHP and member (inperson or Are services in place?Any confusion about processes?Ongoing status of preMCL authorized services.Member PHP representative Targeted Follow Up For HighNeed MembersPHPs perform timesensitive follow up to High Need Members Provider Note: Providers may be invited to participate in Follow Up sessions NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 • https://files.nc.gov/ncdma/How DoesMedicaidManagedCare AffectEnrollment

31 Guidefor LTSSFinalforWebPosting.pdf Memb
Guidefor LTSSFinalforWebPosting.pdf Member EducationMember Guide to explaining enrollment pathways for beneficiaries with disabilities and older adults NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Member Education: Non Emergency Medical Transportation Provider Note: Providers can help educate members about this option. Enrolled Members will be able to reserve post MCL appointments 31 days PRIOR to their effective date. Sara selects ABC Health Plan on December , 2019. Her managed care effective date will be February 1, 2020.Sara has an appointment on Febr

32 uary 2, 2020.Sara can reserve her 2/2/20
uary 2, 2020.Sara can reserve her 2/2/2020 appointment directly from ABC in January, 2020. In Development: Additional Educational Materials to Help Members Understand this Option NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Number to call if I have issues getting care after my start date My health plan is: Number to call if I have questions about my supplies Number to call if I need to schedule a ride to an appointment after I start getting care through my health plan. My primary care provider is When I will start getting care through my health plan:We wan

33 t to ensure Members have simple, clear,
t to ensure Members have simple, clear, “pocket reference” answers to these questions. Member Education NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 RESOURCES NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 General Overview of Provider Transition to Managed CareMCT 101 Provider Transition to Managed Care https://medicaid.ncdhhs.gov/ncmedicaidmanaged caretrainingcourses Information on Benefits under Managed Care MCT 108 Clinical Policies under Managed Care https://files.nc.gov/ncdma/documents/Clinical PoliciesWebinarFINAL2019061

34 3.pdf To Contact the PHPs about Contract
3.pdf To Contact the PHPs about Contracting Information about Provider Network Adequacy Requirements, Grievances and Appeals and Other PoliciesMCT 104 Key Policies for Providers in Managed Care https://files.nc.gov/ncdma/ProviderPolicies Webinar5.9.19Final.pdf Information about Provider Rates and ContractingMCT 102 Provider Payment and Contracts https://files.nc.gov/ncdma/documents/Providers/Re vised6.26.19ProviderPayments ContractingWebinarFINAL.pdf https://medicaid.ncdhhs.gov/providers Please visit the NC DHHS Medicaid Provider webpage Information about Standard Plan and T

35 ailored Plans MCT 106 Behavioral Health
ailored Plans MCT 106 Behavioral Health Services: Standard Plan and Transition Period https://files.nc.gov/ncdma/MCT106TransitionFinal.pdf Provider Education: General Resources NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 DHHS Crossover Resource Page Crossover Guidance to be Provided Finding Members’ Managed Care StatusResources to Support Members through Transition through Managed CareGuidance on Submitting Prior AuthorizationsContacting the PHPsOverview of PHP Crossover RequirementsAdditional Crossover Information https://medicaid.ncdhhs.gov/providers

36 CrossoverSpecific Information Coming So
CrossoverSpecific Information Coming Soon NC Medicaid | MCT Transition of Care Crossover Series| 9/19/2019 Need More Information?To submit a question to the Medicaid Team: MedicaidSWAT@dhhs.nc.gov If member has a question about enrollment and PHP selection: Contact the NC Medicaid Enrollment Broker 5500 (free call) www.ncmedicaidplans.gov Want to review earlier MCT Trainings? https://medicaid.ncdhhs.gov/providers Want to review Medicaid Bulletins? https://medicaid.ncdhhs.gov/documen ts/2019medicaidbulletins In Development:Guidance if Member or Provider has issue at Crossover