Medicaid Managed Care 101: - PowerPoint Presentation

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Medicaid Managed Care 101:A Framework for Cost-Conscious, Quality Care

Joan Alker Tricia BrooksSarah SomersKelly WhitenerRuth KennedyCCF Annual Conference 2015

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TodayWhat we’ll talk about….

Consumer InformationEnrollment DisenrollmentPlan choiceTypes of managed careBenefits and EPSDTNetwork adequacyConsumer protectionsQualityThe State perspectiveWhat we’ll defer to MC 201….Payment methodologiesActuarial soundnessRate settingContract requirements

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Approaching Our Work on Managed Care

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Populations Enrollment

Consumer InformationTricia Brooks

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Share of Medicaid Enrollees in Managed CareHistorically children and low income families

Recent shifting of duals and disabled to achieve better cost controls and care coordination for high need, high cost populationsAll expansion adults

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Voluntary vs. Mandatory6

Voluntary enrollment can be offered to anyone in Medicaid

Non-exempt groups can be mandated to enroll in managed care

Waiver is required to enroll exempt populations

Low voluntary enrollment can result in inadequate numbers of enrollees

Particularly true for high risk, high cost populations

Issues can sometimes be addressed through well-designed payment arrangements

States more often move toward mandatory coverage

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Populations7

State Plan Amendment

Children

Parents

Non-disabled Adults

Need 1915(b) Waiver to Mandate Exempt Groups:

Children with special health care needs or disabilities

Children receiving foster care or adoption assistance

American Indians

Dual

eligibles

(poor elderly eligible for Medicare)

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Consumer Issues that States Must Address in Building Delivery Systems that Include Managed Care

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ChoiceVoluntary

Choice of FFS or voluntary enrollment in a managed care planMandatoryRisk-based managed care plansChoice of plansException for rural areas where choice of primary care provider is requiredOther protections also existPrimary care case managementChoice of providers

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Plan Selection vs. Auto-AssignmentGoal for states is as to enroll as quickly as possibleSome states require that enrollees select a plan upfront when applying

Others wait until after eligibility has been determinedAll must have auto-assignment (default enrollment) process for those who do not chooseNumber of plans to choose from varies by state and region10

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Auto-Assignment (Default Enrollment)Must preserve existing provider arrangements or relationships with providers that have traditionally served Medicaid

If not possible, must distribute “equitably” among plansNPRM would codify additional criteria to use in default enrollment, including quality

In practice, states assign based on a variety of factors

(e.g., proximity to providers, enrollment of family members, and performance based measures)

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Other Enrollment IssuesNo current enrollment provisions relating to voluntary managed care

Many states enroll directly and offer opt-out NPRM addresses both

No minimum period of time allowed for plan selection

Varies, by state, from a number of days to months

sometimes longer for disabled populations

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Enrollment BrokersStates often contract with external enrollment brokers to provide choice counseling and conduct enrollment activities (438.810(a))

Must be independent from the managed care entities and free from conflict of interestsMixed evidence of the effectiveness of enrollment brokers NPRM requires choice counseling and establishes broader requirement for beneficiary support system13

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Disenrollment Requested by Plan

May not disenroll based on utilization, change in health status, special needsContract should specify reasons plans may use for requesting disenrollmentRequested by the EnrolleeFirst 90 days At least once every 12 months, with 60 day noticeAt any time for causeMay require enrollee to seek redress through grievance system before disenrollingEffective no later than the first of the second month following the month of the request

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Cause for DisenrollmentEnrollee moves out of service area

Plan does not cover service based on moral or religious objections Enrollee needs related services to be performed at same time that are not availableOthers, including but not limited to, poor quality, lack of access to covered services or qualified providers15

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Consumer EducationHealth insurance literacy Low-income uninsured may have little or no experience with managed care

May be transitioning from FFS to MCBenefitsNetworkDrugsEnrollment

Accessing Services

Getting Help

Appeals

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Notices and Written InformationAll notices and informational or instructional materials must:

Be in an easily understood language and formatBe available in prevalent languages and alternative formats needed by those with special needs (e.g. limited vision, limited reading proficiency)Inform enrollees and potential enrollees of the availability and how to access alternative formatsProvided upon eligibility determination in time to support plan selection17

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Language SupportStates must…

Identify prevalent languages spoken by a significant number or percentage of enrollees and potential enrolleesState and plans must…provide written information in all prevalent languagesprovide oral interpretation for all non-English languagesmust inform enrollees and potential enrollees of availability and how to access language supports18

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State ResponsibilitiesMechanism to help enrollees and potential enrollees understand managed careMust ensure that managed care plans fulfill their responsibilities

Information must include:Basic features of managed careWhich groups are…Able to enroll voluntarilyExcluded from enrollmentRequired to enrollDisenrollment rights19

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NPRM has new and very detailed information requirements

MC Plan ResponsibilitiesMechanism to help enrollees and potential enrollees understand plan requirements and benefitsInformation must include:Benefits and how to accessCost-sharingService areaProvider informationRestrictions on choice of providerWhen services of covered out of network

Grievances and appeals

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Marketing RestrictionsDistribution of materials must be approved by state in consultation with Medical Care Advisory Committee

Must distribute to everyone in service areaCan’t sell other productsInfo must not be fraudulent, misleading or confusingCold-calling is prohibited21

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Other Beneficiary ProtectionsAccess to emergency services without prior authorization

Defines emergency medical conditions, services, and out-of-network accessNo restrictions on patient-provider communicationsLiability for paymentAnti-discrimination22

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Roll Out of New MC ImplementationNo Standards but….Must be adequate time for system development

Sufficient resources to ensure smooth transitionPhased-in approach may work best23

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Types of managed care entitiesBenefits and EPSDT

Network Adequacy and Access Standards24Sarah Somers

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Medicaid Managed Care – Key TermsContract, RFP

Risk contractCapitationPMPM25

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Medicaid Managed Care EntitiesMCO – Managed Care Organization

PIHP, PAHP – Prepaid Health Plan (Inpatient or Ambulatory)PCCM – Primary Care Case Management“Managed’ fee for servicePACE – Program of all-inclusive care for the elderly26

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NPRM

Adds New DefinitionsPCCM Entity – Primary care case management entity NEMT PAHP – Non-Emergency Transportation Prepaid Ambulatory Health Plan27

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BenefitsBasic requirement: S

tates must ensure that all services covered under Medicaid state plan are “available and accessible”28

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Adequacy of Services/Networks

MCOs/PHPs must:Make covered services available to the same extent they are available to other beneficiaries Assure that they have adequate capacity to serve expected enrollment, including services and providers PCCM contracts must provide for arrangements/referrals to sufficient numbers of providers to ensure prompt service delivery 29

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Services for Enrollees with Special Health Care Needs

States must:Identify such persons* to plansAssess individual needs (using appropriate health care professionals)Allow direct access to specialistsRequire plans to produce a treatment plan (optional)Developed by provider with enrollee inputApproved by plan *as defined by the state

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Network AdequacyNo specific federal standardsContracts

State lawExample: Virginia Contract (pp. 39, 245)Example: California Regulations (28 Cal. Code. Regs.1300.67.2)31

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Early and Periodic, Screening, Diagnosis and Treatment (EPSDT)

Required for beneficiaries under age 21Outreach and informing“Screens” (check ups)TreatmentAssistance with accessing servicesGreat Resource

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Policy Reasons for EPSDT

Low-income children are more likely to have: Vision, hearing and speech problemsUntreated tooth decayElevated lead blood levelsSickle cell diseaseBehavioral Health problemsAnemiaAsthmaTransportation barriersAnd more . . .

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EPSDT Requirements: Mandatory Screenings

Medical ScreensHealth and developmental historyUnclothed physical examImmunizationsLab tests, including lead blood testsHealth educationOther Screens

Vision, including eyeglasses

Hearing, including hearing aids

Dental, including relief of pain, restoration of teeth and maintenance of dental health

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EPSDT Requirements: Treatment

All services that could be covered under state Medicaid plan (mandatory and optional)All Medicaid-covered services necessary to “correct or ameliorate physical and mental illnesses and conditions,” even if the service is not covered under the state planCMS Guidance: no hard limits on hours/visits38

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EPSDT Requirements: Outreach and Informing

Effective and aggressiveOral and writtenTranslatedTargeted (e.g. pregnant teens, non-users)Transportation and appointment assistance (prior to screen due date)Coordination with other entities

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EPSDT: Issues in Managed Care

Non-coverage of servicesCarve outs, failure of state to ensure services are providedLimits on number of visits/hoursPrior authorization for screens, delaying servicesStricter medical necessity definition than state uses40

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Questions?41

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Grievances and Appeals42

Sarah Somers

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Medicaid Due Process: Legal Authority

ConstitutionMedicaid statuteFederal regulationsState lawContracts (MC)43

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What triggers right to hearing?Denial of application for benefits/failure to act with reasonable promptness

Agency has taken an action erroneouslyReduction, suspension, termination of servicePASRR, transfer or discharge from NF44

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Right to Appeal, cont’d“Action” of MCO:

Denying, reducing, terminating or otherwise limiting services or denying payment for servicesFailing to timely provide servicesDenying request for disenrollment or exemption“otherwise adversely affecting the individual”45

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Notice

Must include:Action takenReasons for actionRight to file appealRight file state hearing requestExpedited resolutionContinued benefits46

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GrievanceAn expression of dissatisfaction about any matter other than an action

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Continued BenefitsMust continue pending final hearing decision if hearing is requested w/in 10 days of action

When MCO appeal taken and beneficiary loses, must again request services continue pending fair hearing decisionBeneficiary can be required to pay for benefits if he ultimately loses ISSUE – no continued benefits beyond authorization period 48

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Quality Measurement and Improvement49

Tricia Brooks

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Quality Assessment and Improvement StrategyCurrent regulations focus quality measurement and improvement strategies on MCO’s and PIHP’s.

NPRM expands quality requirements to all delivery systems, including FFS and all types of MC entities50

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Each State Contracting with an MCO or PIHP must….

Have a written strategy for assessing and improving qualityObtain public input Ensure plan complianceReview effectiveness and update the strategy Submit strategy to CMS, as well as updates and reports on implementation and effectiveness51

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Required Elements of Quality StrategyAssess the quality and appropriateness of care to everyone, and to those with special health needs

Identify and provide to plans at enrollment, the race, ethnicity, and primary language of each enrollee Monitor and evaluate plan complianceIncorporate national performance measures if applicableArrange for annual independent external quality review (EQR)Ensures adoption and dissemination of practice guidelines52

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MC Entity Must Conduct Performance Improvement ProjectsUse objective measurements

Assess clinical and nonclinical areasImplement system interventions to improve careEvaluate effectivenessSubmit state or CMS specified performance measurement dataIdentify both underutilization and overutilization of servicesAssess quality and appropriateness of care for enrollees with SHCN53

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External Quality Review (EQR)

Applies to MCO, PHIP, HIOEQR organization must meet federal standardsAnalyzes and evaluates aggregated information on quality, timeliness, and access to health care services Reports must be submitted to CMS but vary across states in organization and level of detail due to differing interpretation of the regulations54http://www.healthlaw.org/issues/medicaid/managed-care/EQR-Overview06162014pdf#.VQ7JvBDF_2w

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EQR?Validates performance measures and improvement programs :

Mandatory EQR ActivitiesEvaluate quality, timeliness, and access to careAssess plan’s strengths and weaknesses, and recommend quality improvement projectAppraise how well each plan responded to previous QI recommendationsOptional EQR Activities

Validate encounter level data

Administer or validate consumer or provider surveys

Calculate state-required performance measures

Conduct detailed PIP reviews

Conduct focused, one-time studies

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NPRM adds network adequacy validation to mandatory activities

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Common Issues Across EQR Reports Data collection methods vary

No federally required measures; states can pick and choose but tend to use most commonChallenging to compare across states or plansMCO’s come and go, so difficult to form a picture of system performanceComprehensiveness of the reporting to CMS is improving56NPRM lays foundation for alignment and more consistent reporting on quality

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CHIP57

Kelly Whitener

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CHIP Managed Care RulesThe Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) applied several Medicaid managed care provisions to CHIP at section 2103(f)(3) of the Social Security Act:

Section 1932(a)(4): Process for enrollment and termination and change of enrollmentSection 1932(a)(5): Provision of informationSection 1932(b): Beneficiary protectionsSection 1932(c): Quality assurance standardsSection 1932(d): Protections against fraud and abuseSection 1932(e): Sanction for noncompliance 58

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CHIP Managed Care RulesCMS provided initial guidance on these rules in two State Health Official (SHO) lettersSHO#09-008

offered guidance on implementing the new requirements generally, including submitting CHIP managed care contracts to CMS for review for the first timeSHO#09-013 offered additional guidance on the quality provisions in particular Both letters indicated more information was forthcoming, and it arrived on June 1 this year, proposing managed care regulations in CHIP for the first time!59

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How is CHIP managed care different?Contracts & RatesContracts are typically not reviewed by CMS, and they do not have to be approved prior to implementation

Capitation rates are not reviewed by CMS and they do not have to meet actuarial soundness requirementsBeneficiary EnrollmentThere is no requirement for beneficiaries to have a choice of plans at enrollment, but must have another option if they choose to disenroll from the managed care planBeneficiaries can be required to pay premiums prior to enrollment60

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The State Perspective61

Ruth Kennedy

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Questions and Discussion62

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ResourcesCMS “Medicaid Managed Care Enrollment Report,” July 2011

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdf CMS Medicaid Managed Care Web Pages http://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/managed-care/managed-care-site.html MACPAC “The Evolution of Managed Care in Medicaid,” June 2011 http://www.mhpa.org/_upload/MACPAC_June2011_web.pdf Kaiser Family Foundation “A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50-State Survey” http://kff.org/medicaid/report/a-profile-of-medicaid-managed-care-programs-in-2010-findings-from-a-50-state-survey

/

Kaiser Family Foundation “Medicaid Managed

Care

Tracker”

http

://kff.org/data-collection/medicaid-managed-care-market-tracker

/

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NHeLP Resources“A Guide to Oversight, Transparency, and Accountability in Medicaid

Managed Care” http://www.healthlaw.org/publications/browse-all-publications/managed-care-toolkit-march-2015#.VaMGs5NViko “Survey of Medicaid Managed Care Contracts: EPSDT Vision and Hearing Services” http://www.healthlaw.org/publications/search-publications/managed-care-survey-EPSDT Model Provisions: #1 Grievances and Appeals; #2 Enrollment and Disenrollment; #3 Network Adequacy; #4 Accessibility & Language Access; #5 Reproductive Health http://www.healthlaw.org/publications/search-publications Network Adequacy in Medicaid Managed Care: Recommendations for Advocates http://www.healthlaw.org/publications/search-publications/network-adequacy-in-medicaid-managed-care#.VaMJdJNViko

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Contact65

Sarah Somers somers@healthlaw.org www.healthlaw.orgJoan Alkerjca25@georgetown.edu Tricia Brookspab62@georgetown.edu

Kelly Whitener

kdw29@georgetown.edu