Music City Chapter Conference September 26 2013 State hired Mckinsey and Company Modeling program after Arkansas Health Care Payment Improvement Initiative Retrospective bundled payments Primary care medical home ID: 189258
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AAHAMMusic City Chapter Conference
September 26, 2013Slide2
State hired Mckinsey and CompanyModeling program after Arkansas Health Care Payment Improvement Initiative
Retrospective bundled payments
Primary care medical homeWill begin with TennCare and State employees Goal to have majority of “healthcare spend” based on episodes and population-based payments within next three to five years
Tennessee Plan for Payment ReformSlide3
Episode based paymentsReward one or more providers for total performance, specific event, procedure or treatment of condition
Episodes will cover a specific pre-defined period during which patients receive care from multiple providers
Each episode has a “quarterback”Leads and coordinates all providers involved in care
Helps drive improvement
Pre-determined with episode definition and may be physician or hospitalEpisodes are “triggered” by hospital inpatient or outpatient procedure or encounter
Tennessee Plan for Payment ReformSlide4
Retrospective episode-based paymentsProviders receive reimbursement from payers based on usual negotiated rates as they currently do
Quarterback receives rewards or penalties based on overall cost of episode
Commendable and acceptable levels of cost determined based on retrospective cost dataCalculate risk-adjusted average cost per episode for the total patient population served during the performance period for the episode
Share savings if average cost below commendable level
No change in payment if average cost between commendable and acceptablePay portion of excess costs if costs exceed acceptable
Tennessee Plan for Payment ReformSlide5
Three initial episodes selectedTotal Joint Replacement
Greatest impact for state employee population
Orthopedic surgeon will be quarterbackAsthma ExacerbationHospital will be quarterbackPerinatalObstetrician or Family Practice physician will be quarterback
Tennessee Plan for Payment ReformSlide6
MCOs to start providing data to quarterbacks January 2014Additional episodes rolled out in batches every 3 to 6 months
Within 3 to 5 years episodes and population based payment models account for majority of healthcare spend
Tennessee Plan for Payment ReformSlide7
Year 2 TennCare Rate Variation
Aon on track to complete the analysis by October
New data could result in minor changes to bands for Year 2 in order to maintain budget neutralityWhen final percentages are available, TennCare will host a webinar for all hospitals
THA will send impact information to all hospitals
TennCare bureau will review MCO contract amendment language and contract negotiations should begin in NovemberNo changes will be implemented until all contract amendments have been signed
Amendments will be retroactive to July 1, 2013Slide8
Transition of CoverKids to TennCare
On July 30, Blue Cross notified providers CoverKids and pregnant women in HealthyTNBabies would be using the TennCare Select network, effective October 1
These groups previously used the state employee network
Contract amendment placed providers serving those populations into the TennCare Select network at existing TennCare Select rates
Change was automatic unless provider notified Blue Cross in writing of rejection prior to August 29Slide9
Transition of CoverKids to TennCare
The
Blue Cross communication states “
CoverKids program
and HealthyTNBabies program members are not TennCare Select Members”
THA requested clarification from the TennCare bureau on several issues not communicated by Blue Cross
Kids age 6 through18
under 138% of poverty
required by the ACA
to be moved into
Medicaid
Will be implemented beginning January 2014
Still discussing with CMS whether move will be all at once or at time of recertification
Unclear if they will stay in TennCare Select or be auto-assigned to MCOSlide10
Transition of CoverKids to TennCare
Women
in HealthyTNBabies who
were pregnant and under the care of an OB on October
1, 2013 could stay with that OB OB
would be reimbursed under the
previous rate
100 percent
Medicare bump
will
be implemented for doctors that saw
kids age 6 through 18 under 138 percent of poverty
Will receive increased payment for selected E&M codes
State does not have spending authority to fund interim payment increase for physicians or hospitals
Agreed to increase all TennCare Select rates effective July 1, 2014 funded by hospital assessmentSlide11
TennCare Benefit Changes
Beginning October 1, 2013
TC won’t coverFacets injectionsAllergy medicine of any kindTENS services for chronic lower back pain
These will have limits:
Trigger point injections – only pay for 4 trigger point injections in each muscle group every 6 monthsSlide12
TennCare Benefit Changes
Limits,
con’t:Epidural Injections – only pay for 3 epidural shots every 6 monthsUrine Drug Screenings – Only pay for 12 urine drug screenings per year
All of above apply to add adults 21 or olderSlide13
TennCare Benefit Changes
Starting October 1
There will be a $1.50 co-pay for generic prescriptionsApplies if member currently pays a $3 co-pay for brand name prescriptions
Does
not apply if member is in CHOICES Group 1 or CHOICES Group 2For drugs within member’s monthly limit,
won’t pay
co-pay forSlide14
TennCare Benefit Changes
For drugs within member’s monthly limit,
won’t pay co-pay for:
Birth control
Medicine received in hospice careMedicine received in a medical emergency (in the ED)Medicine member takes while pregnant (ex. vitamins)Slide15
Insurance ExchangeSlide16
Insurance Exchange Enrollment Opportunity
Data provided by Baptist
Healing
Trust
Three-fourths
of the uninsured
live in 16 states
CA
TX
FL
NY
GA
IL
NC
OH
PA
NJ
MI
AZ
VA
TN
WA
IN
16Slide17
Expansion Population
Because Medicaid has not been expanded in Tennessee, there will be a
donut hole
Those below 100% of federal poverty level AND who do not qualify for Medicaid today are NOT ELIGIBLE FOR THE EXCHANGE
They will have not have access to any health insurance
17Slide18
Affordable
Care Act
includes:
Insurance requirements & regulatory changes
Tax credits and cost-sharing subsidies
Individual mandate/penalties
Establishes e
ssential health benefits
18Slide19
Levels of
Coverage
Plan Pays
On Average
Enrollees Pay
on Average*
(In addition to the
monthly plan premium)
Bronze
60%
40%
Silver
70%
30%
Gold
80%
20%
Platinum
90%
10%
*
Based on the aggregate cost under the plan when benefits are provided to a standard population. This may not be the same for every (or any specific) enrolled person.
QHP Plan Levels of Coverage
19Slide20
Enrollment Periods
Initial open enrollment period: October 1, 2013 through March 31, 2014
Annual open enrollment periods will be October 15 – December 7 in succeeding years
Special enrollment periods available in certain circumstances during the year
20Slide21
Initial Open Enrollment Period
for the Individual Market
Enroll during the initial open enrollment period
On or before December 15, 2013
Between the 1
st
and 15
th
day of January – March
Between the 16
th
and the last day of December - March
Coverage is effective
January 1, 2014
First day of the following
month
First day of second following month
October 1, 2013 – March 31, 2014
21Slide22
Apply Online, By Phone or
In Person
Enter basic information
Healthcare.gov has
checklist
Choose level of coverage
Compare health plans
Confirm plan selection
Apply for coverage
Exchange verifies information/determines
eligibility
6. Pay first month’s premium
22Slide23
New Rules
Cannot be denied coverage
Modified
community rating (only can adjust
premium for age, tobacco & geography; cannot adjust for gender or health status)
Mandated coverage
of
10 essential health benefits determined by HHS
23Slide24
Essential Health Benefits
Ambulatory patient services
Emergency services
Hospitalization, maternity and newborn care
Mental health & substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative & habilitative services & devices
Laboratory services
Preventive & wellness services
Chronic disease management
Pediatric services (including oral & vision care)
24Slide25
Exchange Eligibility
Marketplace eligibility requires consumer to:
Live in its service area AND
Be a
U.S
. citizen or national OR
Be a non-citizen who is lawfully present in the U.S. for the entire period for which enrollment is sought
Not be incarcerated
25Slide26
Consumer Assistance
Applicant may be eligible for two forms of assistance to afford coverage in the health insurance marketplace:
Premium
tax credits
Cost-sharing
subsidies
26Slide27
Premium Tax Credit
Eligibility
for the premium tax credit is
based
on:
Household income and family size
(previous year end)
Income between 100% to 400% of the
federal poverty level
$23,550 - $94,200 for family of four in 2013
Not
eligible for government-sponsored coverage or affordable employer-sponsored insurance
27Slide28
Premium Tax Credit
Amount
of the premium tax credit depends on:
Actual
household income as a percentage of the federal poverty level and family size
The premium for the
second lowest cost silver level qualified health plan,
adjusted for the age of the covered person
A sliding scale that increases the taxpayer’
s own contribution towards the premium cost as income increases
28Slide29
Cost-Sharing Reduction
Cost-sharing subsidies for those that receive
premium tax credit
People with income between 100% and 250% of
federal poverty level
Federal government shares in cost of co-pays and deductibles
Silver
plans only
29Slide30
Resources & Training
30Slide31
National Consumer Information
Provider-focused website
www.marketplace.cms.gov
CMS consumer-focused website
www.HealthCare.gov
24-hour CMS consumer call center for the individual exchange
800-318-2596
1-855-889-4325 (TTY)
Now providing general information
Starting 10/1/13 – eligibility & enrollment assistance
31Slide32
Outreach Efforts for Enrollment
Important terms to understand:
Navigators
receive funding from CMS to conduct outreach.
There are two in Tennessee:
Structured Employment Economic Development Corporation (SEEDCO)
Tennessee
Primary Care Association
Certified application counselors (CACs)
are trained individuals who provide consumer enrollment assistance. They are accredited by CMS, but are not funded by CMS.
Certified Enrollment Entity (CEE)
is a designation hospitals must apply for and be granted by CMS before their employees can be trained and accredited CACs.
http://marketplace.cms.gov/help-us/cac-apply.html
32Slide33
CAC Training
CAC training modules are posted online at the health insurance marketplace
Remember, your organization must first be a registered CEE in order for employees to complete the training
Modules are available at:
http://marketplace.cms.gov/training/get-training.htmlSlide34
CAC Training
CMS backlog with CAC application responses
CMS Consumer Support team has established the following email address for CAC-related questions: CACquestions@cms.hhs.gov.
Include
the organization nameand topic in subject line
and be sure to include contact info with
email
Slide35
TDCI Emergency Rules
Last week, the Tennessee Department of Commerce & Insurance (TDCI) released
emergency rules (http://state.tn.us/sos/rules_filings/09-29-13.pdf) requiring
registration for navigators and
certified application counselors for the new health insurance exchange
.Slide36
TDCI Emergency Rules
The department also has released:
FAQ 1 Offering educational information(http://
www.tn.gov/insurance/documents/9_20NavigatorFAQ1.pdf
)FAQ 2
Application forms, fingerprinting and background check requirements
(
http
://www.tn.gov/insurance/documents/9-20NavigatorFAQ2.pdf
)
-
Registration requirements and application for navigator or certified application
counselor
(CAC) ENTITY
(
http://www.tn.gov/insurance/documents/navigator_entity_packet_2013.pdf
)
-
Registration requirements and application for navigator or certified application
counselor
INDIVIDUAL
(
http://www.tn.gov/insurance/documents/navigator_individual_packet_2013.pdf
)
Slide37
Enrollment of uninsured critical issue for hospitalsCMS navigator grant
for
Tennessee exchange enrollment only $1.4 millionTennessee hospitals saw 345,000 uninsured individuals in EDs in 2011 (out of 889,000
uninsured statewide
)THA will make $3 million of grant funds available to hospitalsGrant amounts will be based on the level of uninsured each member facility serves in the ED
The minimum grant amount would be $10,000
Insurance Exchange Enrollment
37Slide38
THA Grants
$3 million in grants available to acute care and research hospitals who are THA members
Grant amounts will be based on 2011 JAR uninsured ED volume
Deadline for application is Oct. 31, but applications will be funded as they are received
Criteria and details in package emailed to CEOs
Questions: email
EnrollmentGrant@tha.comSlide39
THA Grants
Grant information/application sent to hospital CEOs
Acute care hospitals
Hospital systems containing acute care hospitals OR
Research hospitals
System hospitals may apply individually or as a system
Approved grant uses will be flexible so they can be tailored to your community
39Slide40
THA Grants
Include (but not limited to):
Salary/benefit costs of hospital staff (or temporary staff) to become certified as CACs (explain health coverage options to uninsured & assist with enrollment)
Independent contractor fees to provide or assist with community education
Cost to print educational materials
Cost to analyze hospital data for a targeted campaign effort
40Slide41
THA Grants
Partnering with not-for-profit organizations that specialize in working with populations that lack insurance. Examples include:
Project Access
Tennessee Health Care Campaign
Partner with local insurance agents/brokers to work with uninsured individuals
41Slide42
THA Grants
Quarterly reports will be required to include successes & obstacles so hospitals can learn from each other
THA will provide exchange resource materials
Questions: email
EnrollmentGrant@tha.com
42Slide43
THA website
Resource guide for Tennessee hospitals
List of Tennessee agents/brokers who have committed to assist individual exchange applicants
THA grant information
Sample hospital application
THA grant application
Webinar/audio recording
THA Resources
43Slide44
Materials hospitals can customize and use locally
Brochures
Posters
Tent Cards
Stickers
THA Resources
44Slide45
Questions?
45