Facilitated by Alabama Primary Health Care Association

Facilitated by

Alabama Primary Health Care Association

Medicaid Transformation

Session Overview

Statutory RCO RequirementsRCO Planning PrinciplesStatewide RCO regionsTimeline and Anticipated Next Steps

Medicaid System Transformation

“Will not expand Medicaid under the current system”…Governor Robert Bentley

Alabama Legislature – SB 340Provides for the delivery of medical services to Medicaid beneficiaries on a managed care basis through regional care organizations or alternate care providers


• Managed Care (Risk Based) • Medicaid will contract with qualified

organizations (RCO or ACP) where the organization assumes risk for the cost of services covered under the contract and incurs loss if the cost of services exceeds the payment under the contract (10/1/2016)

Medicaid System TransformationRegional Care Organizations•An organization of health care providers that contracts with Medicaid to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of the state and meets requirements of enabling statute


Alternative Care Providers (ACP)•A contractor, other than a RCO that agrees to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of the state pursuant to a risk contract; traditional commercial MCO


• ACP Triggers• Medicaid may contract with an alternate

care provider if:– The RCO fails to meet contract requirements– If no organization has been certified as an

RCO or probationary RCO by October 1, 2016

– If no RCO is willing to accept the contract

Medicaid System Transformation• Collaborators• Private health carriers, third party

purchasers, provider, health care center, health care facility, state and local gov. entity, or other public payers, corporations, individuals and consumers who are expecting to collectively cooperate, negotiation or contract with another collaborator or RCO

Statutory RCO RequirementsMedicaid Responsibilities 1.Establish statewide managed care regions2.Establish policy and process for application and

certification as collaborators; certify qualified collaborators

3.Establish criteria for probationary and full certification of RCOs; certify qualified RCOs

Statutory RCO RequirementsMedicaid Responsibilities 4.Establish quality standards and minimum service delivery network requirements5.Establish and support statutory quality assurance and improvement provisions6.Establish requirements for HIT, data analytics, quality of care, quality improvement measurement and standards

Statutory RCO Requirements

Medicaid Responsibilities

7.Conduct initial readiness audits and ongoing financial audits 8.Monitor federal Medicaid regulatory compliance throughout implementation and management to assure FFP is maintained

Statutory RCO RequirementsMedicaid Responsibilities

9.Establish procedures to safeguard integrity of claims payment and protect against wrongful denial of claims 10.Establish policy and process to address grievances of enrollees and RCO or ACP


Governance Structure

12 members risk-bearing members8 non-risk bearing (statutory) members3 community representatives

Statutory RCO RequirementsGovernance

•Risk-bearing Members (12)•Participants bear risk by contributing cash, capital, or other assets to the RCO or contract to treat Medicaid beneficiaries at a capitated rate per beneficiary even if the RCO does not reimburse the participant


Governance•Non-Risk-bearing Members (8)•Participants that do not represent risk bearing members include 5 medical professionals providing care to Medicaid patients in that region

3 of these will be primary care physicians; 1 from APHCA/ALNMA, 2 from regional board of health


Remaining 2 medical professionals include an optometrist and pharmacist

• None of the non-risk bearing professionals can be risk bearing or be employed by a risk bearing organization

Statutory RCO RequirementsGovernance

Community Representatives (3)Participants shall include:Chair of the citizens’ advisory committeeAnother citizens’ advisory committee member elected by the committee (must be member of AL Arise or AL Disabilities Leadership CoalitionBusiness executive nominated by Chamber of Commerce in the region

Statutory RCO Requirements• Citizens’ Advisory Committee• Committee will advise the Board

on ways the organization may be more efficient in providing quality care and carry out other functions and duties assigned to it by the RCO and approved by Medicaid

At least 20% shall be Medicaid patients enrolled in the RCO

Planning Principles

1. Any Willing Provider - A provider may contract with any RCO to provide services in a Medicaid region if the provider is willing to accept the payments and terms offered comparable providers

Medicaid Redesign Principles

2. Provider Reimbursement Floor – established by AMA for providers inside and outside of the region; may be higher for in region providers, but must be at least the Medicaid floor (current rate?) to prevent RCOs from unfairly excluding providers outside of the region

Medicaid Redesign Principles3. Every RCO will contract with Children’s

Hospital of Birmingham, UAB Hospital, & other hospitals as necessary to ensure specialty services remain available

4. Maternity Care Program will be included in RCO services and capitation

5. PCN scope of case management will be included in RCO services and capitation

Medicaid Redesign Principles6. Capitation amount for each region will be

region specific. 7. 700,000 out of 900,000 Medicaid patients will

be covered by RCOs 8. Family planning and dentistry will not

participate in RCOs during phase 1 9. LTC will not be included in RCOs

Statewide Medicaid Regions

1. Market demand will determine the number of RCOs per region; each will have a minimum of 60,000 eligibles; larger regions help to minimize risk

2. Regions not modeled after any existing government regions or districts; other Medicaid regions will transition into RCO regions (i.e., maternity care)

Statewide Medicaid Regions

3. Regional organization intended to maintain hospital and physician referral patterns/patient relationships; minimize border crossover issues (also, see any willing provider)

4. Patient residence establishes basis for RCO assignment and capitation

• Draft Map; final adoption to occur by October 1, 2013

• Public Hearing

Timeline and Next Steps

• Public comments for policies through Administrative Procedures Act (35 days for public comment)

• Opportunity for Public Hearing

Timeline and Next StepsOctober 1, 2013- Establish/Adopt Medicaid Managed Care RegionsOctober 1, 2014- Organizations seeking to become a RCO must have governing board and structure approved by MedicaidApril 1, 2015- Probationary RCOs must demonstrate ability to establish adequate medical service delivery network


October 1, 2015- Probationary RCOs must meet financial requirementsOctober 1, 2016- Probationary certification expires; must demonstrate capability of providing services pursuant to a risk contract

Timeline and Next StepsNext StepsRules around Collaboration – possible emergency rule submitted in SeptemberProvisional Certification – possible rules submitted by January 2014 (requirements, application content, risk bearing tests)


Next StepsRCO Certification – final rules possible by April 2014AMA open to RCO applications for provisional status possibly from April – August 2014

Provider Activities1.Understand RCO system design, requirements, timeline2.Internally assess your role within the planning, development, implementation of RCO and ongoing program3.Collaborate as allowed under statute with others at appropriate time4.Educate patients at appropriate time

Questions

Alabama Primary Health Care AssociationSharon Parker, RN CVRN, CHTS-CP

Chief Quality [email protected]

334-386-3985

mailto:[email protected]

Facilitated by Alabama Primary Health Care Association

Documents

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