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

Care

Joan Alker Tricia Brooks

Sarah SomersKelly WhitenerRuth Kennedy

CCF Annual Conference 2015

Today

What we’ll talk about….• Consumer Information• Enrollment • Disenrollment• Plan choice• Types of managed care• Benefits and EPSDT• Network adequacy• Consumer protections• Quality• The State perspective

What we’ll defer to MC 201….• Payment methodologies• Actuarial soundness• Rate setting• Contract requirements

Approaching Our Work on Managed Care

What do children and

their families need?

How do we make sure that kids

and families are well served?

What do they need to

know?

POPULATIONS

ENROLLMENT

CONSUMER INFORMATION

Tricia Brooks

Share of Medicaid Enrollees in Managed Care• Historically children

and low income families

• Recent shifting of duals and disabled to achieve better cost controls and care coordination for high need, high cost populations

• All expansion adults0%

10%

20%

30%

40%

50%

60%

70%

80%

0.03

0.14

0.294

0.5758

0.63

0.7170.7422

Voluntary vs. Mandatory

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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

Populations

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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)

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 plan

Mandatory

• Risk-based managed care plans– Choice of plans

• Exception for rural areas where choice of primary care provider is required

• Other protections also exist

• Primary care case management– Choice of providers

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Plan Selection vs. Auto-Assignment

• Goal for states is as to enroll as quickly as possible• Some states require that enrollees select a plan

upfront when applying• Others wait until after eligibility has been determined• All must have auto-assignment (default enrollment)

process for those who do not choose• Number of plans to choose from varies by state and

region

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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 plans

NPRM 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 Issues

• No 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 Brokers

• States 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 interests

• Mixed evidence of the effectiveness of enrollment brokers

NPRM requires choice counseling and

establishes broader requirement for

beneficiary support system

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Disenrollment

Requested by Plan• May not disenroll based on

utilization, change in health status, special needs

• Contract should specify reasons plans may use for requesting disenrollment

Requested by the Enrollee• First 90 days • At least once every 12

months, with 60 day notice• At any time for cause• May require enrollee to seek

redress through grievance system before disenrolling

• Effective no later than the first of the second month following the month of the request

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Cause for Disenrollment• Enrollee 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 available• Others, including but not limited to, poor quality, lack

of access to covered services or qualified providers

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Consumer Education

• Health insurance literacy • Low-income uninsured may

have little or no experience with managed care

• May be transitioning from FFS to MC

Benefits

NetworkDrugs

Enrollment

Accessing Services

Getting Help

Appeals

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Notices and Written Information

• All notices and informational or instructional materials must:- Be in an easily understood language and format- Be 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 formats

• Provided upon eligibility determination in time to support plan selection

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Language Support

• States must…• Identify prevalent languages spoken by a significant

number or percentage of enrollees and potential enrollees• State and plans must…• provide written information in all prevalent languages• provide oral interpretation for all non-English languages• must inform enrollees and potential enrollees of

availability and how to access language supports

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State Responsibilities

• Mechanism to help enrollees and potential enrollees understand managed care

• Must ensure that managed care plans fulfill their responsibilities

• Information must include:– Basic features of

managed care– Which groups are…

• Able to enroll voluntarily• Excluded from enrollment• Required to enroll

– Disenrollment rights

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NPRM has new and very detailed information

requirements

MC Plan Responsibilities

• Mechanism to help enrollees and potential enrollees understand plan requirements and benefits

• Information must include:– Benefits and how to

access– Cost-sharing– Service area– Provider information– Restrictions on choice of

provider– When services of covered

out of network– Grievances and appeals

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Marketing Restrictions

• Distribution of materials must be approved by state in consultation with Medical Care Advisory Committee

• Must distribute to everyone in service area• Can’t sell other products• Info must not be fraudulent, misleading or confusing• Cold-calling is prohibited

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Other Beneficiary Protections

• Access to emergency services without prior authorization

• Defines emergency medical conditions, services, and out-of-network access

• No restrictions on patient-provider communications

• Liability for payment• Anti-discrimination

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Roll Out of New MC Implementation

• No Standards but….- Must be adequate time for system development- Sufficient resources to ensure smooth transition- Phased-in approach may work best

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TYPES OF MANAGED CARE ENTITIESBENEFITS AND EPSDT NETWORK ADEQUACY AND ACCESS STANDARDS

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Sarah Somers

Medicaid Managed Care – Key Terms

• Contract, RFP- Risk contract

• Capitation- PMPM

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Medicaid Managed Care Entities

• MCO – Managed Care Organization• PIHP, PAHP – Prepaid Health Plan

- (Inpatient or Ambulatory)• PCCM – Primary Care Case Management

- “Managed’ fee for service• PACE – Program of all-inclusive care for the elderly

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NPRM Adds New Definitions

• PCCM Entity – Primary care case management entity

• NEMT PAHP – Non-Emergency Transportation Prepaid Ambulatory Health Plan

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Benefits

• Basic requirement: - States must ensure that all services covered under

Medicaid state plan are “available and accessible”

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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

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Services for Enrollees with Special Health Care Needs

• States must:- Identify such persons* to plans- Assess individual needs (using appropriate health

care professionals)- Allow direct access to specialists

• Require plans to produce a treatment plan (optional)- Developed by provider with enrollee input- Approved by plan

*as defined by the state

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Network Adequacy

• No specific federal standards- Contracts- State law

• Example: Virginia Contract (pp. 39, 245)• Example: California Regulations (28 Cal. Code.

Regs.1300.67.2)

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32

33 33

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

• Required for beneficiaries under age 21• Outreach and informing• “Screens” (check ups)• Treatment• Assistance with accessing services

Great Resource

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Policy Reasons for EPSDT

Low-income children are more likely to have:

Vision, hearing and speech problems Untreated tooth decay Elevated lead blood levels Sickle cell disease Behavioral Health problems Anemia Asthma Transportation barriers And more . . .

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EPSDT Requirements: Mandatory Screenings

Medical ScreensHealth and

developmental historyUnclothed physical

exam Immunizations Lab tests, including lead

blood testsHealth education

Other ScreensVision, including

eyeglassesHearing, including

hearing aidsDental, 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 plan

• CMS Guidance: no hard limits on hours/visits

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EPSDT Requirements: Outreach and Informing

• Effective and aggressive- Oral and written- Translated- Targeted (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 services- Carve outs, failure of state to ensure services are

provided• Limits on number of visits/hours• Prior authorization for screens, delaying

services• Stricter medical necessity definition than state

uses

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Questions?

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GRIEVANCES AND APPEALS

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Sarah Somers

Medicaid Due Process: Legal Authority

• Constitution• Medicaid statute• Federal regulations• State law• Contracts (MC)

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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 erroneously• Reduction, suspension, termination of service• PASRR, transfer or discharge from NF

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Right to Appeal, cont’d

• “Action” of MCO:- Denying, reducing, terminating or otherwise

limiting services or denying payment for services- Failing to timely provide services- Denying request for disenrollment or exemption- “otherwise adversely affecting the individual”

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Notice• Must include:

- Action taken- Reasons for action- Right to file appeal- Right file state hearing request- Expedited resolution- Continued benefits

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Grievance

• An expression of dissatisfaction about any matter other than an action

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Continued Benefits

• Must 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 decision

- Beneficiary can be required to pay for benefits if he ultimately loses

• ISSUE – no continued benefits beyond authorization period

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QUALITY MEASUREMENT AND IMPROVEMENT

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Tricia Brooks

Quality Assessment and Improvement Strategy

• Current 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

entities

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Each State Contracting with an MCO or PIHP must….

• Have a written strategy for assessing and improving quality

• Obtain public input • Ensure plan compliance• Review effectiveness and update the strategy • Submit strategy to CMS, as well as updates and

reports on implementation and effectiveness

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Required Elements of Quality Strategy• Assess 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 compliance• Incorporate national performance measures if

applicable• Arrange for annual independent external quality review

(EQR)• Ensures adoption and dissemination of practice

guidelines

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MC Entity Must Conduct Performance Improvement Projects

• Use objective measurements• Assess clinical and nonclinical areas• Implement system interventions to improve care• Evaluate effectiveness• Submit state or CMS specified performance

measurement data• Identify both underutilization and overutilization of

services• Assess quality and appropriateness of care for enrollees

with SHCN

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External Quality Review (EQR)• Applies to MCO, PHIP, HIO• EQR organization must meet federal standards• Analyzes 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 regulations

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http://www.healthlaw.org/issues/medicaid/managed-care/EQR-Overview06162014pdf#.VQ7JvBDF_2w

EQR?Validates performance measures and improvement programs :

Mandatory EQR Activities

- Evaluate quality, timeliness, and access to care

- Assess plan’s strengths and weaknesses, and recommend quality improvement project

- Appraise how well each plan responded to previous QI recommendations

Optional 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

Common Issues Across EQR Reports • Data collection methods vary• No federally required measures; states can pick and

choose but tend to use most common• Challenging to compare across states or plans• MCO’s come and go, so difficult to form a picture of

system performance• Comprehensiveness of the reporting to CMS is

improving

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NPRM lays foundation for alignment and more consistent

reporting on quality

CHIP

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Kelly Whitener

CHIP Managed Care Rules

• The 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 enrollment- Section 1932(a)(5): Provision of information- Section 1932(b): Beneficiary protections- Section 1932(c): Quality assurance standards- Section 1932(d): Protections against fraud and abuse- Section 1932(e): Sanction for noncompliance

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CHIP Managed Care Rules

• CMS provided initial guidance on these rules in two State Health Official (SHO) letters- SHO#09-008 offered guidance on implementing the new

requirements generally, including submitting CHIP managed care contracts to CMS for review for the first time

- SHO#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!

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How is CHIP managed care different?

Contracts & Rates• Contracts 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 requirements

Beneficiary Enrollment• There 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 plan

• Beneficiaries can be required to pay premiums prior to enrollment

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THE STATE PERSPECTIVE

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Ruth Kennedy

QUESTIONS AND DISCUSSION

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Resources• CMS “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/

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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Contact

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Sarah Somerssomers@healthlaw.org www.healthlaw.org

Joan Alkerjca25@georgetown.edu

Tricia Brookspab62@georgetown.edu

Kelly Whitenerkdw29@georgetown.edu