UPDATE: Medicaid Expansion, Implementation of HB 2572, Medicaid Managed Care
Medicaid Managed Care Transformation - NCACDSS...SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY...
Transcript of Medicaid Managed Care Transformation - NCACDSS...SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY...
Medicaid Managed Care Transformation
NC Medicaid
July 31, 2019
1. Why Managed Care?
2. Benefits of Managed Care?
3. Managed Care in Context
4. What Has Happened So Far
5. Managed Care Timeline
6. Managed Care Updates
7. DSS Supports
8. Issues and Concerns
9. Transition of Care
10.Next Steps
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Agenda
In 2015, the NC General
Assembly enacted Session
Law 2015-245, which
directed the Department of
Health and Human Services
(DHHS) to transition
Medicaid and NC Health
Choice from fee-for-service
to managed care.
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
Medicaid Transformation
3
“North Carolina has
continued to perform
below average in a
national ranking of state
health systems, moving
from 35th in 2018 to
34th this year.”
https://www.northcarolinahealthnews.org/2019/0
6/13/health-report-cards-north-carolina-below-average-performance-access/
Opportunities for Health
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• Integration of care
• Implement whole-
person centered, and
well-coordinated
system of care
• Address medical and
non-medical drivers
of health.
Opportunities to Improve Health
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Managed Care In Context
• Transitioning to managed care is most significant change
that NC Medicaid has ever undertaken.
• With any rollout of this magnitude, there will be have been
issues and questions that arise.
• We are committed to doing everything possible to resolve
problems quickly
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
What has happened so far?
• Phase 1 Enrollment Packets started to be distributed on 7/8 (205,000+)
• Phase 1 Open Enrollment began 7/15
NC Medicaid Website is live
− Ncmedicaidplans.gov
Enrollment Broker Call Center is open and accepting calls
− Toll Free Phone Number: 1-833-870-5500
− TTY: 1-833-870-5588
Health Plan Member Service Lines are open and accepting calls
− WellCare: 1-866-799-5318 |
− UnitedHealthcare: 1-800-349-1855 |
− HealthyBlue: 1-844-594-5070 |
− AmeriHealth Caritas: 1-855-375-8811 |
− Carolina Complete Health: 1-833-552-3876 |
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019 7
8
Medicaid managed care rumor #1
Medicaid Managed
Care has been delayed
You may have heard…
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
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Medicaid managed care rumor #1
Medicaid Managed
Care has been
delayed
FALSE TRUE
• Managed Care is still slated to go
live Nov. 1st 2019
• An approved budget is necessary to
support managed care
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019 10
Medicaid Transformation Timeline
Jan. Feb.Sept. Oct. Dec.July Aug.
Health Plans Provide Beneficiary Support
7/15/2019 – 9/13/2019
Open Enrollment
10/14/2019 -12/13/2019
Open Enrollment
02/01/2020
Managed Care Day 1
11/01/2019
Managed Care Day 1
Nov.
PHASE 1: Regions 2 & 4
PHASE 2: Regions 1, 3, 5 & 6
June
2019
2020
Enrollment Broker Provides Beneficiary Support – Choice Counseling
10/1/2019
Enrollment Packets Begin
Local DSS will continues to determine Medicaid Eligibility and Help direct beneficiary to proper Support System
Auto-Assignment
• NEMT Services for Managed
Care Members will begin
11/1/2019
• NEMT vendors will begin
accepting appointments on
10/1/2019 for appoints
scheduled on or after
11/1/2019
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How will we measure success?
• Member Health Measures
− Quality Indicators
• Member satisfaction
− DHHS, PHPs, EB measures
− Complaints and Grievances
• Call center data
− Reported average speed to answer , abandonment rates, hold times
• Notices and correspondence
− Outbound mail communications to consumers
• Voluntary plan selection rates
− Represents the percent of population who actively select their health plan vs.
being auto-assigned into a plan
• Provider Enrollment
− Number of providers enrolled with Medicaid
− Number of providers contracted with PHPs
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
Inquiry Type (Call Reason)
# o
f Tic
ke
ts
Medicaid Contact Center Inquiries (Call Reasons) – Week of July 22 (to date)
So what do we know so far?
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Open Enrollment Metrics
Enrollment Broker
Call Center
8,817 Calls
Handled
NCmedicaidplans.gov
5,010 Website Visits
NC Medicaid Managed
Care Mobile App
3780 Sessions
All information for the period of July 25, 2019
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Open Enrollment Metrics
NCmedicaidplans.gov
1384 web chats
NC Medicaid Managed
Enrollments
3477 Enrollments
All information for the period of July 25, 2019
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Medicaid managed care rumor #2
Providers are
not enrolling
in managed
care
You may have heard…
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019 16
Network Adequacy & Member Enrollment• DHHS’ priorities
− Medicaid and NC Health Choice beneficiaries have broad access
to providers
− NC providers continue to participate in the Medicaid program.
• Foundation
− Large Provider Network - 90,412 Medicaid Direct (FFS) providers
enrolled 11/2018*
− Provider Choice
− Rate Floors
− Centralized credentialing
− No deadline established for provider contracting
− PHP Network adequacy requirements
− Ongoing oversight and monitoring of Network Adequacy standards
− Clear contract terms to hold PHP’s accountable with wide range of
remedies (CAPs, liquidated damages, termination of contract)
*Consideration- when comparing provider numbers consider that not all enrolled providers are currently billing Medicaid.
Providers Enrolled
− All current providers are not yet enrolled
− As of 7/24/2019 there were over 23,000 providers enrolled in Managed Care Medicaid
Issues with Provider Enrollment
- Some providers are not in the directory
- Beneficiaries cannot locate their PCP
- Provider Information is displayed differently than in NC FAST
Solutions
Networks will grow, most providers will contract
− DHHS will monitor networks between now and go-live and ongoing
− Beneficiaries can wait (the EB will remind them later)
− Beneficiaries will be auto Assigned
− Beneficiaries can change plans until January 31, 2020
− DHHS is focused on correcting information
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Where are we now?
18
Medicaid managed care rumor #2
FALSE
Providers are
not enrolling
in managed
care
TRUE
• Providers are contracting
• Provider numbers will increase daily
until we go live
• DHHS will hold PHPs accountable to
meeting network adequacy
standards and ensuring that we
have sufficient providers to meet
member needs
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DSS Support?
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• Managed Care on-boarding sessions (Feb-Mar 2019)
• Health Plan cross functional training (April 2019)
• Monthly webinars (ongoing)
• Virtual office hours (ongoing)
• Enrollment Broker onsite for in-person support
(begins July 2019)
• DHHS staff onsite for in-person support (begins July 2019)
• County Playbook
• DSS staff in ALL 27 Phase 1 counties trained as of June 14
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What has happened so far?
• Heads of Household for some minors unable to make selections.
• Authorized Representative not displaying for Enrollment Broker
• Beneficiaries may not be able to find their Primary Care Provider of choice in the provider directory.
• The Enrollment Broker call center agents can now verify that the person is the head of household associated with the minor.
• The Enrollment Broker call center agents can now verify that the person is the authorized representative.
• Beneficiaries do not have to choose now. A reminder call will be mailed in August. May be auto assigned and can change later.
Issue Solution
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What issues have we encountered?
• A few individuals have received letters who should not have
• Provider Directory information
• Corrections have been mailed. New letters will go out (in case of Dual Eligibles)
• EB revisions to directory
• Provider Corrections in NCTRACKS
Issue Solution
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What issues have we encountered?
QUESTION: What should I do if contacted by
PHP for a meeting?
QUESTION: What if a PHP wants to set up a
booth in my lobby?
QUESTION: What if a PHP wants to contract
with DSS?
QUESTION: What if I have not heard from the
PHP?
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Other Areas of Concern?
• PHPs can engage in permitted marketing
activities in certain locations:
• Community centers or health fairs
• Markets/Malls /Retail establishments
• Hospitals, Pharmacies and Other Provider
Sites• Only in common areas, not treatment areas; all PHPs contracted
must have equal opportunity to be represented
• Schools• Only at university campuses or at community-based events/health
fairs
• Other state-approved community-based
events or locations
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DSS, PHP, EB Interactions
• PHP marketing
−What’s not permitted• Direct or indirect cold-call marketing+
• Practices that seek to influence enrolment in conjunction with sale of any
other insurance product +
• Activities that could mislead, confuse or defraud members or potential
members +
• Offer of material or financial gain to members or inducement to enroll +
• Practices that are discriminatory or that target prospective members based
on health status+
• Direct mailings
• Offering of coupons for produce of value
• Outreach activities related to enrollment (must refer to Enrollment Broker)
• Outreach activities/materials in treatment areas
• Activities that seek to target individuals currently enrolled in another
Contractors’ plan
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DSS, PHP, EB Interactions
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Tailored Plan Implementation Update
• Eligibility Update/Revisions
−Data criteria
−Services available only in Tailored Plan
−Meeting eligibility criteria when enrolled in a Standard
Plan
−Urgent Need for Services in a Tailored Plan
• Eligibility Reconciliation
• Exemption Form
−Beneficiary Form
−Provider Form
• Crisis Services Memo
• Policy Papers – next Care Management Data Strategy
PaperSOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
Benefit Packages/Services
BH, TBI and I/DD Services Covered by Both SPs and BH I/DD Tailored Plans
BH, I/DD and TBI Services Covered Exclusively by BH I/DD Tailored Plans(or LME-MCOs Prior To Launch)
Enhanced behavioral health services are italicizedState Plan BH and I/DD Services• Inpatient behavioral health services• Outpatient behavioral health emergency room services• Outpatient behavioral health services provided by direct-
enrolled providers• Partial hospitalization• Mobile crisis management• Facility-based crisis services for children and adolescents• Professional treatment services in facility-based crisis program• Peer supports (move from( b)(3) to state plan)* • Outpatient opioid treatment• Ambulatory detoxification • Clinically managed residential withdrawal (aka social setting
detox)* • Research-based intensive behavioral health treatment• Diagnostic assessment • EPSDT• Non-hospital medical detoxification• Medically supervised or ADATC detoxification crisis stabilization
State Plan BH and I/DD Services• Residential treatment facility services for children and adolescents• Child and adolescent day treatment services• Intensive in-home services• Multi-systemic therapy services• Psychiatric residential treatment facilities• Assertive community treatment• Community support team • Psychosocial rehabilitation• Substance abuse non-medical community residential treatment• Substance abuse medically monitored residential treatment• Clinically managed low-intensity residential treatment services* • Clinically managed population-specific high-intensity residential programs*• Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)• Substance abuse comprehensive outpatient treatment program (SACOT)**• Substance abuse intensive outpatient program (SAIOP)**
Waiver Services• Innovations waiver services• TBI waiver services • 1915(b)(3) services (excluding peer supports if moved to state plan)
State-Funded BH and I/DD ServicesState-Funded TBI Services
Only BH I/DD TPs will cover a subset of high-intensity State Plan BH services; TBI, Innovations and 1915(b)(3) waiver services; and State-funded BH, I/DD, and TBI services
*DHHS will submit a State Plan Amendment to add this service to the State Plan** updated 7/31/19
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Current Behavioral Health and Non Behavioral Health
LME / MCO
NC Innovations
I/DD
Substance Use
Mental HeathState Funded
Doctors
Hospital
Physical
Therapy
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Future and Tailored Plans
LME / MCO
NC Innovations
I/DD
Substance Use
Mental HeathState Funded
Doctors
Hospital
Physical
Therapy
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Future and Tailored Plans
Tailored Plan
• NC Innovations
• Respite
• Supported Employment
• ICF-IID• Enhanced Services
• State Funded Services
Doctors
Hospital
Physical
Therapy
Care
Management
Care
Management
Who are the LME /MCOs?
Alliance Health
Cardinal Health Innovations
Eastpointe
Partners
Sandhills Center
Trillium
Vaya
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Similar• Both require physical health and behavioral health.
• Both offer comprehensive array behavioral health services
Different
• TPs target individuals with significant BH, TBI & I/DD
needs, thus services in the plan match individuals needs.
• 1915(b)(3), Innovations, TBI wavier services and state-
funded behavioral health and I/DD services will only be
available in TPs or LME-MCOs (prior to TP launch).
• Care management will be available to all TP enrollees.
• TPs can have closed provider network for BH.
Plans are tailored to meet the needs of members
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How are SPs and BH I/DD TPs different?
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Foster Care Update
• Design in Progress
• Approach will address
−Unique needs of children in foster care, adoptive
placements and those formerly in foster care up to age
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−Statewide
−Specific PHP staffing
− Transition of Care
• DSS Feedback will be sought
• Timeline – 2021
• Until then- Foster Children remain in current system
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
• Procurement Continues
• Silent Period in force
• https://www.ncdhhs.gov/request-information
• Numerous updates to RFP
• Most recent
− https://files.nc.gov/ncdhhs/20190724-Omb-RFP-30-
190485-DHB-Addendum-5-Revisions-to-the-
RFP.pdf
−Revisions to RFP
−Extend opening
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Ombudsman
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
• DHHS transfer of claims data
• PHP Expectations
−Honor Prior Authorizations
−Offer Appeal Rights
−Non Participating providers
• Pay claims and authorize service
−Non Emergency Medical Transportation (NEMT)
• Accept NEMT appointments for post-MCL services one
month prior
• Identify NEMT utilizers through claims detail.
• Substance Use Disorder (SUD)-related
Requirements
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Transition of Care
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:
Preparing for Managed Care: Helping Members through Crossover Process
When I will start getting care through my health plan
We want to
ensure
Members
have simple,
clear, “pocket
reference”
answers to
these
questions.
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Supporting Members through the Crossover Experience
• DHHS will be creating member-facing tools
to assist members “know where to go.”
• Will focus on supporting members to
organize information and to be aware of
“who to call” with questions or issues.
• We want members to “be prepared, not
scared.”
SOURCE:
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
Upcoming DHHS-Sponsored Webinars on Crossover
• For August 15, 2019: MCT 112
− Supporting the LTSS Community through the Transition to Managed Care
− As NC transitions to managed care, North Carolina is establishing processes for
ensuring providers and members have a smooth transition. This webinar will discuss
activities related to Prior Authorization submissions and provider payment
considerations at the time of transition.
• For September 5, 2019: MCT 113
− NC’s Transition to Managed Care: The Crossover Series
− This session provides general crossover guidance, with a focus on identifying
beneficiary managed care detail and guidance on submitting prior authorization
requests during the crossover period.
• For September 19, 2019: MCT 114
− NC’s Transition to Managed Care: The Crossover Series (Continued)
− This session is a continuation of the session on Sept. 5, 2019, providing a brief
review of topics previously covered and additional guidance for supporting
beneficiaries through the transition to Medicaid Managed Care.
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
Questions to SSI Attendees
• What other information do you anticipate
beneficiaries will need/want to prepare for
Crossover?
• How can DSSs best support members to
understand these elements?
• What are your insights on effective
distribution mechanisms?
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
• Summer
−Phase 1 Open Enrollment (July 15-September 13)
−Standard Plan/Tailored Plan Split
−Health Plan/Provider contracting to build adequate
networks
− Foster Care Policy Recommendation
• Fall
−Phase 1 Auto-Assignment (September 16)
−Readiness Reviews – network, operations, IT
−Phase 2 Open Enrollment (October 15-December 13)
−Phase 1 Health Plan Effective (November 1)
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Upcoming Major Activities
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
ABOUTELIGIBILITY
Continue to come to local DSS
Find contact information at
ncdhhs.gov/localdss
ABOUTCHOOSING
A PLAN OR PCPAND ENROLLING
Go to ncmedicaidplans.gov
(chat available)
Use theNC Medicaid
Managed Caremobile app
Call 1-833-870-5500(the call is free)
TTY: 1-833-870-5588
ABOUTNC MEDICAID
MANAGED CARE PLAN OR BENEFITS
Call theirHealth Plan
ABOUTNC MEDICAID
DIRECT BENEFITS
AND CLAIMS
Call the Medicaid Contact Center
toll free:
1-888-245-0179
40
Contacts for Beneficiaries
SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019
Questions
41
MEDICAID MANAGED CARE WEBCAST | JULY 15, 2019