California Department of Managed Health Care€¦ · California Department of Managed Health Care
Medicaid/CHIP Managed Care Regulations: Ensuring ... · Managed Care Project • Series of six...
Transcript of Medicaid/CHIP Managed Care Regulations: Ensuring ... · Managed Care Project • Series of six...
Medicaid/CHIP Managed Care Regulations: Ensuring Accountability & Transparency
Joan Alker Sarah Somers Kelly Whitener
September 29, 2016
Children in Managed Care
• CMSfinalizedsweepingchangestoMedicaidandCHIPmanagedcareregula;onsinMay2016
• Regula;onssetminimumstandards;stateshaveflexibilitytodomore
• Manyopportuni;esforlegalandhealthadvocatestotakeac;on
2
Flagpoten+alac+onsforlegalandhealthadvocates
Why are these rules so important?
66% of children in Medicaid/CHIP are enrolled in MCOs
22% of children in Medicaid/ CHIP are enrolled in
PCCMs
11% of children in Medicaid/ CHIP are enrolled in
FFS
Source:CMSMedicaidManagedCareEnrollmentReport2013
3
Managed Care Project
• Seriesofsixexplainerbriefsandwebinars① LookingattheRulethroughaChildren’sLens(6/17)② ImprovingConsumerInforma;on(6/23)③ EnhancingtheBeneficiaryExperience(7/19)④ AssuringNetworkAdequacyandAccesstoServices(8/5)⑤ AdvancingQuality(9/8)⑥ EnsuringAccountabilityandTransparency(9/29)
• Fallmee;nginD.C.withchildhealthandlegaladvocatestostrategizeoverimplementa;on
• ThankstoRobertWoodJohnsonFounda;on
4
Our Topic Today: Ensuring Accountability & Transparency
• Contrac;ngRequirements• MedicalLossRa;o• ActuarialSoundness&RateSegng• WebsitePos;ngRequirements• CHIP
5
Flagpoten+alac+onsforlegalandhealthadvocates
CONTRACTING REQUIREMENTS
Kelly Whitener
6
Managed Care Contracts
• Fundamentallegaldocumentdefiningtheresponsibili;esofthestateandtheplan
• Historicallydifficulttoobtain,butnowmustbepostedonthestate’swebsite*
*42C.F.R.§438.602(g)(1) 7
ManagedCareOrganiza;ons(MCO)PrepaidInpa;entHealthPlans(PIHP)PrepaidAmbulatoryHealthPlans(PAHP)PrimaryCareCaseManagementEn;;es(PCCMen;;es)
Nolaterthanthera;ngperiodstar;ngonoramerJuly1,2017
Managed Care Contracts
*hnp://www.healthlaw.org/publica;ons/managed-care-toolkit-march-2015#.V-qzgJMrIWp 8
Reviewyourstate’smanagedcarerequestforproposalsandresul+ngcontractstomakesuretheycomplywithMedicaidstatute,regula+ons,andcaselaw,aswellasanyrelevantstatelaw.Contractsshouldalsohaveprovisionstoholdplansaccountableformee+ngthestandards,suchassanc+ons.Forfurtherguidanceonthisissue,seeNHeLP’sGuidetoOversight,Transparency,andAccountabilityinMedicaidManagedCare.*
Standard Contract Requirements §438.3(a)
• StatesmustsubmitcontractstoCMSforreviewandapproval,atleast90dayspriortothedesiredeffec;vedate.
9
ManagedCareOrganiza;ons(MCO)PrepaidInpa;entHealthPlans(PIHP)PrepaidAmbulatoryHealthPlans(PAHP)
Effec;veasofJuly5,2016
Enrollment Discrimination Prohibited§438.3(d)
• Plansmustaccepteligibleindividualsintheorderinwhichtheyapply
• Planscannotdiscriminateonthebasisofhealthstatus,needforhealthservices,race,color,na;onalorigin,sex,sexualorienta;on,genderiden;ty,ordisability
10
ManagedCareOrganiza;ons(MCO)PrepaidInpa;entHealthPlans(PIHP)PrepaidAmbulatoryHealthPlans(PAHP)PrimaryCareCaseManagementEn;;es(PCCMen;;es)
Effec;veasofJuly5,2016
Services that may be Covered§438.3(e)
• Plancontractsmustdescribetheservicestheplanisrequiredtocoveraswellasthoseservicesthatmaybecoveredvoluntarily
• Plansmayprovidealterna;veservicesordeliverservicesinalterna;vesegngsundernew“inlieuof”provisions
11
ManagedCareOrganiza;ons(MCO)PrepaidInpa;entHealthPlans(PIHP)PrepaidAmbulatoryHealthPlans(PAHP)
Effec;veasofJuly5,2016
• PlansmustcomplywithfederallawsoutsideofMedicaid,liketheCivilRightsAct,theAmericanswithDisabili;esAct,andnow,sec;on1557oftheAffordableCareAct
• Sec;on1557prohibitsdiscrimina;ononthebasisofrace,color,na;onalorigin(includingimmigra;onstatusandEnglishlanguageproficiency),sex,age,ordisability
12
Effec;veasofJuly5,2016
Compliance with Applicable Laws §438.3(f)
ManagedCareOrganiza;ons(MCO)PrepaidInpa;entHealthPlans(PIHP)PrepaidAmbulatoryHealthPlans(PAHP)PrimaryCareCaseManagementEn;;es(PCCMen;;es)
Discrimination
*hnp://www.hhs.gov/civil-rights/for-individuals/sec;on-1557/13
IndividualswhobelievethatplanshavediscriminatedagainstthemmayfileacomplaintwiththeOfficeofCivilRightsatHHS.Formoreinforma+ononfilingacomplaintandlinktotheOCRcomplaintform,consulttheHHSwebsite.*
• Statesandplansmustcomplywithconflictofinterestsafeguardstoensurestateemployeesresponsibleforoverseeingtheplansareimpar;al
• Stateemployeesmaybepreventedfromhavingafinancialinterestinplanswhileinthoserolesandevenamerleavingstateemploymentinsomecases
14
Effec;veasofJuly5,2016
Compliance with Conflict of Interest Safeguards§438.3(f)
ManagedCareOrganiza;ons(MCO)PrepaidInpa;entHealthPlans(PIHP)PrepaidAmbulatoryHealthPlans(PAHP)PrimaryCareCaseManagementEn;;es(PCCMen;;es)
• PlansmustprovidethestateandCMSwithaccesstofinancialrecordsoftheplanandanysubcontractors
• Inspec;onsandauditscanoccuratany;meandcanincludenotjusttherelateddocumentsbutalsothephysicalpremises,facili;es,andequipment
15
Effec;veforthera;ngperiodbeginningonoramerJuly1,2017
Inspection and Audit of Records§438.3(h)
ManagedCareOrganiza;ons(MCO)PrepaidInpa;entHealthPlans(PIHP)PrepaidAmbulatoryHealthPlans(PAHP)PrimaryCareCaseManagementEn;;es(PCCMen;;es)
Subcontracts §438.3(k)
• Allsubcontractsmustfulfillthemanagedcarerequirementsfortheserviceorac;vitydelegatedtothem
16
ManagedCareOrganiza;ons(MCO),PrepaidInpa;entHealthPlans(PIHP),PrepaidAmbulatoryHealthPlans(PAHP),andPrimaryCareCaseManagementEn;;es(PCCMen;;es)subcontracts
Effec;veforthera;ngperiodbeginningonoramerJuly1,2017
Subcontracts §438.230 1. Theplanmaintainstheul;materesponsibilityfor
complyingwithallthetermsandcondi;onsofitscontractwiththestate
2. Iftheplandelegatesanyofitsobliga;onstoasubcontractor,thedelegatedac;vi;esmustbespecifiedinthecontract&thesubcontractormustagreetocomplywiththestate’sterms
3. Subcontractorsaresubjecttothesameauditandinspec;onstandardsasplans
4. Allsubcontractsmustallowfortermina;onorotherremediesifthestateorplandecidesthesubcontractorisnotperformingsa;sfactorily
17
Parity in Mental Health and Substance Use Disorder Benefits §438.3(n)
• Thementalhealthandsubstanceusedisorderparityrequirementsmaybemetthroughdifferentarrangements- MCOprovidesallbenefits- MCOprovidessomebenefitsandPIHP/PAHPprovidesothers- MCOprovidessomebenefitsandthestateprovidesothers
throughFFS
• Compliancemustbedemonstratedinthecontractandsuppor;ngdocumentssubminedtoCMS
18
States,MCOs,andanyPIHPorPAHPprovidingservicestoMCOenrollees
Effec;veasofJuly5,2016
Parity
*hnps://www.medicaid.gov/medicaid-chip-program-informa;on/by-topics/benefits/mental-health-services.html 19
Thespecificsofmentalhealthandsubstanceusedisorderparityarecomplicated.Moreover,theyareevolving,givenhowrecentlytheparityrulewasfinalized.Advocatesshouldwatchforaddi+onalguidancefromCMSandfromsupportcenters,includingNHeLP.*
Long Term Services and Supports§438.3(o)
• Servicesthatcouldbeauthorizedthroughahomeandcommunitybasedwaivermustmeetcertainstandards,like:- Integratedinthecommunity- Selectedbytheindividual- Ensureindividualrightsofprivacy,dignity,andrespect
20
MCOs,PIHPs,andPAHPsthatincludeLTSSasacoveredbenefit
Effec;veasofJuly5,2016
Additional Rules for PCCMs & PCCM Entities§438.3(q)
• PCCMsandPCCMen;;esmustmeetsomeofthesameavailabilityofservicesandbeneficiaryprotec;onsthatapplytoMCOs:- Provideforreasonablehoursofopera;on,including24-houremergencycare- Restrictenrollmenttobeneficiarieswholivenearoneofthedeliverysites- Havesufficientnumbersofproviderstoensurepromptandhighquality
treatment- Prohibitdiscrimina;onbasedonhealthstatusorneedforhealthcareservices- Allowenrolleestodisenroll
21
PrimaryCareCaseManagement(PCCM)PrimaryCareCaseManagementen;;es(PCCMen;;es)
Effec;veforthera;ngperiodbeginningonoramerJuly1,2017
Additional Rules for PCCM Entities§438.3(r)
• Addi;onally,PCCMen;;esmustsubmittheircontractstoCMSforreviewandapproval
• CMSwillbelookingforcompliancewiththeapplicablecontrac;ng,consumerinforma;on,andqualityprovisions
22
PrimaryCareCaseManagementen;;es(PCCMen;;es)
Effec;veasofJuly5,2016
Covered Outpatient Drugs§438.3(s)
Fournewrequirementsforplansthatprovideoutpa;entdrugs:1. Statesandplansmustcoveralloutpa;entdrugs
thatarewithinthescopeofthestatute- Plansmustcoverdrugsthatarewithinthescopeofthecontract,
eveniftheyarenotontheformulary(drugsnotontheformularymaybecoveredthroughapriorauthoriza;onprocess)
- Statesmustcoverdrugsoutsidethescopeofthecontractbutwithinthescopeofthestatute
23
MCOs,PIHPs,andPAHPsthatprovideoutpa;entdrugs
Effec;veasofJuly5,2016
Covered Outpatient Drugs§438.3(s)
2. Plansmustreportalldrugu;liza;ondatasothatthestatehasalltheinforma;onnecessarytobillmanufacturersfordrugrebates
3. Plansmusthaveadrugu;liza;onreviewprogramtoassurethatprescrip;onsareappropriate,medicallynecessary,andnotlikelytoresultinadversemedicaloutcomes
4. Plansmusthaveapriorauthoriza;onprogram- Plansmustrespondtorequestforpriorauthoriza;onwithin24hours- Plansmustdispensea72-hoursupplyofacoveredoutpa;entdrugin
anemergencysitua;on
24
• Plansandsubcontractorsmustretaincertainrecordsforatleast10years- Enrolleegrievances&appeals- Basedata- MLRreports- Programintegritydataanddocumenta;on*
Recordkeeping§438.3(u)
*See42C.F.R.438SubpartH 25
ManagedCareOrganiza;ons(MCOs)PrepaidInpa;entHealthPlans(PIHPs)PrepaidAmbulatoryHealthPlans(PAHPs)Subcontractors
Effec;veasofJuly5,2016
MEDICAL LOSS RATIO
Sarah Somers
26
Medical Loss Ratio§438.8
• BasicRule:EachplanmustreportaMLRcalculatedaccordingtotheregula;ons- Ifstateschoosetosetaminimum,itmustbeatleast85%
27
ManagedCareOrganiza;ons(MCO)PrepaidInpa;entHealthPlans(PIHP)PrepaidAmbulatoryHealthPlans(PAHP)
Effec;veforra;ngperiodbeginningonoramerJuly1,2017
Medical Loss Ratio§438.8
• Defini&on:theamountaplanspendstoprovidecoveredservicescomparedtothetotalcapita;onpaymentrevenue
• Equa&on:Incurredserviceclaims+healthquality
expenditures+fraudreduc;on
÷ adjustedpremiumrevenue
28
Medical Loss Ratio§438.8
• Incurredclaims:directclaims,unpaidclaims,withholdsfromproviders- Mustdeductoverpaymentrecoveries,drugrebates,e.g.
• Healthqualityimprovement:ac;vi;esrelatedtoEQR,HIT,orotherslikelytoincreasedesiredhealthoutcomes,groundedinevidence- Notcostcontainmentormarke;ng
29
Medical Loss Ratio§438.8
• Adjustedpremiumrevenue:premiumsminuslocaltaxes,licensingfees,andregulatoryfees
30
Medical Loss Ratio§438.8
• Statesarenotrequiredto:- SetaminimumMLR- RequirerefundsfromplansifMLRnotmet
• Statesmust:- RequireeachplantoreportMLRandrelateditems
31
UrgeyourstatetorequireaminimumMLRof85percentifitdoesnotdosoalready.
ACTUARIAL SOUNDNESS AND RATE SETTING
Sarah Somers
32
Actuarial Soundness and Rate Setting
• KeyTerms:- BaseData:historicaldatausedtodevelopcapitatedrates
(e.g.encounterdata)- Ra&ngPeriod:;meperiodforwhichmanagedcarerates
arebeingdeveloped- Riskadjustment:methodologyaccoun;ngforhealth
statusofenrolleesandriskthattherewillbegreaterservicecostsforthem
33
Actuarial Soundness§438.4
• BasicRule:Ratesmustbeprojectedtomeetallreasonableandappropriatecostsnecessarytoprovidecoveredbenefitstoenrollees
34
ManagedCareOrganiza;ons(MCO)PrepaidInpa;entHealthPlans(PIHP)PrepaidAmbulatoryHealthPlans(PAHP)
PhasedinfromJuly5,2016tora;ngperiodbeginningonoramerJuly1,2019
Actuarial Soundness§483.4
• Ratesmustbe:- cer;fiedbyanactuary- approvedbyCMS
• MustbedevelopedsothatplanwillachieveaMLRofatleast85%
• MaynotvarybasedsolelyonrateofFFPfordifferenteligibilitycategories
35
Rate Setting §438.5
• Stepstosetrates:- Iden;fyandconsiderbaseu&liza&onandpricedata- Developandapplytrendsincostandu&liza&onof
servicesbyactualexperienceofMedicaidbeneficiaries- Developthenon-benefitpartoftheratetoaccountfor
opera;onalexpenses(e.g.admincosts,licensingfees)- TakeintoaccountpastMedicalLossRa&os- Selectriskadjustmentmethodologyusinggenerally
acceptedmethodology- Makeothernecessaryadjustments
36
Rate Setting§483.5
• Statesmustprovideandusebasedataconsis;ngof- Allvalidatedencounterdata- FFSdata- Auditedfinancialreportsreflec;ngcoverageofthe
Medicaidpopula;onforatleastthethreemostrecentyearsbeforethera;ngperiod• Statesthatcannotmeetthatstandardmayaskforanexcep;on
butmusthavecorrec;veac;onplantocomeintocompliancewithregula;on
37
Actuarial Soundness and Rate Setting
hnps://www.medicaid.gov/medicaid-chip-program-informa;on/by-topics/delivery-systems/managed-care/downloads/2016-medicaid-rate-guide.pdfhnps://www.medicaid.gov/federal-policy-guidance/downloads/cib070116.pdf 38
Thisisahighlytechnicalareaoftheregula+ons.CMShasprovidedaddi+onalwriRenguidanceexplainingtheserequirements.SeeCMS2016MedicaidManagedCareRateDevelopmentGuideandCMCSInforma+onalBulle+n,Addendumto2016MedicaidManagedCareRateDevelopmentGuide.
WEBSITE POSTING REQUIREMENTS
Kelly Whitener
39
Website Posting
• Statesmustoperateawebsite*• Provisionsthroughouttherulerequirecertain
informa;ontobepostedonthestate’swebsite
*42C.F.R.§438.10(c) 40
Encourageyourstatetoprovideopportuni+esforwebsitetes+ngandfeedback,andtoexploretheadvantagesofhavingallrelatedconsumermaterialspostedonthestate’swebsiteasasinglesourceofconsumerinforma+on,ratherthanlinkingtoindividualplanwebsites.
Website Posting • Enrolleehandbook• Providerdirectory• Drugformulary• Annualmanagedcare
programreport• Networkadequacy
standards• Documenta;onof
compliancewithavailability&accessibilityofservices
• Plancontract• Accredita;onstatus• Qualityra;ng• Statequalitystrategy• Qualitymeasuresand
performanceoutcomes• Qualitystrategyreviews• AnnualEQRreport• Planownership&control
informa;on• Auditresults
41
CHIP
Kelly Whitener
42
CHIP Contracting Requirements
GeneralRule • Medicaid’sstandard
contrac;ngprovisionsaregenerallyapplicabletoCHIPat§457.1201
• Medicaid’ssubcontrac;ngrequirementsarealsoapplicabletoCHIPat§457.1233(b)
NotableDifferences• CMSreviewsCHIPcontracts
butdoesnotrequirepriorapproval
• SubmissionofCHIPratesisonlyrequiredonrequest
• Provisionsrelatedtodualeligibles,LTSS,andoutpa;entdrugsdonotapplytoCHIP
43
CHIP Payment Rate Requirements
RateDevelopmentStandards• CHIPratesarenotsubject
toasmanyrequirements• Ratesmustbebasedon
publicorprivateratesforcomparableservices&popula;ons
• Statesmustprovideadescrip;onofhowratesaredevelopeduponrequest
MedicalLossRa&o• ApplicabletoCHIPat
§457.1203(c)
44
45