Colorado Medicaid Update

Transcription

1 Colorado Medicaid Update Colorado Welfare Fraud Council and Social Services Technical and Business Staff Conference April 6, 2016 Susan E. Birch, MBA, BSN, RN, Executive Director 1

2 Presentation Agenda Current Landscape: Colorado and the Affordable Care Act o Effect on number of Coloradans insured o Our partnership with Connect for Health Colorado Looking into the Future: Becoming the Healthiest State o Enhanced accountability & driving value HCPF fights fraud, waste and abuse Our Program Integrity Unit Eligibility determinations Questions 2

3 Our Mission Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources 3

4 Historic Uninsured Rates: 6.7% Source: Colorado Health Institute s 2015 Colorado Health Access Survey, Infographic by Colorado Health Institute. 4

5 Medicaid & the Colorado Coverage Landscape Administration Costs:*3% (estimates vary) Source: Insured percentages and uninsured estimates from Colorado Health Institute s (CHI) 2015 Colorado Health Access Survey. Infographic by CHI. 5

6 Open Enrollment Summary Note: figures are approximate and based on the last day of each open enrollment period Medicaid 158,521 (expansion only) 76,194 (all enrollees) 54,447 (all enrollees) CHP+ * 3,720 3,549 Connect for Health Colorado 118, , ,583 Total 277, , ,579 *CHP+ was not measured in isolation during the open enrollment. Approximately 23,000 EBNE kids (Medicaid and CHP+) enrolled during the first open enrollment. 6

7 Becoming the Healthiest State Coverage is the first step... Key focus areas Governor s Vision 2018: Behavioral Health Reduce substance use disorders Reduce impact on daily life of mental illness Physical Health Reduce obesity rates Increase immunization rates Health Systems New federal regulations require enhanced screening and revalidation of providers enrolling with Colorado Medicaid. 7

8 Sound Stewardship of Financial Resources Benefits Coordination (3rd party liability) more than $72 million Drug Rebates more than $324 million Program Integrity more than $8 million ACC net savings $77 million Policy Interventions more than $41 million Data cited above is from FY

9 Fighting Fraud, Waste & Abuse Efforts span the entire Department: Benefit Design Prior Authorizations Client Over-utilization Program Nursing Facility Section Health Programs & Client and Clinical Care Offices Eligibility reviews & internal audits Program integrity is woven into all aspects of how we cover and pay for medical services. 9

10 Benefits Coordination Medicaid is the payer of last resort Responsible third parties should pay before Medicaid considers payment. Estate Recovery Trust and Repayment Recovery Tort and Casualty Recovery Post-Payment Recoveries Benefits Coordination Our Benefits Coordination Section makes sure the correct party pays for our members medical services. 10

11 Fighting Fraud, Waste & Abuse Audits and Compliance Division Consists of our Program Integrity Section, Federally Required Eligibility and Claims Reviews Section and the Audit Information Management Section Provider Fraud, Waste and Abuse Beneficiary Fraud Leading a national beneficiary fraud taskforce of Program Integrity Directors or their delegates More than 22 states participating Identifying best practices for reducing beneficiary fraud, waste and abuse Learning to leverage federal and state resources to address this growing concern 11

12 Program Integrity Fights Beneficiary Fraud Our HCPF team works hard to Assist county fraud investigators Share best practices and foster consistency among counties Work with our many partners, including law enforcement, District Attorneys and the Attorney General, Department of Justice and Drug Enforcement Agency Provide Medicaid data to partners to assist in investigation and prosecution of cases Assess tips and referrals and conduct preliminary investigations when needed Program Integrity Develop and establish HCPF policies and procedures for Medicaid fraud, waste and abuse 12

13 Eligibility determinations Eligibility partners are key to the success of the Medicaid program! Ensure that those who qualify receive timely services Ensure that those who do not qualify never enter the system Time and money saved Investigation and administrative costs Cost of medical services rendered to the ineligible Credibility Trust in government entities Proper use of tax dollars 13

14 Questions? 14

15 Thank You Susan E. Birch, MBA, BSN, RN Executive Director Health Care Policy & Financing 15