Reimbursement Models For School Based Health Centers Under Managed Care

Transcription

1 Reimbursement Models For School Based Health Centers Under Managed Care Colleen Sonosky, JD Center for Health Services Research and Policy School of Public Health and Health Services The George Washington University (and) The HRSA Center for Health Services Financing and Managed Care

2 SBHC in and out of Network Purchasers Pays SBHC (Approach A) Purchaser MCO Pays SBHC State Requires-Out of Network Payment (Approach B) Purchaser MCO SBHC SBHC Participates in MCO Network (Required or Voluntary) (Approach C) MCO SBHC SBHC Paid By PCP (Approach D) Purchaser Purchaser MCO MCO PCP/IPA SBHC NETWORK OF SBHCs SBHC

3 Approach A: SBHC Out of MCO Network Purchaser MCO SBHC

4 Approach A: SBHC Out of MCO Network, continued Carve-out Approach or exclusion found in IL Provider 56: Medicaid provider category for SBHCs SBHCs enrolling as Medicaid providers bill SMA on FFS basis for services furnished to children and adolescents in Medicaid MCOs Policies to avoid duplication of payment

5 Approach A: SBHC Out of MCO Network, continued Contract Language Offset of amount paid to SBHCs Listing of services Notification Withhold of confidential information

6 Approach B: MCO Pays Out- of- Network SBHC Purchaser MCO SBHC

7 Approach B: MCO Pays Out- of- Network SBHC, continued State example: Michigan State Title V agency designates SBHCs as qualified providers Medicaid contract requires MCOs to pay SBHCs for services furnished to enrolled children on FFS basis without prior authorization

8 Approach B: MCO Pays Out- of- Network SBHC, continued Contract Language General Duties (payment, information, nondelegation) Listing of services Documentation Rate and timeliness of payment Distribution between FQHC and Non-FQHC

9 Approach C: Contract Requirement or Voluntary Arrangement to Include SBHC in Provider Network Purchaser MCO SBHC Network of SBHCs

10 Approach C: Contract Requirement or Voluntary Arrangement to Include SBHC in Provider Network, continued PCP v. non-pcp Responsibilities Operational hours of SBHCs General Requirements Credentialing Patient records Encounter data Referrals Prescriptions

11 Approach C: Contract Requirement or Voluntary Arrangement to Include SBHC in Provider Network, continued Contract Language Requirement to subcontract Purchaser s supplemental payment Model subcontract As PCP As participating provider As PCP and participating provider

12 Incentives for Subcontracting with SBHCs Establish financial incentives for MCOs to subcontract with SBHCs Enhanced capitation rates Enhanced scoring in competitive bidding Increased Medicaid enrollment

13 Approach D: SBHC Paid By PCP Purchaser MCO PCP/IPA SBHC

14 Approach D: SBHC Paid By PCP SBHC forms contractual or other relationship with community-based primary care providers (PCPs). Community-based primary care providers are participating in a managed care provider network

15 Approach D: SBHC Paid By PCP (continued) Issues To Be Worked Out Between SBHC and PCP/ Community-Based Provider: Scope of services to be provided by SBCH. How the SBHC will be reimbursed by the PCP for services provided fee schedule/partial capitation? How clinical and billing information will be shared by the SBHC with the community-based primary care provider and vice-versa.

16 Sample Managed Care Provider Subcontracts AAP, Model Managed Care Agreement (1998). AHLA, Managed Care Contracting Handbook: A Guide for Payors and Providers, 4 th Ed. (June 2001). AMA, Model Managed Care Contract (2 nd Ed.) (2000), Epstein, Becker & Green, PC, "Model Agreement," School- Based Health Centers and Managed Care: Contracting Issues and Options (July 2000), Center for Health Care Strategies, Inc., New Mexico Human Services Department, Medical Assistance Division, SBHC/MCO Pilot Project, Agreement to Provide School-Based Health Center Services Between School-Based Health Center Contractor and Managed Care Organization (March 6, 2001) (template for use in Salud! program).

17 Other SBHC Resources Opportunities to Use Medicaid in Support of School-Based Health Centers, American Academy of Pediatrics, Policy Statement: School-Based Health Services and Other Integrated School Health Services (January 2001), Center for Adolescent Health and the Law website, Center for Health and Health Care in Schools (CHHCS) website, National Assembly on School-Based Health Care, Partners in Access: School-Based Health Centers and Medicaid, Policies and Practices (October 2001), pdf. George Washington University Center for Health Services Research and Policy, Purchasing Specifications: School-based Health Center Services (January (2002),