Welcome to the Managed Care 101 Webinar

Transcription

1 Welcome to the Managed Care 101 Webinar Communication Access Real-time Transcription (CART) is available by clicking here: The login: Username: OLL Password: OLL The transcripts along with the webinar will be posted on the MLTSS webpage 1

2 Managed Care 101 Alissa Halperin August 20, 2015

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4 GoToWebinar Housekeeping: Attendee Participation Your Participation Open and close your control panel Join audio: Choose Mic & Speakers to use VoIP Choose Telephone and dial using the information provided Submit questions and comments via the Questions panel Note: Today s presentation is being recorded and will be available on our website within 48 hours.

5 Training Outline General Managed Care Overview Medicaid Managed Care Overview Medicare Managed Care Overview Managed Long-Term Supports and Services Questions 9/22/2015 5

6 What is Managed Care? Both a service delivery structure and a financing arrangement.

7 Understanding Fee-For-Service (FFS) Payments: Payments are made for each service rendered. Gatekeeper: System does not typically pre-approve services or specialty visits. Does not typically provide coordination of care across providers or coverage. Benefit Package: A standardized benefit package. There may be prior authorization requirements and benefit limit exceptions. Provider Network: Any willing provider who is willing to accept the defined payment. Historically, states structured their Medicaid programs as FFS delivery systems. Since the 1990s, many states have moved Medicaid populations to managed care for Medicaid healthcare services. Only in recent years have more and more states been moving Medicaid LTSS populations for LTSS delivery. 9/22/2015 7

8 Understanding Managed Care - Generally Gatekeeper: MCO serves as primary gatekeeper for access to benefits. Referrals: PCP charged with serving as gatekeeper for access to specialists. Benefits Package: Defined set of covered services that may vary by insurance company. There may be prior authorization requirements and benefit limit exceptions. Provider Network: Selective contracting with certain providers. Formulary: List of pharmaceuticals that will be available typically tiered. Utilization Review/Management: Staff at MCO manage things such as in patient admission and length of stay as well as access to/approval of services Capitation/Capitated Payment: MCO agrees to provide covered services for a fixed monthly payment (capitated payment). If the MCO provides services that cost less than the payment, it makes money. If the MCO provides services that cost more than the payment, it loses money. Defined Service Area: The approved area in which the MCO operates 9/22/2015 8

9 Types of Managed Care Managed Care Organizations (MCO) or Health Maintenance Organization (HMO) Plan has a defined set of benefits and contracts with providers to provide the full range of the benefits to their enrollees. Centered on PCP as the organizer All non emergent care requires prior approval (other than primary care) Preferred Provider Organization (PPO) Member selects provider of choice Initial PCP visit/ specialty prior authorization not required Point of Service (POS) At time of need, member selects HMO or PPO pathway 9/22/2015 9

10 Rules Governing Managed Care Federal Law The HMO Act of 1973 established certain federal standards for HMOs that elected to operate under federal law. Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L ) applies certain federal minimum requirements to state-regulated insurers as well as to employer-sponsored plans, including managed care plans. State Law - Act 68 of 1998 (amending the Insurance Company Law of 1921) sets many managed care requirements - essind=0&act=68&mobile_choice=suppress 9/22/

11 Medicaid Managed Care

12 Understanding Medicaid Managed Care Medicaid Managed Care is when state government pays an entity to provide a defined benefit package and meet quality and performance standards established in a contract to a distinct portion of the state s Medicaid population in exchange for a fixed, capitated payment. Similar to the general managed care model described earlier, however, there are additional rules governing Medicaid managed care that apply and there are some different features. 9/22/

13 Key Features of Current Medicaid Managed Care Regulations Fixed minimums around many areas, including but not limited to: Participants Rights Grievance and Appeal Requirements Choice of at least 2 plans Marketing Credentialing Enrollment Processes Limits on cost-sharing External Quality Review requirements Network Access and Adequacy Sometimes states can modify the federal rules to require more or less than the federal rules require. Typically, states can provide better or more generous protections for the consumer than the fixed minimums. 9/22/

14 Other Features in Medicaid Managed Care Carve-outs Some services will be carved out of the plan benefit package. Dental or behavioral health services are some examples. Readiness Plans must demonstrate readiness to the state before they may proceed with enrollment and service delivery. Process can be lengthy. Credentialing Process often includes meeting state and/or Medicaid participating provider requirements. Rates Capitated payments to MCOs must be actuarially sound Emergency and Urgently Needed Services must be covered when provided by Out-of-Network providers 9/22/

15 Rules Governing Medicaid Managed Care Federal Regulations at 42 CFR 438 govern Medicaid Managed Care title42-vol4-part438.xml New Proposed Regulations just published for comment at - 9/22/

16 Medicare Managed Care

17 Understanding Medicare Managed Care Medicare Managed Care plans are also referred to as Medicare Advantage Plans or Medicare Part C plans Medicare Managed Care provides everything covered by Part A and Part B but through a private managed care company under contract with the Medicare program Most also provide Part D Many provide additional supplemental benefits beyond just what Parts A and B and D cover (for example, OTC) Enrollees usually pay a monthly premium to be in a Medicare Managed Care Plan (in addition to Part A or B premiums) and usually pay different cost-sharing amounts (deductibles and copayments) than are charged under Parts A and B 9/22/

18 Key Features Medicare Managed Care Fixed minimums around many areas, including but not limited to: Participants Rights Grievance and Appeal Requirements Marketing Enrollment Processes Network Access and Adequacy 9/22/

19 Rules and Requirements for Medicare Advantage Regulations at 42 CFR 422 cover Part C title42-vol3-part422.xml - and for plans that also include Part D benefits 42 CFR 423 cover Part D title42-vol3-part423.xml Medicare Managed Care Manual - Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs- Items/CMS html 9/22/

20 MLTSS Medicaid Managed Long-Term Services and Supports

21 What is MLTSS? Managed Long-Term Services and Supports (MLTSS) is a managed care program through which a state pays an entity to manage delivery of LTSS, most typically through a capitated payment arrangement Examples include: MLTSS (LTSS-Only) Plans Managed ALL Medicaid Services Including LTSS PACE (LIFE in PA) Integrated Care Plans 9/22/

22 Federal Requirements What are the legal requirements for States that implement MLTSS? States must have Federal Managed Care Authority and States must have Federal Home and Community Based Authority in their Medicaid Programs Federal Medicaid managed care authorities include 1915a, 1915b, and Federal Medicaid HCBS authorities include: 1915(c), 1915(i), 1915(j), 1915(k), and 1115 There are requirements and limitations related to each authority Federal regulations for general Medicaid Managed Care 42 CFR 438 et. seq. Federal regulation for Medicare Managed Care; Integrated programs 42 CFR 422 et seq. Many guidance documents and manuals with which plans must comply CMS Guidance to States on MLTSS (2013) 9/22/

23 CMS MAY 2013 MLTSS Guidance To States The guidance outlines 10 key elements to a good MLTSS program. Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSSguidance.pdf These have been incorporated into the new proposed Medicaid Managed Care regulations. Guidance calls for: Thoughtful and adequate planning for MLTSS development as well as stakeholder engagement in the process. Enhanced Provision of HCBS: All MLTSS programs must be implemented consistent with the ADA and Olmstead. Under the law, MLTSS must be delivered in the most integrated fashion, in the most integrated setting, and in a way that offers the greatest opportunities for active community and workforce participation. 9/22/

24 CMS MAY 2013 MLTSS Guidance To States Guidance also calls for: Alignment of Payment Structures and Goals: States must design their payment structures so that they support the goals of their MLTSS programs and the essential elements of MLTSS. Effective programs hold providers accountable through performance-based incentives and/or penalties. On an ongoing basis, states must evaluate their payment structures and make changes necessary to support the goals of their programs. Support for Beneficiaries: MLTSS participants must be offered conflict-free education, enrollment/disenrollment assistance, and advocacy in a manner that is accessible, ongoing, and consumer-friendly. Person-centered Processes: All MLTSS programs must require and monitor the implementation and use of person-centered needs assessment, service planning, and service coordination policies and protocols. MLTSS programs should provide opportunities for and encourage use of self-direction of services. Comprehensive, Integrated Service Package: MCOs must provide and/or coordinate the provision of all physical and BH services and all LTSS and must ensure that participants receive those services and supports in the amount, duration, scope, and manner as identified through the person-centered assessment and service planning process. 9/22/

25 CMS MAY 2013 MLTSS Guidance To States Qualified Providers: States must ensure that MCOs develop and maintain a sufficient network of qualified LTSS providers that ensure access to all services. During transition to MLTSS, states should encourage, or require through contract provisions, the incorporation of existing LTSS providers as MCO network providers to the extent possible. States must provide, or require MCOs to provide, support to traditional LTSS providers, which may include areas such as information technology, billing, and systems operations, to assist them in making the transition to MLTSS. Participant Protections: States must ensure that participant health and welfare is assured in MLTSS, including a statement of participant rights and responsibilities; a critical incident management system with safeguards to prevent abuse, neglect and exploitation; and fair hearing protections including the continuation of services during an appeal. Quality: States are expected to maintain the highest level of quality in all MLTSS operations and services through the development and implementation of a comprehensive quality strategy that is integrated with any existing state quality strategies. The design and implementation of a quality improvement strategy must be transparent and appropriately tailored to address the needs of the MLTSS population. 9/22/

26 State Requirements What are the Legal Requirements for States that implement MLTSS? State agencies often need authority from the legislature to develop an MLTSS program or to develop the licensure requirements around a new kind of entity (like a LTSS-Only plan). Many states also set requirements in regulations or contract provisions. State managed care or insurance laws, like Act 68 in Pennsylvania, often apply. 9/22/

27 What is the Current Landscape of MLTSS? Currently: PACE a total of 114 PACE programs in 32 States (as of 2015) As of May 2015, 22 States were offering MLTSS Duals Demonstrations operating in 9 states (capitated model), pending in 2 states (capitated model), and operating in 2 states (MFFS) States are Developing New MLTSS Programs Developing New Integrated Programs Modifying existing programs to add new services or new populations Expanding existing programs to new service areas 9/22/

28 Goals of MLTSS Improve coordination of services and resolve fragmentation of care and accountability, which has become a bigger problem as LTSS remains in FFS while other types of care are in managed care. Develop a person centered system of care that addresses range of individual needs by: Increasing access to HCBS Services to NFCE and also NFI Safely decreasing institutional utilization Improving clinical and quality outcomes Building on consumer choice Medicaid Budget Predictability 9/22/

29 Key Features of State MLTSS Programs Passive or automatic enrollment Varying array of Covered Services Broad Provider Network with Choices (including choice of care manager) Continuity of Care in providers and care plans Person-Centered Care/Service Planning Advocate for Participant Independent Ombudsman Use and Importance of Health Information Technology 9/22/

30 Key Features of State MLTSS Programs Care Coordination Approach Interdisciplinary Team Systems for Continual Data Feedback and Analysis Reliance on Evidence-Based Practices Heightened Requirements Around Accessibility Incorporation of Participant-Directed Services Value-Add Services 9/22/

31 QUESTIONS?

32 GoToWebinar Housekeeping: time for questions Your Participation Please continue to submit your text questions and comments using the Questions panel For more information, please send your to Note: Today s presentation is being recorded and will be provided within 48 hours.