The Transition to Medicaid Managed Care in Illinois

Transcription

1 The Transition to Medicaid Managed Care in Illinois December 12, 2013 Presented by: Sharon R. Miller

2 Transition to Medicaid Managed Care Welcome Who Am I? 30 yrs. Experience in Managed Care Adjunct Professor at Benedictine University teaching Managed Care and Business of Health Care Classes (MPH program)

3 What We Will Cover

4 What We Will Cover What We Will Cover The Basics of Managed Care Medicaid Now Taking You Inside the Payer World Different Departments and Rules Managed Care Reimbursements Capitation Reimbursement vs. Risk Medicaid Managed Care: Shifting Roles

5 Why are We Covering This???? Managed Care programs are not just unique to Illinois this is a nationwide movement. I Heard that Managed Care Does Not Work.not true What does this have to do with me and my job? A Shift in levels of patient responsibility.

6 The Basics of Managed Care (HMO model) Managed Care is NOT new.been around since the 1920 s; then became popular in the late 70s. Health Insurance Companies establish networks of providers Patient selects a Health Plan Patient selects a Primary Care Provider (PCP) All medical services approved through this PCP Other rules: referrals, pre-cert needed for ER visits and certain medical procedures Tight controls over services

7 The Basics of Managed Care Our Focus HMO style

8 Medicaid Now IDoA sends claim to State State contracts with provider Contract pays based on a fee for service IDoA reimburses provider Eligibility and need determined thru Case Mgmt. Provider bills IDoA Pt. sees provider

9 Taking You Inside the Payer World State Contracts with Insurance Companies to Manage all aspects of the Patient s Experience

10 Working with Payers the new Medicaid configuration State oversees compliance State contracts with insurance company State still handles eligibility Patient is managed through insurance company This is called a Risk Contract Insurance company accepts a fixed rate to manage patient

11 Review of Medicaid Changes to Managed Care Changing Patient Relationship New: patient relationship is with the insurance company, not the State Changing: Claims Processing done by Insurance Companies New: State pays lump sum to insurance company (more on this later) State keeps eligibility function and takes on oversight function Day-to-day handled by insurance company

12 Taking You Inside the Payer World DEPARTMENTS Administration Marketing/Sales Finance Customer Service MIS Dept. *** Operations/Claims Insurance Company *** Medical Affairs *** Provider Relations *** UM/QA

13 Managed Care Reimbursement: Capitation Reimbursement Models How Do Providers Get Reimbursed with Managed Care?

14 Managed Care Reimbursement: Capitation Reimbursement Models Many Different Ways: FFS P4P (Pay for Performance) Hospital Case Rates Volume Rates Full Capitation Fee Schedules DRG Hospital Bed Type Primary Care Capitation

15 Managed Care Reimbursement: Capitation Capitation This is a payment methodology where a fixed amount of money is paid in advance to the insurance company for the delivery of health care services. New term: PMPM Per Member Per Month

16 Managed Care Reimbursement: Capitation Capitation Example 1,000 patients (members) Capitation rate = $ per month Total pre-paid per month to insurance company = $1,063,760 Sounds good, right????

17 Managed Care Reimbursement: Capitation What Does the Insurance Company Need to Do for this Advance Payment? Everything in their contract!!!! Doctor Services Hospital Services Long Term Care Services Ancillary Care Services Anything/Everything Else

18 Managed Care Reimbursement: Capitation And..the Insurance Company does NOT get 100% of the capitation because of something called a Risk Pool Insurers will get paid 80% capitation with 20% withheld. In order to collect on the withhold, the insurance company needs to meet certain quality measures set by the State. If they meet the measures, they get the 20% back at the end of the year.

19 Capitation vs. Risk RISK CONTRACTS This is what capitation is all about: RISK If the insurance company controls the risk, they profit. If the insurance company does not control the risk, they lose money.

20 Medicaid Managed Care: Your Shifting Roles Eligibility Confirmation!!! Know What s Covered and What s Not!!! Understand Who is Responsible for What!!!

21 Medicaid Managed Care: Your Shifting Roles OVERSIGHT OVERSIGHT OVERSIGHT

22 Questions

23 Contact Information: Sharon Miller