MAXIMUS Webinar Series

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1 MAXIMUS Webinar Series The New Beneficiary Support System Requirements and Other Beneficiary Protections Continuing the Discussion on the CMS Rule for Medicaid & CHIP Managed Care June 8,

2 Introductions Jinnifer Wattum Senior Director MAXIMUS Health Services Cathy Kaufmann Principal HMA 2

Background on the Rule First major update to Medicaid and CHIP managed care regulations since 2002 Managed Care is now the predominant form of Medicaid 74% of Medicaid and 81% CHIP enrollees

3 Background on the Rule First major update to Medicaid and CHIP managed care regulations since 2002 Managed Care is now the predominant form of Medicaid 74% of Medicaid and 81% CHIP enrollees get all or part of their benefits through a managed care organization 39 states and D.C. contract with private managed care plans 2/3 of all Medicaid beneficiaries enrolled in managed care 3

4 State Comprehensive Managed Care 4

5 Key Goals To support State efforts to advance delivery system reform and improve the quality of care To strengthen the experience of beneficiary care and key protections To increase program integrity by improving accountability and transparency To align key requirements of Medicaid and CHIP managed care with other health coverage programs 5

6 What We Will Cover Today Beneficiary support system and choice counseling requirements Modernization of information requirements Language and disability access Enrollment and disenrollment protections Appeals and grievances Effective dates and considerations for compliance Questions 6

Beneficiary Support System States are required to establish a beneficiary support system to assist beneficiaries in making informed choices about plan enrollment System includes both technology

7 Beneficiary Support System States are required to establish a beneficiary support system to assist beneficiaries in making informed choices about plan enrollment System includes both technology supports and operational/support services Must be an independent system that helps beneficiaries and potential enrollees understand information provided by the state or plans about managed care This support must be provided both before and after enrollment 7

Special help for beneficiaries receiving or who want to receive Long-Term Services & Supports (LTSS) Final

resources Assistance must be available in multiple ways (via phone, online and in-person), as well as via

8 Beneficiary Support System (cont.) Beneficiary support system must provide: Choice counseling Assistance in understanding managed care Special help for beneficiaries receiving or who want to receive Long-Term Services & Supports (LTSS) Final rule dropped requirement that BSS provide training to plans and network providers about community-based resources Assistance must be available in multiple ways (via phone, online and in-person), as well as via auxiliary aids and services when requested Must conduct outreach to beneficiaries and potential enrollees about these supports Special provisions for LTSS beneficiaries (covered in last webinar) 8

9 Choice Counseling Choice counseling is a critical function of the beneficiary support system Must be available at initial enrollment and whenever there can be (or must be) a plan change Emphasis on personalized, timely, unbiased and knowledgeable assistance Any entity that provides choice counseling will be considered an enrollment broker and subject to the existing HHS independence and conflict-of-interest standards Enrollment broker function incorporated here and expanded to address these new requirements MCOs cannot support any beneficiary support system activities 9

10 Audience Poll How many of you believe your state already meets the beneficiary support system requirements? 1. 1 Done and done: Yes, I m confident we meet or exceed the requirements We are close to meeting them, but we will need to make a few changes / expand our services a little more We have a few requirements in place but have a lot of work to do in the next two years Nope and nope: we are nowhere near meeting these requirements! 5. 5 Doesn t apply: my state doesn t use managed care for Medicaid or CHIP. 10

11 Implementing the Beneficiary Support System States have a fair amount of flexibility in how they meet these requirements States can offer services beyond those required in the final rule States already providing the services and resources required in a beneficiary support system don t need to create a new system States can use multiple contracts/existing partnerships to meet the requirements Remember that conflict free requirements apply these entities can t have a financial interest in any MCOs or providers in the state Beneficiary support and enrollment broker services are eligible for FFP (50 percent admin match) 11

12 Modernization of Information Standards Final information standards match what was in the proposed rule Extensive requirements to support beneficiaries actively selecting a plan and providing them better information about their coverage and rights Clarify that the full range of electronic communications is permitted ( , texts and website posting of required information) Beneficiaries must be able to obtain paper versions of all materials upon request and free of charge 12

13 Standardize Materials States are required to develop models for standard information for plans to use, including model handbooks, notice templates and definitions of key terms States are also required to maintain a Medicaid managed care website that provides member handbooks, provider directories and drug formulary lists Information can be provided via a link to the managed care plan s website Can also be provided by the BSS on its website or in enrollment packets 13

14 Support for Limited English Proficiency (LEP) & Disabilities Final rule adds definition of LEP used by the Office of Civil Rights: Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak or understand English may be LEP and may be eligible to receive language assistance with respect to the particular service, benefit or encounter Important member materials must be provided in state s prevalent languages: Prevalent left undefined, up to states to determine 14

15 Support for LEP & Disabilities Taglines in large print and in locally prevalent languages are required on all written materials Required to provide oral interpretation services in all languages (not just prevalent), as well as auxiliary aids and services for enrollees with disabilities (upon request and free of charge) and to notify enrollees about how to access these services 15

16 Marketing Maintains prohibitions on communication from Medicaid managed care plans that seeks to influence plan selection Recognition that a single legal entity may be operating both marketplace and Medicaid lines of business Note that consumers may move back and forth between Medicaid and QHP and may prefer to remain with same carrier and consumer should have access to information about coverage options Clarifies the limitations do not apply to QHPs even if have a Medicaid line of business 16

Enrollee (Member) Handbooks Plans must send each enrollee a handbook within a reasonable time after receiving notice of enrollment This handbook must include information that enables the enrollee to

17 Enrollee (Member) Handbooks Plans must send each enrollee a handbook within a reasonable time after receiving notice of enrollment This handbook must include information that enables the enrollee to understand how to effectively use the managed care program, including at minimum: Benefits provided by the plan and how to access them Benefits provided by the state and how to access them Emergency coverage Cost sharing How to select a provider (freedom of choice among) Enrollee rights Grievances and appeals 17

18 Provider Directories Provider Directories may be provided online (and by print via request) but updated no later than 30 days after the plan receives updated provider information Printed provider directory must also be updated monthly Provider information must include the provider s cultural and linguistic capabilities, including languages spoken and whether the provider has completed cultural competence training Must also note whether the provider s office/facility is accessible for people with physical disabilities 18

19 Enrollment Process New requirements for voluntary and mandatory managed care enrollment Final rule seeks to standardize these processes across states States can still choose whether or not to allow an initial choice period or auto-enroll Protection maintained for enrollee choice, but backed off proposed requirement for mandatory 14-day FFS enrollment Strong pushback from states on this proposal Instead, state must provide potential enrollee, the opportunity to actively elect to receive covered services through the managed care or FFS delivery system in a voluntary enrollment state or make a different plan selection in a mandatory enrollment state Again, heavy emphasis on beneficiary education and personalized support when it comes to enrollment 19

20 Enrollment Process (cont.) Passive enrollment into managed care remains an option for states Must allow enrollee a period of time to make an active choice or select a different plan Beneficiaries must receive an explanation at the time of enrollment about the implications of being enrolled and how to choose a different plan Process must seek to preserve existing relationships with providers (left undefined) or providers with history of serving Medicaid beneficiaries Only plans with capacity and not subject to sanctions can receive passive enrollments If not possible to preserve provider relationships, beneficiaries must be distributed equitably across plans 20

21 Enrollment Process (cont.) If state does not utilize passive enrollment, a default enrollment process is required for beneficiaries who do not select a plan Plan must have capacity and distribution across plans should be equitable May also consider family member enrollment, plan performance and accessibility of provider offices for people with disabilities 21

22 Disenrollment by a Member If State limits disenrollment by beneficiary choice, plan contracts must provide that a beneficiary may request disenrollment: For cause, at any time Without cause, at the following times: During the 90 days following the date of the beneficiary's initial enrollment, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later 22

For Cause Disenrollment Disenrollment for cause by a member permitted for: Move out of the service area Needed services unavailable through the plan s network

23 For Cause Disenrollment Disenrollment for cause by a member permitted for: Move out of the service area Needed services unavailable through the plan s network Exclusion of covered services by the plan on moral/religious grounds Additional provision for enrollees receiving LTSS: Change in status on part of their provider 23

24 Disenrollment of a Member by a Plan Plans maintain ability to disenroll members but states are prohibited from allowing this disenrollment if it is for: Changes in member health Member s use of services Diminished mental capacity or uncooperative/disruptive behavior related to the member s special health needs Exception is when plan can show keeping the member enrolled would interfere with its ability to furnish services to either this particular enrollee or other enrollees 24

25 Discontinuation of a Plan Requires states to maintain transition of care policies to assure continuity of care for members when a plan is terminated Focus is on members who would suffer serious health impacts or hospitalization/institutionalization if care is not maintained 25

26 Grievances & Appeals Definitions and timelines aligned with private market and Medicare Advantage Managed care appeals and grievance requirements apply to Pre paid Ambulatory Health Plans (PAHPs) Plans must have a single-level internal appeals process before proceeding to State Fair Hearing If plan doesn t comply with timelines, beneficiary may go directly to State Fair Hearing CMS did not finalize requirements that plans implement online appeals and grievance systems 26

27 Continuation of Benefits Pending Appeal Requires plans to continue coverage of services pending an appeal decision If an enrollee requests services within an authorization period, the plan may not end coverage at the end of that authorization period 27

28 Care Coordination & Transitions of Care States must have a continuity of care policy to ensure continued access to ongoing sources of care during beneficiary transitions (FFS to plan, or from one plan to another) Standards expanded to include coordination between settings and with services provided outside the plan (either through a different plan or FFS) Plans must make best effort to complete initial health screening within 90 days of enrollment for new enrollee 28

final rule (July 5 th ) Grievances & Appeals Apply to any rating period for contracts starting on or

29 Key Dates Beneficiary Support System Effective date of July 1, 2018 Information Standards Apply to any rating period for contracts starting on or after July 1, 2017 Enrollment Apply as of effective date of final rule (July 5 th ) Grievances & Appeals Apply to any rating period for contracts starting on or after July 1, 2017 Until then, requirements from 2002 rule apply Until then, requirements from 2002 rule apply 29

30 Beneficiary System Supports: Considerations States will need to review existing services/resources provided under the beneficiary support system umbrella to determine whether or not they meet all of the requirements Choice counseling (conflict free) Personalized beneficiary support and navigation pre- and post-enrollment Monitoring system to identify and resolve systemic issues (LTSS) Additional infrastructure, contracts or training likely to be required in many states 30

31 Information Standards: Considerations Significant improvements to member communications (materials/websites) Standardized language & templates Translations or (preferably) materials written in prevalent languages Robust managed care website with working links to: Plan handbooks Provider directories Formularies Updated systems and policies to take advantage of electronic communications Updated contracts and monitoring systems for plan handbooks and member materials 31

32 Enrollment & Disenrollment: Considerations Many states already align with enrollment and disenrollment requirements but will need to conduct a gap analysis System and policy updates will be required Improvements to notices about enrollment process, options and implications and how to contact beneficiary support system will be needed 32

33 Grievances & Appeals: Considerations States are required to develop and establish a monitoring system for all managed care programs that includes appeals and grievances Will need to develop standard language about the process and enrollee rights State will need to provide beneficiaries receiving LTSS with guidance around grievances and appeals Firewalls for organizations providing beneficiary support services and representing beneficiaries in appeals 33

34 Questions Discussion 34

35 Thank You! Want to discuss further? Contact: To view the recording of this webinar and others, please visit: 35

MAXIMUS Webinar Series. CMS Rule for Medicaid and CHIP Managed Care. Version

MAXIMUS Webinar Series. CMS Rule for Medicaid and CHIP Managed Care. Version MAXIMUS Webinar Series CMS Rule for Medicaid and CHIP Managed Care What It Means for States 1 Introductions Bruce Caswell President MAXIMUS Kathleen Nolan Managing Principal HMA Cathy Kaufmann Managing