Managed Care Rules: Improving Consumer Information. Kelly Whitener Tricia Brooks Sarah Somers June 23, 2016
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1 Managed Care Rules: Improving Consumer Information Kelly Whitener Tricia Brooks Sarah Somers June 23, 2016
2 Children in Managed Care CMS finalized sweeping changes to Medicaid and CHIP managed care regula;ons in May, 2016 Regula;ons set minimum standards; states have flexibility to do more Many opportuni;es for legal and health advocates to take ac;on Flag poten+al ac+ons for legal and health advocates 2
3 Why are these rules so important? 11% of children in Medicaid/ CHIP are enrolled in FFS 22% of children in Medicaid/ CHIP are enrolled in PCCMs 66% of children in Medicaid/CHIP are enrolled in MCOs Source: CMS Medicaid Managed Care Enrollment Report
4 Managed Care Project Series of six explainer briefs and webinars 1 Looking at the Rule through a Children s Lens (released) 2 Improving Consumer Informa2on (6/23) 3 Enhancing the Beneficiary Experience (7/11) 4 Assuring Network Adequacy and Access to Services (8/4) 5 Advancing Quality (9/8) 6 Ensuring Accountability and Transparency (9/29) Fall mee;ng in D.C. with child health and legal advocates to strategize over implementa;on Thanks to Robert Wood Johnson Founda;on 4
5 Our Topic Today: Consumer Information Basic Rules and Applicability Consistency in Informa;on Electronic Informa;on Requirements Language and Format Provisions State and Plan Requirements Flag poten+al ac+ons for legal and health advocates 5
6 Background Prior rules not sufficiently clear or direct Did not reflect use of current technology Oien inadequate or lack of ;mely informa;on to make an informed plan selec;on and understand benefits and rights Informa;on varies from plan to plan, lacks consistency Benefits Gekng Help Accessing Services Drugs Appeals 6
7 Applicability All Medicaid managed care plans regardless of authority (state plan op;on, 1115 demonstra;on, or 1915(b) waiver) and CHIP Basic rules informa;on must be easily understood and in a readily accessible manner and format apply to states, enrollment brokers, and all types of plans Some differences for PCCM en;;es depending on scope of responsibili;es, while PCCMs only need to meet basic requirements 7
8 Timeline Provisions at are effec;ve, star;ng with ra;ng periods beginning on or aier July 1, Ra;ng period = the 12- month period selected by the State. States may contract for mul;ple years but must set rates for approval to CMS to 12 month periods. Find out when your state s next ra+ng period starts. 8
9 Basic Rules All required consumer informa;on must be provided in a manner that is easily understood and is readily accessible. Applies to the state, enrollment brokers, and ALL types of managed care en++es, including MCOs, PIHPs, PAHPs, PCCMs, and PCCM En++es. States have flexibility to define easily understood such as a grade reading level. Encourage your state to engage stakeholders in defining easily understood. A best prac+ce is to have all informa+on consumer tested! 9
10 State Requirements Use beneficiary support system ( ) to provide educa;on and choice counseling. Ensure through contracts that each MCO, PIHP, PAHP, and PCCM en;ty complies with this sec;on. Operate a website. 3 rd Brief & Webinar Encourage your state to provide opportuni+es for website tes+ng/feedback, and to explore the advantages of having all prevalent consumer materials posted on state s website (rather than linked to plan s website). 10
11 Consistency in Information Key Managed Care Terms States must define and require plans to use. States have flexibility to expand the list of standardized terms. Encourage your state to seek stakeholder input on terms and defini+ons. Appeal Copayment Durable medical equipment Emergency medical condi;on Emergency medical transporta;on Emergency room care Emergency services Excluded services Grievance Habilita;on services and devices Health insurance Home health care Hospice services Hospitaliza;on Hospital outpa;ent care Medically necessary Network Non- par;cipa;ng provider Physician services Plan Preauthoriza;on Par;cipa;ng provider Premium Prescrip;on drug coverage, Prescrip;on drugs Primary care physician Primary care provider Provider Rehabilita;on services and devices Skilled nursing care Specialist Urgent care 11
12 Electronic Information Requirements Informa;on may NOT be posted electronically unless it meets all standards Rule updates defini;on of readily accessible Informa;on must be provided in paper form upon request Applies to states, enrollment brokers, MCOs, PIHPs, PAHPs, PCCMs,* and PCCM En++es Readily accessible: info must comply with modern accessibility standards such as sec;on 508 guidelines (a). Informa;on: - must be posted in a prominent and readily accessible place on the state s, MCO s, PIHP s, PAHP s, PCCM s, or PCCM en;ty s website. - can be electronically retained and printed. - is consistent with content and language requirements. The enrollee is no;fied that the informa;on is available at no cost upon request in paper form, which must be provided within 5 business days. 12
13 Prevalent Language Requirements States must establish a methodology for iden;fying prevalent non- English languages spoken throughout the state and in each plan service area States have flexibility to determine what is a significant # or % of LEP consumers. Encourage your state to consult with stakeholders in establishing these parameters. New defini;on of prevalent: a non- English language determined to be spoken by a significant number or percentage of poten2al enrollees and enrollees that are limited English proficient (LEP). Defini;on of LEP: poten2al enrollees and enrollees who do not speak English as their primary language and who have a limited ability to read write, speak, or understand English. 13
14 Oral Interpretation and Written Translation General Requirements: Apply to States and Plans Oral interpreta;on - Applies to all languages, not just prevalent - Includes auxiliary aids (TTY/TDY and American Sign Language) Wriven transla;on - 12 point font - Prevalent languages (area varies) - Large print taglines (18 point font) States and enrollment brokers Applies generally to poten2al enrollees Transla;ons and taglines in prevalent languages in the state MCOs, PIHPs, PAHPs, and PCCM ennnes Applies generally to enrollees Transla;ons for prevalent languages in service area Taglines for prevalent languages in state 14
15 Applicability of Language and Format Requirements to Critical Materials Rule defines cri;cal materials minimally as: - Enrollee handbooks - Provider directories - Appeal and grievance no;ces - Denial and termina;on no;ces States have flexibility to expand list of crincal wrioen materials. Encourage your state to involve stakeholders in assessing addi+onal materials that should be subject to language and format requirements. 15
16 Other Opportunities for Stakeholder Engagement on Language & Format Wording and placement of taglines on nonces is important to geqng the message across. Encourage your state to seek stakeholder input/feedback on development of tagline language. While plans are required to provide informanon in alternanve formats, the rule does not require specific formats. Encourage your state to involve stakeholders in determining the alterna+ve formats that must be available to enrollees. Plans must have mechanisms to help enrollees and potennal enrollees understand the requirements of the plan. Encourage your state to engage stakeholders in assessing what mechanisms are needed to help consumers understand the plan. 16
17 Information for Potential Enrollees Informa;on must be provided to poten;al enrollees within a ;meframe that enables use of the informa;on to choose a plan. Applies to states or contracted representa+ve(s) (e.g., enrollment brokers, choice counseling en+ty) Encourage your state to engage stakeholders in determining what is a sufficient +meframe. Clear informa;on about the right to disenroll. The basic features of managed care. Which popula;ons are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily. 3 The service area covered by each plan. Which benefits are covered by the plan or provided directly by the state. Where and how enrollees can obtain counseling or referral services not provided by the plan for moral or religious objec;ons. Provider directory and prescrip;on drug formulary informa;on. Any cost- sharing requirements. Requirements of each plan to provide adequate access to covered services, including the state s network adequacy standards. 4 The plans responsibili;es for coordina;on of enrollee care. Quality and performance indicator data for each plan, including enrollee sa;sfac;on. 5 17
18 Information for Enrollees Applies to MCOs, PIHPs, PAHPs, and PCCM en++es (when appropriate). Encourage your state to engage stakeholders in determining what defines regular use of a provider that considers provider type. For example, regular use of an OB/ GYN might be once annually. Plans must provide: Enrollee handbooks Provider directories Drug formularies Physician incen;ve plans (upon request) Make a good faith effort to provide wriven no;ce within 15 days to enrollees if PCP or regular provider leaves the network 18
19 Enrollee Handbooks Informa;on must be provided to poten;al enrollees within a reasonable ;me following enrollment. Applies to MCOs, PIHPs, PAHPs, and PCCM en++es (when appropriate). Encourage your state to engage stakeholders in determining what is a reasonable +me. ABBREVIATED LIST OF ENROLLEE HANDBOOK REQUIREMENTS Detailed benefit informa;on and how to access. Procedures for obtaining benefits. Cost sharing. How transporta;on is provided. Details about aier- hours and emergency services. Restric;ons on enrollee s freedom of choice among network providers. Specific informa;on about accessing family planning services. How and where to access counseling or referral services that the plan does not cover based on moral or religious objec;ons. How and where to access benefits provided by the state. Enrollee rights and responsibili;es. The process of selec;ng or changing the enrollee s primary care provider. Detailed informa;on on grievance, appeal, and fair hearing procedures and ;meframes. How to exercise an advance direc;ve. How to access auxiliary aids and services, including addi;onal informa;on in alterna;ve formats and languages. The toll- free telephone number for member services, medical management, and any other unit providing services. Informa;on on how to report suspected fraud or abuse. Other content required by the state. 19 3
20 Flexibility in Providing Enrollee Handbook Mail a printed copy Provide electronically aier enrollee agrees to receive the informa;on electronically Inform enrollees by mail or that informa;on is posted on website and include Internet address Provide content through auxiliary aids and services Give enrollees a 30- day no;ce of significant change States may require other content, or define what is a significant change. Encourage your state to engage stakeholders in development of the enrollee handbook to ensure it is useful, thorough, and easy to understand; and in defining what is a significant change. 20
21 Provider Directories Specific informa;on must include Available in electronic or paper form Paper updated monthly Electronic updated within 30- days Encourage your state to engage stakeholders in determining addi+onal content or standardized formats for provider directories. Provider s name, as well as any group affilia;on. Street address(es). Telephone number(s). Web site URL, as appropriate. Specialty, as appropriate. Whether the provider is accep;ng new enrollees. The provider s cultural and linguis;c capabili;es, including spoken and American Sign languages offered by the provider or a skilled medical interpreter at the provider s office, and whether the provider has completed cultural competence training. Whether the provider s office has accommoda;ons for people with physical disabili;es, including offices, exam room(s) and equipment. 21
22 Drug Formularies Required informa;on is limited to: - Medica;ons covered (both generic and brand name) - Drugs ;er Must be posted on plan s website (and available in paper form upon request) No requirements for ;meliness of updates. Encourage your state to engage stakeholders in iden+fying addi+onal content, standardizing the format, or se[ng +meliness standards for updates to drug formularies. 22
23 For More Information Kelly Whitener - kdw29@georgetown.edu Tricia Brooks - pab62@georgetown.edu Sarah Somers - somers@healthlaw.org
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