Medicaid Managed Care Mega Reg Overview. Medicaid Managed Care Congress Baltimore, Maryland May 18, 2016

Transcription

1 Medicaid Managed Care Mega Reg Overview Medicaid Managed Care Congress Baltimore, Maryland May 18,

2 About ACAP 2

3 About ACAP 3

4 About ACAP Mission: To strengthen not-for-profit Safety Net Health Plans in their work to improve the health of lower-income and vulnerable populations. Vision: To improve the health and well-being of lower-income and vulnerable populations and the communities in which they live. Who We Are: 1. Trusted Authority 2. Advocate for Lower Income and Vulnerable Populations 3. Center of Excellence and Accountability 4

5 ACAP s 56 Member Safety Net Health Plans Operate in 26 States 5

6 ACAP s 56 Member Safety Net Health Plans Arizona University of Arizona Health Plans California Alameda Alliance for Health CalOptima CenCal Health Central California Alliance for Health Community Health Group Contra Costa Health Plan Gold Coast Health Plan Health Plan of San Joaquin Health Plan of San Mateo Inland Empire Health Plan Kern Family Health Care L.A. Care Health Plan Partnership HealthPlan of California Santa Clara Family Health Plan San Francisco Health Plan Colorado Colorado Access Denver Health Connecticut Community Health Network of Connecticut District of Columbia Health Services for Children With Special Needs Florida Prestige Health Choice Georgia CareSource Hawaii AlohaCare Illinois CountyCare Family Health Network Indiana CareSource MDwise Kentucky CareSource Passport Health Plan Maryland Maryland Community Health System Priority Partners 6

7 ACAP s 56 Member Safety Net Health Plans Massachusetts Boston Medical Center HealthNet Plan Commonwealth Care Alliance Neighborhood Health Plan Minnesota Metropolitan Health Plan New Hampshire Well Sense Health Plan New Jersey Horizon NJ Health New York Affinity Health Plan Amida Care Elderplan & Homefirst GuildNet VillageCareMAX VNSNY CHOICE YourCare Health Plan Ohio CareSource Oregon CareOregon Yamhill Community Care Organization Pennsylvania AmeriHealth Caritas Pennsylvania UPMC for You Rhode Island Neighborhood Health Plan of Rhode Island Texas Children s Medical Center Health Plan Community Health Choice Cook Children s Health Plan Driscoll Health Plan El Paso First Health Plans Sendero Health Plan Texas Children s Health Plan Virginia Virginia Premier Washington Community Health Plan of Washington Wisconsin Children s Community Health Plan 7

8 A Few Words About Medicaid Managed Care 8

9 Capitated Managed Care Will Account For Almost Half of All Medicaid Spending by 2016 Capitation as a Percentage of All Medicaid Spending, Source: Projected Savings of Medicaid Capitated Care: National and State-by-State. The Menges Group, The most recent year in which data are available for all states is

10 Capitated Managed Care Will Account For Almost Half of All Medicaid Spending by 2016 Capitation as a Percentage of All Medicaid Spending, : $239.6 B paid via capitation $295.8 B paid via fee-for-service Source: Projected Savings of Medicaid Capitated Care: National and State-by-State. The Menges Group, The most recent year in which data are available for all states is

11 Medicaid Managed Care Enrollment Continues to Rise Capitation as a Percentage of All Medicaid Spending, Source: CMS Medicaid Managed Care Enrollment Reports, Enrollment for 2012 was estimated. 11

12 Enrollment in Medicaid-Focused Health Plans More Than Tripled from 2000 to 2012 Source: CMS Medicaid Managed Care Enrollment Reports,

13 Comprehensive Managed Care Programs Have More Quality Assurance Requirements than Other Program Types Source: CMS Medicaid Managed Care Enrollment Reports,

14 MCO Accreditation Fee-For-Service programs are not accredited Twenty-seven states require MCO accreditation, according to CMS Managed Care State Profiles 1. Arizona 2. Delaware 3. Florida 4. Georgia 5. Hawaii 6. Indiana 7. Iowa 8. Kentucky 9. Maryland 10. Massachusetts 11. Michigan 12. Minnesota 13. Missouri 14. Nebraska 15. 1New Hampshire 16. New Mexico 17. North Dakota 18. Pennsylvania 19. Rhode Island 20. South Carolina 21. Tennessee 22. Texas 23. Utah 24. Virginia 25. Washington D.C. 26. West Virginia 27. Wisconsin 14

15 Safety Net Health Plans Make Up 41% of All Medicaid Managed Care Plans, Serve 45% of Enrollees Source: HMA Enrollment Data,

16 The Medicaid Managed Care Mega Reg (Otherwise known as Medicaid and Children s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability) 16

17 Status of the Regulation The final rule was published April 25, 2016 (display) and May 6, 2016 (Federal Register). The rule and CMS fact sheets on the regulation can be found here. The NPRM was issued May 25, 2015 (display) and June 1, 2015 (Federal Register). ACAP and over 800 other entities and individuals submitted comments by the due date July 27, 2015 at 5pm. ACAP s comments are available here. 17

18 CMS Principles Governing Updated MMC Regulations 1. Align with other coverage environments Health Insurance Marketplaces Commercial Medicare Advantage 2. Support delivery system reform 3. Implement payment and accountability improvements 4. Improve enrollee protections 5. Modernize regulations, and improve quality of care 18

19 Major Issue Areas in Regulation 19

20 Major Issue Areas in Regulation Actuarially Sound Rates Rate Development and Certification Process Medical Loss Ratio Requirements and Calculation Information Requirements Contracts Involving Indians, Indian Health Care Providers and Indian Managed Care Entities CHIP Alignment 20

21 Major Issue Areas in Regulation Beneficiary Experience and Protections Quality Requirements Program Integrity Standards and Sanctions Standard Contract Requirements Payment Accountability Encounter Data Requirements Provider Network Issues 21

22 Implementation Timeframes 22

23 Final Regulation Implementation Timeframes Find comprehensive list of implementation dates in CMS fact sheet here. Implementation dates vary from immediate to three years or longer. Immediate (FFP for external quality review) 60 days after publication No later than rating period for contracts starting on or after July 1, 2017 July 1, 2018 July 1, 2019 No later than July 1, 2018 And so on 23

24 Implementation Dates of Note 60 Days after Publication Some Standard contract requirements Actuarial soundness requirements Rate development requirements Rate certification submission requirements Program integrity requirements and Sanctions Managed care enrollment and disenrollment requirements Marketing standards (including regarding QHPs) 24

25 Implementation Dates of Note 60 Days after Publication Quick turn-around implementation timeframes relate to requirements for CMS and states, but Many impact plans directly, including: Contracts Compliance (438.12) Marketing ( ) Coordination and continuity of care ( ) And many others! 25

26 Implementation Dates of Note Rating Periods Starting on/after July 1, 2017 Medical Loss Ratio standards MLTSS cause for disenrollment State readiness reviews Appeals and grievances standards Coordination and continuity of care requirements Additional Standard contract requirements Actuarial soundness requirements Rate certification submission requirements Program integrity requirements 26

27 Implementation Dates of Note Rating Periods Starting on/after July 1, 2018 Actuarial soundness, varied requirements Network adequacy standards State agency screen and enroll providers 27

28 Implementation Dates of Note July 1, 2018: MCO state quality strategy Rating periods starting on/after July 1, 2019: Actuarial soundness requirements to include consideration of 85 percent MLR No later than 3 years from date of final notice in Federal Register: Quality Rating System (QRS) Final notice is anticipated in 2018 (draft rule in 2017), so QRS will be effective roughly in

29 Promising? Painful? Provisions for Plans to Ponder 29

30 Actuarial Soundness Actuarial soundness rules needed strengthening to ensure transparency and fairness for CMS, states and plans. An improved rule would have increased transparency in rate setting between CMS, states, and health plans. The final regulation requires states to submit sufficient detail and documentation to CMS enable another actuary to assess the reasonableness of the methodology and the assumptions supporting the development of the final capitation rate. It does not include a similar requirement for states to share information with plans. Plans are encouraged to request data from states during contract negotiations. CMS writes: managed care plans have the option of not contracting with states if they believe the capitation rates are too low to reflect the populations, services, and other obligations under the contract. CMS approval of rates is a final administrative action. States still be permitted to employ rate ranges, but must provide certification to CMS of a specific rate for each rate cell. 30

31 Quality Reporting and Improvement Quality reporting and improvement standards need to be comprehensive, accurate and fair and must apply to all delivery systems and be stratified by population. The regulations were an opportunity to rectify an imbalance between fee-for-service (FFS) and managed care quality requirements. CMS declined to apply the quality rating system (QRS) to FFS Medicaid. CMS deleted a proposal to require states to maintain a FFS quality strategy plan as well as a managed care quality strategy plan. Also, CMS considered requiring all Medicaid health plans to be accredited, but CMS declined to finalize this requirement for all Medicaid health plans, deeming it to be duplicative of other EQR efforts. 31

32 Network Adequacy Network adequacy provisions should be realistic and attainable, should be set at the state level rather than by the federal government, and must address telemedicine and other technological advances. CMS opted not to set federal time and distance standards, requiring states to do so for certain provider types if they are covered under the contract. These provider types include adult and pediatric primary care providers, OB/GYN, pediatric dental, adult and pediatric specialists, pharmacy, and others. The final rule also allows state to adjust time and distance standards by provider type. CMS added telemedicine to the list of elements states must consider when developing network adequacy standards. 32

33 Provider Directories Requirements for updating provider directories must be realistic, operationally feasible, and useful for enrollees. In addition, they must recognize the joint responsibility of plans and providers. CMS extended the requirement for updates to electronic provider directories from three to 30 days, aligning with the requirement for paper directories, and also with requirements for qualified health plans and Medicare Advantage plans. CMS retained the requirement that paper directories be updated monthly, although they may be made available to enrollees only upon request. 33

34 Provider Screening and Enrollment CMS proposed that all network providers be screened and enrolled by the state Medicaid agency, leading to concerns that providers would be discouraged from participating in health plan networks. Plans requested permission to enroll providers tentatively while they undergo the state s screen and enroll process, and for existing providers to be grandfathered. CMS finalized the provider screening and enrollment process. However, the regulation will allow health plans to execute network provider agreements for up to 120 days pending the outcome of the state s effort. 34

35 Medical Loss Ratio A minimum MLR is not necessary, but if implemented should include an upper limit, be phased in, be lower (80%) for CHIP, and exempt Medicare- Medicaid plans. CMS finalized a minimum MLR requirement for Medicaid and CHIP MCOs of 85 percent, based on a single year of experience. Case management and care coordination are included in the numerator as activities that improve health outcomes, but certain activities related to accreditation (provider credentialing, for example) will not be allowed as part of the numerator. States may require a remittance by the plan for the reporting year if the MLR does not meet the minimum standard, but CMS will not. CMS will require states to use the MLR calculation to develop rates for future years. CMS declined to prohibit a minimum MLR requirement for Medicare-Medicaid plans, stating all MCOs must calculate and report MLR for Medicaid, and that CMS is unable to provide state specific technical assistance to determine how best to calculate and report the MLR in these instances. Minimum MLR requirements must be in place no later than the rating period for contracts starting on or after July 1,

36 Information Standards Timelines for implementing revised information standards must be adequate for both states and plans to complete the requirements. For example, states should receive 18 months and plans should have an additional 12 months to implement updated information standards. New information standards include identifying prevalent non-english languages, making oral interpretation available, providing translations of critical documents, and including tag lines on pertinent documents. CMS will require all information requirements to be implemented no later than the rating period for contracts starting on or after July 1,

37 Grievances and Appeals Standards Aligning Medicaid grievances and appeals standards with Medicare and Marketplace requirements is wise, but the draft regulation would have been improved with refinements related to enrollee written consent, timeframes for filing grievances and filing state fair hearings, and extending implementation timeframes. CMS finalized timeframes for resolving grievances at 90 days, for resolving appeals at 30 days, and for resolving expedited appeals at 72 hours, although it included an allowance for a 14-day extension under certain conditions. The timeframe for requesting a state fair hearing was finalized at 120 days. CMS is requiring that all changes to the grievances and appeals process be implemented no later than the rating period for contracts starting on or after July 1,

38 Managed Long Term Services and Supports Allowing MLTSS members to disenroll if their MLTSS providers leave plan networks could encourage providers to withdraw from an MLTSS network due to a preference for FFS and volume-based payment rates, undermining value-based payment initiatives and enrollee choice. CMS finalized the proposal allowing enrollees to disenroll if they would have to change their residential, institutional, or employment supports provider based on a change in provider status from in-network to out-ofnetwork. 38

39 IMD Services Treating IMD services as an in lieu of service is wise as a means to improve access to needed behavioral health services, but a 15 day per month limit is overly restrictive. Furthermore, the IMD rate should be utilized as a proxy in setting the actuarially sound rate. CMS will allow states to provide monthly capitation payments to health plans for certain enrollees receiving inpatient treatment at an IMD for psychiatric or substance use disorder treatment for up to 15 days per month. The state must price utilization at the cost of the same services through providers included under the state plan, rather than at the IMD rate. 39

40 What s Next? Communication Between CMS, states, plans, and other stakeholders Focus on Implementation Timeframes and feasibility! Additional Guidance Ensuring the best models are considered 40

41 Thank you! Jennifer McGuigan Babcock Vice President, Medicaid Policy/Director of Strategic Operations 41