Network Adequacy Evaluation and Monitoring Efforts
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1 Network Adequacy Evaluation and Monitoring Efforts Presented by: Margaret Tatar, Assistant Deputy Director Health Care Delivery Systems California
2 2 Introduction Today s presentation will cover: Overview of network adequacy standards Program-wide network adequacy review and evaluation Monitoring and future endeavors
3 3 Overview of Network Adequacy DHCS requirements for network adequacy standards are set forth in: Regulations Welfare and Institutions (W&I) Code , , Healthy and Safety (H&S) Code (a)-(f) The Knox Keene Act Managed Care Plan Contracts All Plan Letters
4 4 Knox-Keene Act Standards The Knox-Keene Act of 1975 (Knox-Keene) instituted the Time and Distance Standards as: A PCP must be no more than 15 miles or 30 minutes from the place of residence or place of work of the member unless the member chooses a different provider outside of this geographic area within the MCP s service area.
5 5 Contracts with Medi-Cal Managed Care Plans DHCS contractually requires Medi-Cal managed care plans in all delivery models to abide by the Time and Distance Standards Applicable to Two-Plan, GMC, COHS, and Regional models Exhibit A, Attachment 6 of the contract reads: The contractor shall maintain a network of Primary Care Physicians which are located within thirty (30) minutes or ten (10) miles of a Member s residence unless the Contractor has a DHCS-approved alternative time and distance standard.
6 6 DHCS All Plan Letters (APL) DHCS issues All Plan Letters to inform and communicate policies and requirements. APL provides information pertaining to the implementation of: Welfare and Institutions (W&I) Code Sections ( ) , , and Knox-Keene Time and Distance Standards Link to APL : ters/apl2013/apl pdf
7 7 Program-Wide Review and Evaluation DHCS evaluates access and ensures that Time and Distance Standards are met by: Conducting readiness reviews Reviewing quarterly network submissions Monitoring Grievances and Appeals/State Fair Hearings Conducting Medical Audits Interagency Agreements with DMHC
8 8 Readiness Reviews DHCS conducts extensive readiness reviews of managed care plans prior to implementation, including when a new benefit is added. Includes a thorough review of the network and ensuring that the Time and Distance Standards are met by: Conducting Facility Site Reviews Site surveys that include on-site inspections and staff interviews Reviewing Deliverables Plans must provide policies and procedures that describe how they will deliver the benefits and services
9 9 Monthly Network Submissions Medi-Cal managed care plans submit networks to DHCS for review on a monthly basis. DHCS works in partnership with DMHC to review the networks and determine whether adequate providers are available. A specific focus on specialists is conducted when reviewing networks related to care for Seniors and Persons with Disabilities (SPDs). The network review looks at specialists serving as the PCP to the SPD, mental health professionals, and physician extenders.
10 10 Grievances and Appeals/Fair Hearings Medi-Cal managed care plans submit data on member grievances and appeals on a quarterly basis. DHCS monitors grievances and appeals to observe if a spike in access complaints occurs at any time. DHCS monitors Fair Hearings data to determine if there are any network issues.
11 11 Medical Audits DHCS conducts medical audits at the Medi-Cal managed care plans to review whether access to care needs are being met. Starting in 2015, DHCS Audits and Investigations will visit each health plan annually.
12 12 Interagency Agreements (IA) DHCS has entered into an Interagency Agreement (IA) with the Department of Managed Health Care (DMHC) for three transitions: Seniors and Persons with Disabilities Dual Eligible Demonstration Healthy Families and Rural Expansion (Pending) The IAs focus on financial audits, medical surveys, and network adequacy reviews.
13 13 Specific Program Reviews Non-specialty Mental Health benefits effective January 1, 2014 Provider network adequacy based on the Time and Distance Standards DHCS permitted the use of the telehealth method, particularly in outreach areas Plans were required to submit readiness deliverables alongside DMHC s material modification filing Plans were required to provide attestation to have signed Memorandum of Understanding (MOUs) Plans are required to execute MOUs with the county mental health plans by June 30, 2014
14 14 Specific Program Reviews Cal MediConnect DHCS worked closely with CMS to ensure plan readiness: CMS reviewed provider networks for Medicare DHCS reviewed networks for Medi-Cal through established processes as discussed in previous slides
15 15 Specific Program Reviews MLTSS In-Home Supports and Services (IHSS) Plans were required to execute Memorandum of Understanding (MOUs) with their County Department of Social Services Multi-purpose Senior Services Program (MSSP) Plans were required to contract with the MSSP sites within their counties Community Based Adult Services (CBAS) DHCS validated that each plan had an agreement with the CBAS providers within the plan s county Nursing Facilities (NF) DHCS reviewed the nursing facilities networks to ensure capacity to place patients within 72 hours of need
16 16 The Future of Monitoring in Medi-Cal Managed Care Dashboard Webpage Technical Assistance Corrective Action Plans Workgroups
17 17 Medi-Cal Managed Care Performance Dashboard Initially released in January nd iteration to be released on May 6, 2014 New iterations to be released quarterly Link to DHCS website: Documents/MMCD/MMCD_Dash board_2013.pdf
18 18 Medi-Cal Managed Care Performance Dashboard Medi-Cal Managed Care Performance Dashboard Supports a key goal of DHCS to drive better quality within our Medi-Cal managed care managed care plans Pulls together current information and new trends Will continually evolve based on changes in the Medi-Cal managed care program and in response to requests from stakeholders
19 19 Medi-Cal Managed Care Monitoring Webpage Created in February 2014 Includes resources and tools used to monitor and measure overall health plan performance Houses various reports that measure performance and quality improvement Webpage will be updated to include A&I s medical audits and Corrective Action Plan (CAP) notifications Link to DHCS website: /ManagedCareMonitoring.aspx
20 20 Ongoing Efforts Technical Assistance/Corrective Action Plans (CAP) DHCS evaluates and assesses Corrective Action Plans to bring plans into compliance with State contractual requirements and State and Federal rules and regulations. DHCS provides technical assistance to plans who have been issued minor audit findings in lieu of a Corrective Action Plan (CAP). Workgroups DHCS convenes workgroups both internally and externally to discuss issues and share best practices.
21 21 Thank you!
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