Network Development Strategies Expanding Medicaid Managed Care Eligibility and Enrollment

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1 Network Development Strategies Expanding Medicaid Managed Care Eligibility and Enrollment Preston W. Cody Assistant Director Health Care Services October 2012

2 CLALLAM JEFFERSON GRAYS HARBOR PACIFIC MASON THURSTON KITSAP COWITZ CLARK LEWIS PIERCE SKAMANIA KING WHATCOM SKAGIT SNOHOMISH YAKIMA CHELAN KLICKITAT KITTITAS OKANOGAN FERRY STEVENS DOUGLAS BENTON GRANT FRANKLIN ADAMS LINCOLN WALLA WALLA COLUMBIA SPOKANE WHITMAN GARFIELD PEND OREILLE ASOTIN Primary health care purchasing agency Serving 1.6 million clients, state employees, and retirees Basic Health Health Technology Assessment Medicaid and Medical Assistance Programs Prescription Drug Program Public Employees Benefit Board Uniform Medical Plan Washington Health Program Washington Wellness 2

3 Overview A sustaining vision and long-term commitment Brief history Authority to build a provider network Ensuring network adequacy State successes State challenges Lessons learned 3

4 Brief History MANAGED CARE EXPANSION 4

5 Managed Care Expansion A solid foundation for a seamless transition to 2014 In July 2012, the agency consolidated the Medicaid managed care program, Healthy Options (HO), with the state's Basic Health Plan (BH) to: Improve care Reduce costs by expanding managed care Expand service delivery options Implement payment reform and quality control 5

6 Managed Care eligibility Basic Health eligibility does not change Not open for new enrollment 34,000 members Healthy Options will continue to include: TANF families and children up to age 19 Pregnant Women (eligible for Medicaid) Children s Health Insurance Program (CHIP) 683,402 enrollees as of June 2012 New population to be added 120,000 Categorically Needy Blind/Disabled non-medicare Optional enrollment for foster care children 6

7 New population Medicaid Only, Blind/Disabled clients enroll Exceptions: Living in institutional settings Enrolled in Chronic Care Management Programs Enrolled in the Program of All-Inclusive Care for the Elderly (PACE) On hospice American Indians/Alaska Natives Enrolled in the Washington Medicaid Integration Partnership (WMIP) Enrolled in Private Duty Nursing (PDN) Enrolled in the Medically Intensive Children s Program (MICP) Third Party Insurance 7

8 Assigning new populations Three-phase approach Eastern WA July 1 Western WA September 1 Clark, King, and Pierce Counties November 1 Month Enrollment All Assignments July 743, ,893 September 762,811 56,301 November Unknown 27,000* *Projection as of September 15,

9 Authority: Federal, State, and Managed Care Contract requirements BUILDING A NETWORK 9

10 Federal requirements Requires the State to ensure: Managed Care Organizations (MCO) are in compliance with federal regulations Services and benefits are consistent with the State Plan MCO provider network/enrollee ratio compliance Federal Law Requirements: 42 CFR (d), 42 CFR (a), 42 CFR (b) 10

11 Washington State Law Requires the MCO: Meet State network and quality standards Contract with providers to comply with the Washington State Office of Insurance Commissioner (OIC) regulations State Law Requirements: WAC (1)(c), WAC (1), WAC (4) 11

12 Managed Care Contract MCO provider contracts must : Provide all medically necessary specialty care in and out of health plan network Ensure no balance billing for covered services Ensure enrollees timely access to all covered services within established distance standards Consider cultural, ethnic, race, and language needs Ensure comparable provider access to commercial markets or Medicaid s Fee-for-Service State Contract Requirements: Sections 5.1 through

13 Ongoing monitoring of MCOs ENSURING NETWORK ADEQUACY 13

14 Monitoring Health Plans Weekly updates Various statistics call center, outreach activities Network adequacy reports (approx. everyday 10 days) State outreach and education Monitor complaints to resolution MCOs required to report on enrollee/provider complaints regarding access to care Plan monitoring visit comprehensive plan review

15 Service Areas Effective Service Areas for Healthy Options, Children s Health Insurance Program, Healthy Options Blind/Disabled and Healthy Options Foster Care Programs 15

16 Receiving Medicaid assignments Submit proof of entire network in all service areas (county) awarded MCO must be able to serve anyone eligible and lives in the given service area Report on resolution of access to care complaints MCO must maintain in compliance with Managed Care contract adequacy levels MCO are assigned clients based on results of proposal scores: 40% will be made based on Rates scores 20% will be made based on Quality Assurance Performance Improvement (QAPI) scores 20% will be made based on Access to Care and Provider Network scores 15% will be made based on Care Coordination Scores 5% will be made based on all other Program Section Scores combined 16

17 Analysis of Network Assignment Demonstrates sufficient provider network to receive all eligible enrollees Plan name appears on enrollment form HCA auto-enrolls Enrollment only Demonstrates a mostly sufficient provider network to receive all eligible enrollees, but lacks sufficiency in one or more categories Plan name appears on enrollment form HCA won t auto-enroll Emerging network Does not demonstrate a sufficient provider network to receive eligible enrollees, but may in the future Plan name will not appear on enrollment form 17 Top 5 provider categories include: 1. Hospital 2. Primary Care Provider 3. Pharmacy 4. Obstetric/Gynecologist 5. Pediatrics Top 10 specialty provider categories include: 1. Cardiologist 2. Gastroenterology 3. General Surgeon 4. Neurologist 5. Oncologist 6. Ophthalmologist 7. Orthopedics 8. Otolaryngology 9. Physical Medicine Rehab 10. Pulmonologist

18 STATE SUCCESS 18

19 Moving in the right direction Helps better prepare for Medicaid expansion Three new plans with extensive national experience in serving low-income populations Greater enrollee choice in most service areas Potential cost savings through transition from Fee-for-Service (FFS) to managed care Expect improved health outcomes, especially for the highest risk, highest cost enrollees Greater oversight and strengthened program integrity for publicly-funded programs 19

20 STATE CHALLENGES 20

21 Where do they go? Geography and provider limitations 21 Skamania/Klickitat : Healthy Options clients have FFS option Basic Health must have Managed Care

22 Limited provider participation Impact to networks Federal distance standards are not limited to a specific service area geographically (meaning they can cross county or state borders) Rural areas where limited physicians practice (provider shortage) Provider reimbursement Even distribution of enrollees for health plans viability (assignments) Reconnects and family unit issues Exempted groups (i.e., COB, Children with Special Healthcare Needs, Foster children) 22

23 Availability of Primary Care Physicians Impact to networks About 20% of Primary Care Physicians (PCP) care for some patients covered by Medicaid Close to 80% of PCPs are accepting new patients Only 30% of this group are not including Medicaid covered clients in their expansion plans Just over 20% reported that all their new patients could be Medicaid covered Office of Financial Management June 2012 report: 23

24 LESSONS LEARNED 24

25 Lessons learned Focus on how changes will benefit enrollees first Continuously monitor provider networks More resources need to be devoted to stakeholder management including enrollees, taxpayers, and political, advocate, and provider communities Large systems with multiple components and varied parties affected can be successfully changed through consistent communication, leadership, and transparency 25

26 MORE INFORMATION 26