Presentation to State Medicaid Managed Care Advisory Committee: Network Adequacy. March 2014

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1 Presentation to State Medicaid Managed Care Advisory Committee: Network Adequacy March 2014

2 Network Access: Federal & State Laws & Regulations In Medicaid, MCOs must: Have sufficient capacity to serve the expected enrollment SSA 1932(b)(5) ; Texas Government Code Meet service area needs with geographic distribution of preventative, primary care, and specialty service providers 42 C.F.R ; Texas Government Code Establish and maintain networks providing access to services covered under state contract by looking at geographic location of providers and Medicaid enrollees and the physical accessibility of the location for Medicaid enrollees with disabilities 42 C.F.R Submit out-of-network (OON) utilization reports (HHSC is required to set benchmarks for OON utilization and establish standards for reasonable reimbursement rates) Texas Government Code Page 2

3 Network Access: Federal & State Laws & Regulations Federal regulations do not specify time and distance standards measuring provider access MCO state contracts or state laws governing the operation of MCOs establish these standards HHSC established these standards for Medicaid in 1 T.A.C Medicaid MCOs must comply with TDI s licensing standards Page 3

4 Senate Bill 7, 83 rd Legislative Session Medicaid Managed Care Advisory Committee is required to provide recommendations and input on implementation and operation of several topics, including Medicaid managed care provider network adequacy (S.B. 7, SECTION 2.07) S.B. 7, SECTION 2.04 (Government Code (a)(20) requires MCOs: Provider network adequacy plans to include long term services and supports (LTSS), nursing services, and therapy services Make certain network adequacy data available to the public such as sufficiency of provider networks, length of time to approve or deny authorization requests, and length of time between authorization approval and initiation of services (specifically specialty care, LTSS, nursing services, and therapy services) Demonstrate they have a sufficient number of LTSS and specialty pediatric care providers of home and community based services before providing services to clients Page 4

5 HHSC Managed Care Provider Network Assumptions Medicaid Providers must be enrolled with Texas Medicaid Managed Care Organizations (MCOs) are limited to Medicaid enrolled providers Pharmacy All Medicaid pharmacies must be enrolled with Texas Medicaid Page 5

6 Provider Access From Member s Residence Provider Type Primary Care Provider (PCP) + Additional Frew requirement for Medicaid Acute Care Hospital Specialists (including OB/GYN) Outpatient Behavioral Health All Other Provider Types Access Requirement 30 miles 90% of child members must have access to at least two PCPs 30 miles 75 miles 75 miles 75 miles If covered services are not available in-network, MCOs must provide members access to out-of-network providers Page 6

7 Network Pharmacy Access From Member s Residence Urban County Type Access Requirement 80 % access within 2 miles Suburban 75% access within 5 miles Rural Urban, suburban, and rural 90% access within 15 miles 90% access to a 24 hour pharmacy within 75 miles Page 7

8 MRSA Network Pharmacy Access From Member s Residence County Type Access Requirements Urban 75% access within 2 miles Suburban 55% access within 5 miles Rural Urban, suburban, and rural 90% access within 15 miles 90% access to a 24 hour pharmacy within 75 miles Page 8

9 Network Access MCO Contracts: Distance Requirements for Dental Plans Provide access to network dental providers within the following distances measured from the member s place of residence: 30 miles 95% must have access to two open practice main dentists (urban areas) 75 miles 95% must have access to two open practice main dentists (rural areas) 75 miles 90% must have access to one specialist (urban and rural) Page 9

10 Medicaid Out-of-Network Utilization Thresholds HHSC monitors health and dental plan use of out-of-network facilities and providers In each service area, out-of-network use should not exceed the following thresholds each quarter: 15% of inpatient hospital admissions (health plans) 20% of emergency room visits (health plans) 20% of all other services (health and dental plans) A plan can request special consideration when it exceeds the utilization threshold if efforts to contract out-of-network provider are demonstrated If the State grants special consideration, it removes the non-contracted provider from the plan s compliance calculations Sources: Tex. Gov. t Code (a)(11); 1 T.A.C (e)(2) Page 10

11 1115 Waiver s Network Adequacy Reporting Requirements STAR, STAR+PLUS and Children s Medicaid and Dental Services programs HHSC must submit reports documenting network adequacy during readiness review, quarterly, annually, and if significant changes in an MCO s operations affect adequate capacity and services Page 11

12 Provider Network Adequacy Analysis Evaluate GeoAccess standards Analyze GeoAccess maps Analyze provider data MCO reports Network panel status reports Provider turnover rates Enrollment Broker reports Consider access to care complaints Review out-of-network utilization Provider directories accuracy Page 12

13 Exceptions to Network Adequacy MCOs may request distance standards exceptions for all provider types under limited circumstances Examples: Lack of Medicaid enrolled providers of type and specialty in the area Lack of providers of type and specialty in area Contracting issues Page 13

14 Next Steps Work to amend MCO reporting requirements to monitor network adequacy and ensure it includes data elements required by S.B. 7 (specifically for LTSS, nursing services, and therapy services) Amend the following as needed to reflect Committee recommendations: Texas Administrative Rules Managed Care Contracts Uniform Managed Care Manual Page 14

15 Resources HHSC Texas Medicaid Program Webpage: Medicaid Managed Care Initiatives Webpage: TMHP Provider Website: Page 15

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