Managed Long Term Care and Support Services

Transcription

1 Opportunities and Threats Managed Long Term Care and Support Services Authority in the Affordable Care Act allows CMS to test capitated and managed fee for services financial alignment models and seeks to improve care and control costs for dually eligible Medicare and Medicaid beneficiaries. Growing Aged, Blind and Disabled Population Increased cost of delivering institutional and community based long term care services Financial Alignment Demonstrations 1

2 Managed Long Term Care and Support Services Virginia was one of the first states to be approved for a capitated financial alignment demonstration (Managed Long Term & Acute Care). Dual Eligibles often have complex health care needs with multiple chronic disease, low income, inadequate housing and transportation. The current delivery system is fragmented, and Medicare and Medicaid often work at cross purposes and impede care coordination. Medicaid and Medicare have overlapping and sometimes conflicting benefits and requirements. Our goals were to create a seamless, integrated service delivery system, align Medicare and Medicaid rules, improve accountability, produce savings AND improve long term and health care services for a very vulnerable population. Managed Long Term Care and Support Services Virginia s capitated demonstration, Commonwealth Coordinate Care, launched in April 2014 expires December Provider meetings occurred on a regular basis Phase in periods were established Prior to the launch extensive review occurred Health plans were selected Networks were established Three way contracts between the health plans, Virginia Medicaid and Medicare were signed. 2

3 Overly ambitious timeline for implementation Program details were still under construction as enrollment started Confusion among beneficiaries Some beneficiaries opted in and out of the program multiple times in one day Passive enrollment was done with incomplete logic data Confusion among providers Letters of intent to participate are not the same as a contract Credentialing must occur and is a long drawn out process Welcome letters identify you have been credentialed and are in network Managed Care Plans lacked experience working with longterm care providers Managed Care Plan contracts did not fit community based care Unanticipated difficulties with maintaining continuity of care due to beneficiary opting in and out Low enrollment Medicaid beneficiaries could not be located Poor health literacy, English as a second language, cognitive impairments, etc. Forty percent opted out leading to enrollment volatility 3

4 Information exchange systems had not been tested Providers did not have real time enrollment information Beneficiaries did not know their status and failed to reenroll in Medicare Part D Co pays who is on first what is on second Plan hopping by beneficiaries did not allow for meaningful health assessment, care plan development or coordinated services Case management was nonexistent Health plans faced significant challenges in developing provider networks Long term care and support service providers had limited experience with managed care and vice a versa Managed care has it s own language Managed care organizations are large Dreaded telephone tree and website Consumer directed care presents challenges Managed care plan staff turnover 4

5 Prompt payment was a challenge due to Transition from API to NPI Clearing house processing new to some Paper CMS 1500 for many waiver providers delayed payment Billing p0rtles did not exist Unclean claims result in non payment Authorization process in general terms worked well Continuing Challenges Continued concern regarding the lack of care coordination Transition protections mask network inadequacies Increased administrative cost in back office Billing Contract maintenance Chasing unclean claims VAHC is moving forward with language that would require all claims to be settled in 30 days placing the burden on the managed care plans 5

6 What health plans want to know What range of services does the provider offer? What assurances can a provider offer that the right people, with the right training will show up at the right time? What quality metrics can a provider offer? How reliable are the caregivers? How is reliability measured? Pricing. How will prices be negotiated? Providers are likely to see utilization pressure Be prepared to drive and demonstrate your outcomes (prove value and cost effectiveness) What providers need to know How will consumers be moved into managed care? All at one time or will the transition occur in phases? Will all providers continue to provide care during the transition period? Non par provider reimbursement? Will providers be required to provide any new or different information during the transition period? Will care continue at current levels during the transition period? Will providers be expected to take on new Medicaid consumers during the transition period? What are the reporting requirements during the transition? Describe when and how consumers can switch payers (process and frequency) How will the claims process change? Where will claims be sent? State? Health plan? What format will claims need to be in? Electronic? Paper? 6

7 Audits How often will the audits occur? Define the conflict resolution process under the Medicaid managed care contract Who, at the health plan, serves as the tie breaker when conflicting information is provided? What is Quality How is quality defined by the health plan? State? Whose definition wins? Important to understand how parameters around quality can lead to an issue of conflicting information and the necessity of a tie breaker Define the conflict resolution process under the Medicaid managed care contract Who, at the health plan, serves as the tie breaker when conflicting information is provided? 7

8 What providers need to know What is the timeframe for submitting a claim? What is the timeframe for getting a claim paid? Health plans require clean claims what does that mean? Who will communicate with consumers? Multiple communications coming from multiple sources can be confusing and frustrating for consumers Describe the appeals process Identify any reporting requirements that will be placed on providers by the health plan What information has to be reported? When? By what method? Opportunities Have a list of managed care contacts Hold meetings Collaboration Identify best practices Don t be afraid to ask for things Help identify ways to improve care, reduce care, and provide exceptional services Create an environment where your organization is a valued partner 8

9 Contact Information Marcia Tetterton, MS, CAE Executive Director Virginia Association for Home Care and Hospice 3761 Westerre Parkway, Suite B Richmond, VA Fax