Transcript WA State Medicaid Managed Care Presentation

Apple Health (Medicaid)
Managed Care Program Overview
Preston W. Cody, Division Director
Health Care Services
November 16, 2015
Introduction
Preston Cody, Division Director
Health Care Services Division
Washington State Health Care Authority
2
Overview
•
•
•
•
•
•
• Rate Setting
• Potential Challenges
Introduction
Overview
Objectives
What is Managed Care?
Managed Care History
Managed Care in
Washington
• Demographics
• Managed Care Churn
• Managed Care Quality
and Contract Monitoring
• Network Adequacy
• Current WA Initiatives
• State Innovation Grant
• Healthier Washington
• Fully Integrated Care
• Behavioral Health
Organizations
• Regional Service Areas
• Earlier Enrollment
• Foster Care Managed Care
3
Objectives
• Provide an introduction to managed care in
Washington
• Provide overview of Managed Care program
operations
• Discuss initiatives to improve the health care
system in the State of Washington
• General conversation about Washington
States Medicaid Managed Care experience
4
What is Medicaid Managed Care?
• Managed Care is a health care delivery system organized to manage
cost, utilization, and clinical and service quality
• Medicaid managed care provides for the delivery of Medicaid
health benefits and additional services through contracted
arrangements between state Medicaid agencies and managed care
organizations (MCOs) that accept a set per member per month
(capitation) payment for these services
• By contracting with MCOs, states can reduce Medicaid costs and
better manage utilization of health services
• MCO contracts with the State Medicaid Agency are profit-limited
contracts
• MCOs strive to reinvest cost savings through shared savings
programs and provider partnerships
• Improvement in health plan performance, health care quality, and
outcomes are key objectives of Medicaid managed care
5
Some Facts about the History of
Managed Care
• One of the earliest references to managed health care in
the country dates back to 1910 in Tacoma, Washington
• In 1947, 400 families organized to form Group Health
Cooperative of Puget Sound
• California was the first state to move its Medicaid
population into a managed care model in the early 1970s
• In the US approximately 80% of Medicaid enrollees are
served through managed care
• Medicaid Managed Care delivery systems and program
implementation are regulated by 42 CFR 438 and various
federal authorities
6
Medicaid Managed Care in
Washington
• Health Care Authority (HCA) is the single state Medicaid
agency in Washington, which means it holds the authority
and receives payment from the federal government for
Medicaid
• HCA and Department of Social and Health Services (DSHS)
have agreements in place that places management and
oversight of most behavioral health programs within DSHS
• Since 1987, Washington has utilized managed care for
physical health coverage (through 1932a) – originally
“Healthy Options” and now “Apple Health”
• Since 1993, the state has operated its mental health
Medicaid benefit via a 1915b waiver - through the RSNs
• Both authorities require enrollment in managed care
7
Medicaid Managed Care in
Washington Today
• 1.8 million Washingtonians enrolled in Apple Health
(Medicaid) and approximately 85% are enrolled in
managed care
– Others to transition into managed care overtime
• 6 Medicaid Managed Care Plans are contracted with
the state to deliver physical health and mild to
moderate mental health services on a county by county
basis
• Molina Healthcare of Washington, Community Health
Plan of Washington, UnitedHealthcare, Coordinated
Care, Amerigroup, Columbia United Providers (CUP)
8
Role of MCOs in Washington
• MCOs provide coordinated care through a defined
network of health care systems and providers
• MCO role goes far beyond paying claims and approving
or denying authorization for services...MCOs invest
significant time and resources to:
–
–
–
–
–
–
Facilitate Care Management
Assure Clinical and Service Quality
Build Provider Networks
Engage & Partner with Communities
Leverage Data and Technology
Monitor & Maintain Compliance (TeaMonitor)
9
Building Provider Networks
• Contract with providers to ensure the availability
of a sufficient number and type of providers
within a required distance to meet the diverse
needs of the members
• To engage providers, most MCOs offer a
continuum of payment approaches including
value based models for provider partners to
provide opportunities to share savings and be
rewarded for high quality care
• Networks are routinely monitored to ensure
Access & Availability standards are maintained
10
Community Engagement
• MCOs partner with community-based
organizations and agencies at the local level to
increase health care coverage, improve health
literacy, drive health education campaigns and
build better connections across the service
delivery continuum
• MCOs hire local and regionally based staff and
resources
11
MCOs’ Role and Contributions to
ACHs
• MCOs are a local resource and thought partner
– MCOs have dedicated staff and subject matter experts
serving on ACH boards, councils and workgroups
across the state
– MCOs participate with HCA and Healthier WA on ACH
discussions
– MCOs partner with other health care stakeholders to
plan and prepare for ACH work
– MCOs work collaboratively with each other as a sector
12
Care Management
• Utilization Management:
– Right Care: Medically Necessary
– Right Time: Pursue Appropriate lower level
interventions first
– Right Provider/Right Care: Pay for
quality/performance and Evidence Based Practices
• Case Management for High Needs Members
– Complex case management, care coordination,
disease management, and health education
– Health Homes as example of strong community based
care management
13
Leveraging Data and Technology
• Advanced healthcare analytics and data.
• Information Exchange and Interoperability
• Examples:
– Claims-based data
– Link4Health (Clinical Data Repository)
– Real-time ED/admission based data (PreManage/EDIE)
– Patient registry
– Shared cost savings analysis
14
Demographics
Managed Care Eligibles and Managed Care Enrollees by County – October 2015
Reflects Enrollees Only
2936
10,934
San
Juan
98%
95%
Island
6,036
38,811
94%
Grays Harbor
Kitsap
17,524
13,372
19,104
94%
163,425
173,665
92%
94%
94%
Thurston
46,787
95%
Pierce
Pacific
4,713
5,033
94% Wahkiakum
Lewis
826
94%
Douglas
Grant
Kittitas
7,908
28,896
96%
96%
88,718
42,803
96%
44,831
95,346
Skamania
179
156
115%
2,265
95%
5,898
7,580
6,077
7708
97%
28,251
96%
Garfield
12,641 Columbia
824
13,303
95%
Walla Walla
904
91%
Asotin
4,714
5046
93%
Klickitat
2,403
471
94%
499
94%
96%
County enrollment in managed care is voluntary.
15
Whitman
98%
92%
91,487
94%
27,247 Franklin
Benton
Clark
Adams
Yakima
85,156
92%
123,263
2,504
94%
27,723
7,616
115,799
2,342
97%
20,717
28,852
775
96%
Lincoln
19,066
Cowlitz 26,531
91%
Spokane
10,467
20,278
324,931
3,297
10,397
10,180
19,564
309,239
12,578
3,003
9,657
Chelan
King
Mason
Pend
Oreille
93%
96%
5,669
Jefferson
49,622
90%
Snohomish
127,198
92%
93%
95%
122,276
4,058
41,549
1,392
96%
3,746
Stevens
1,258
11,983
Skagit
28,217
Clallam
11,324
95%
26,981
Ferry
Okanogan
40,887
2,981
11,476
38,922
Whatcom
Source: ODS Data Warehouse, CLNT-802.2, Run Date: 11/03/2015
ODS Data Warehouse, MC-849.1, Run Date: 11/02/2015
Currently eligible managed care clients are in black font.
Currently enrolled managed care clients are in red font.
The ratio of enrolled to eligible is expressed as a percentage.
January-September 2015
Enrollment Trends
The charts display enrollment over a 9 month period. Enrollment continues to increase for most
programs through the end of September 2015:
•AHAC (Adult expansion population) shows significant increase of 18%. This program was initiated January 1,
2014
•AHF (Family program) or the ‘welcome mat’ group has increased by 5% in large part due to outreach efforts in
2014 to ensure those eligible for Medicaid made application for services
•AHBD had a slight decrease of 1% while CHIP has a slight increase of 2%
16
Apple Health Demographic Analysis, October, 2015
AHAC Enrollment
(as of November 1, 2015)
Jan-Dec 2014
Enrollment Reason
Carry Forward 1/1/2015 2/1/2015 3/1/2015 4/1/2015 5/1/2015 6/1/2015 7/1/2015 8/1/2015 9/1/2015 10/1/2015 11/1/2015 12/1/2015 Grand Total
Auto Assignment
33,919
2,798
1,955
3,258
1,843
1,382
1,164
616
569
675
645
746
323
49,893
Client Choice
6,207
721
460
484
410
381
820
1,124
1,156
1,157
1,196
1,452
16
15,584
Connecting Family
1,104
238
387
339
297
175
191
137
122
180
218
151
60
3,599
Reenrolled with Previous Plan
2,543
670
1,489
1,088
1,041
706
435
251
352
422
419
584
137
10,137
AMG Total
43,773
4,427
4,291
5,169
3,591
2,644
2,610
2,128
2,199
2,434
2,478
2,933
536
79,213
Auto Assignment
Client Choice
Connecting Family
Reenrolled with Previous Plan
CCC Total
32,564
6,180
2,488
3,284
44,516
2,304
504
376
747
3,931
2,019
417
548
1,557
4,541
3,248
502
555
1,274
5,579
1,886
409
521
1,139
3,955
1,443
341
320
774
2,878
1,187
611
272
479
2,549
515
746
179
223
1,663
449
792
224
346
1,811
548
820
264
410
2,042
554
1,178
274
390
2,396
595
1,576
209
591
2,971
248
41
88
94
471
47,560
14,117
6,318
11,308
79,303
Auto Assignment
Client Choice
Connecting Family
Reenrolled with Previous Plan
CHPW Total
18,815
13,068
6,779
10,777
49,439
2,587
982
730
959
5,258
2,180
834
1,016
1,623
5,653
3,232
937
1,051
1,396
6,616
1,872
793
861
1,111
4,637
1,448
686
662
849
3,645
1,125
1,348
571
587
3,631
870
1,970
442
261
3,543
763
2,099
445
505
3,812
869
2,004
490
632
3,995
903
1,996
503
630
4,032
1,003
2,358
418
906
4,685
410
34
159
204
807
36,077
29,109
14,127
20,440
99,753
Auto Assignment
Client Choice
Connecting Family
Reenrolled with Previous Plan
CUP Total
0
0
0
0
0
0
515
5,935
3
6,453
0
997
179
53
1,229
0
670
228
78
976
0
545
219
125
889
0
342
170
100
612
1
436
158
52
647
0
514
101
13
628
0
523
122
51
696
0
535
115
53
703
0
557
138
76
771
1
535
82
109
727
0
15
36
12
63
2
6,184
7,483
725
14,394
Auto Assignment
Client Choice
Connecting Family
Reenrolled with Previous Plan
MHC Total
12,279
24,402
14,454
9,721
60,856
3,696
2,195
1,613
1,157
8,661
2,831
2,001
2,207
1,988
9,027
4,750
2,186
2,089
1,718
10,743
2,816
2,038
1,944
1,471
8,269
2,063
1,697
1,457
1,258
6,475
1,726
2,903
1,303
832
6,764
1,190
3,807
946
385
6,328
1,087
4,149
978
794
7,008
1,219
4,314
1,081
792
7,406
1,190
4,351
1,279
939
7,759
1,383
5,436
936
1,438
9,193
562
101
327
226
1,216
36,792
59,580
30,614
22,719
149,705
Auto Assignment
Client Choice
Connecting Family
Reenrolled with Previous Plan
UHC Total
37,787
9,149
2,152
3,417
52,505
2,310
723
313
858
4,204
1,968
651
559
1,704
4,882
3,179
772
534
1,271
5,756
1,815
1,026
450
1,151
4,442
1,339
700
317
824
3,180
1,123
1,305
364
552
3,344
784
1,929
237
296
3,246
705
2,092
232
402
3,431
848
2,241
308
497
3,894
794
2,183
314
480
3,771
952
2,730
233
682
4,597
395
37
102
132
666
53,999
25,538
6,115
12,266
97,918
251,089
32,934
29,623
34,839
25,783
19,434
19,545
17,536
18,957
20,474
21,207
25,106
3,759
520,286
*Apple Health Adult Coverage Total
*Transactions may contain client duplicates and decrease per month due to loss of eligibility, causing retro changes.
17
AHAC Enrollment November 1, 2015
Apple Health Program Enrollment
By Health Plan
Managed Care Program
AHAC
CHIP
HO
HOBD
HOFC
AMG
80,354
2,269
49,996
9,064
125
*Manage Care Enrollment Total 141,808
CUP CHPW
12,820 98,846
1,391 5,457
37,518 174,606
2,535 18,673
128
483
54,392 298,065 182,376 536,978 193,478 1,407,097
*Enrollment as September 1, 2015
18
Apple Health Demographic Analysis, October 2015
CCC
MHC
UHC
Total
81,723 135,913 94,290 503,946
3,188 14,047 4,148 30,500
85,376 355,038 82,020 784,554
11,897 30,369 12,718 85,256
192 1,611
302 2,841
Enrollment By Age Bracket
The percent of enrollment by age is similar
across health plans, except for the birth to 19
year old category. Both Molina Healthcare
(MHC) and Community Health Plan (CHPW)
have a much larger market share in this
category. This is the result of two factors.
First, managed care enrolled mostly women
and children from its inception until July 2012
when the SSI Blind/Disabled (a mostly adult
population) was added to managed care.
Both MHC and CHPW, longstanding plans in
the marketplace served a higher percentage
of the women/child population.
Second, in July 2012 three new MCOs entered
the marketplace and received a higher share
of the adult blind/disabled population. HCA
methods for assigning new enrollees during
this period of transition rewarded new plans,
resulting in higher enrollment of this
population to new managed care entrants.
19
Apple Health Demographic Analysis, October, 2015
Enrollment By Gender
• Gender is an important determinant of
services that will need to be provided,
as well as programs that need
developed
• Female enrollment in Apple Health is
10% greater than male enrollment
• The distribution of gender patterns
across health plans are similar;
however, AMG has more male
enrollees than female enrollees
20
Apple Health Demographic Analysis, October, 2015
Gender by Age Group and Program
• Using gender and age grouping data to
inform policymakers of the Apple Health
population is crucial for future budgeting
and planning at multiple levels
21
Apple Health Demographic Analysis, October, 2015
Enrollment By Race
• Providing client race is voluntary on
Apple Health program applications
• Collecting this information is crucial to
ensure appropriate programs and
services are available for clients
• The population of Medicaid individuals
is generally homogeneous and is reflective of
the race distribution in the statewide
population
• 25% of the client population’s race is unknown
either because it was “Not Reported” or the
client indicated “Other Race”
22
Apple Health Demographic Analysis, October, 2015
Enrollment Breakdown by Race and Ethnicity
Apple Health
Clients Served
1,422,627
Percentage
•
•
White NonMinority
832,613
59%
Any Minority
451,671
32%
Minority Groups
Amer Indian/ Asian/ Pacific
African American Alaska Nat
Islander Hispanic
113,639
11,650
106,040
305,280
8%
1%
7%
21%
1% of clients indicate they are of mixed race
A client who self-identifies as a member of one or more minority groups is
counted in each of those minority categories, and is counted once in the
Any Minority column. Clients who identify as White with no minority group
membership are tallied under White Non-Hispanic Only column. Some
Medicaid clients will not show up in the percentages because they have an
unknown race
23
Apple Health Demographic Analysis, October, 2015
Managed Care Enrollment By County
•
•
Managed care population by county aligns with population centers in the State of
Washington with King and Pierce counties having higher enrollment followed by
Snohomish and Spokane counties
The analysis of county population provides important information that can be used to
determine provider network adequacy and client needs in different areas
24
Apple Health Demographic Analysis, October, 2015
Enrollment By Preferred Spoken Language
(Other Than English or Spanish)
•
•
•
•
English and Spanish language numbers were 1,192,644 and 128,163 respectively
For 5% (64,750) of Apple Health enrollment, the primary language is not known to HCA
Receiving information in an individual’s primary language enhances one’s ability to
understand and act on information provided to the individual
HCA requires MCOs to translate materials if 5% or more enrollees speak a specific language other than
English
25
Apple Health Demographic Analysis, October, 2015
Health Plan and County Preferred Spoken Language
• Health Plans have the same top two
languages English and Spanish
• County analysis shows the top two
measureable languages as English
and Spanish except in Spokane and
Stevens counties, where it is English
and Russian
26
Apple Health Demographic Analysis, October, 2015
Enrollment by Federal Poverty Level (FPL)
and Income Bracket
•
•
•
27
Apple Health Demographic Analysis, October, 2015
Clients whose application indicates they have
no income is represented on the chart as $0
(zero)
Income is another important determinant in a
client’s ability to access healthcare
Both gross income and the FPL provide an
important picture of the Apple Health
population
FPL Groupings By Race
•
•
•
The largest portion of the population is below 25% of the
FPL and make up 45% of the overall population
The second largest portion of the population is between
101-133% of the FPL and make up 14% of the population
With poverty identified as a barrier to health care access,
this information is crucial to ensure health care services and
transportation programs are in place
28
Apple Health Demographic Analysis, October, 2015
Average Medicaid Managed Care
Client FPL and County Unemployment Rate
•
•
The county unemployment rates (Medicaid and non-Medicaid) were obtained
from the Employment Security Department (ESD) as of August 2015
The highest unemployment exists in Ferry (10%), Pend Oreille (9%), Grays
Harbor (8%), Lewis (8%) and Mason (8%)
29
Apple Health Demographic Analysis, October 2015
Churn
• Without MCO plan lock-in churn can be
expected
30
71
Health Plan Outgoing Churn
(September 2015)
31
Managed Care Health Plan Churn October, 2015
33
Health Plan Incoming Churn
(September 2015)
32
Managed Care Health Plan Churn October, 2015
Health Plan Churn Percentage Per County
Based on County Enrollment
(September 2015)
Average Churn .70%
33
Managed Care Health Plan Churn October 2015
MCO Monitoring
•
•
•
•
•
CFR/EQR Requirements for states
Structured monitoring of MCOs
Performance Improvement Projects
2015 Monitoring results of calendar year 2014
Select Performance Measure and Survey data
34
CFR/EQR Requirements for States Mandatory Activities
• Review of MCOs conducted by an external quality review
organization (annual EQR report)
• Structured monitoring of MCOs (HCA)
• Annual validation of MCO clinical and non-clinical performance
improvement projects (PIP) (HCA)
• Annual validation of MCO performance measures (aka HEDIS
audit by EQRO)
35
CFR Requirements for States Optional Activities
• Validate MCO encounter data
• Surveys (Consumer Assessment of Healthcare Providers
and Systems)
• Additional performance measures
• Additional PIPs and Focused quality studies
36
Structured Monitoring of MCOs
• Coverage and authorization
of services (utilization
management)
• Enrollee Rights
• Grievance System
Availability of services
• Practice Guidelines
Coordination and
• Credentialing
continuity of care
• Timely Claims Payment
Program Integrity
• Subcontracts
Quality assessment and
• Enrollment and
performance
Disenrollment
improvement
Health Information Systems
37 •
• Areas reviewed based
on federal requirements
and monitoring
protocols:
•
•
•
•
2015 Monitoring Results
38
2015 Monitoring Report
39
Well-Child Visits – 3-6 Years of Age
40
Adolescent Immunizations
41
CAHPS – Child and Child with Chronic
Conditions Survey
42
Finance Capacity
• MCOs are risk-bearing entities
• MCOs have risk-adjusted rates
• MCOs are profit-limited. The State Medicaid agency
sets a maximum profit. Profits greater than the limit
must be returned to the Medicaid Agency
• MCOs maintain sufficient reserves as required by the
Office of the Insurance Commissioner
• MCOs have payment model expertise
• MCOs have actuarial resources in order to validate that
rates are actuarially sound
43
Rate Setting Process
• The U.S. Centers for Medicare and Medicaid Services (CMS)
mandates that rates paid to Medicaid-funded MC plans must
be based on actual cost experience and be certified as
actuarially sound. An independent actuary firm, Milliman,
analyzes and certifies the AH rates
• Rate changes are implemented at the start of, and effective
for the remainder of each Calendar Year (CY). The total impact
of the CY 2016 rate change across SFY 2016 and SFY 2017 is
estimated at $470.2 million ($302.0 million GF-F and $168.2
million GF-S)
44
Managed Care Rate Setting
• Apple Health (AH) premium payments (rates) will account for
nearly half of the Washington Health Care Authority’s (HCA)
total budget in State Fiscal Year (SFY) 2016.
• Total AH per member per month (PMPM) premiums including all services, funds and rate groups - are projected to
increase by about 7 percent from SFY 2015 to 2016
• AH rates are increasing because projected costs are
increasing, overall about five percent from 2014 to 2015
• About $11 of the total $14 increase - nearly 80 percent - is
due to pharmacy cost increases
45
AH Adult Cost Trend
2014
2015
Change 2014 to
2015
TOTAL
$375
$372
-$4
-0.9%
Hospital IP
$79
$78
-$1
-1.0%
Hospital OP
$66
$63
-$4
-5.4%
Physician
$59
$58
-$1
-1.0%
Drugs
$62
$72
$10
16.1%
Other
$8
$7
-$1
-15.6%
Sub-capitation
$25
$19
-$6
-24.9%
Benefit change
$1
$2
$1
56.1%
Pass-through
$31
$26
-$6
-17.7%
Admin / tax
$44
$47
$4
8.5%
Cost Component
46
% Change 2014 to
2015
Blind / Disabled Cost Trend
2014
2015
Change 2014 to
2015
TOTAL
$905
$994
$89
9.8%
Hospital IP
$211
$210
-$2
-0.7%
Hospital OP
$136
$128
-$8
-5.7%
Physician
$112
$109
-$2
-2.0%
Drugs
$229
$290
$61
26.5%
Other
$42
$47
$5
12.1%
Sub-capitation
$6
$12
$5
85.7%
Benefit change
$8
$7
-$1
-13.5%
Pass-through
$77
$100
$23
30.2%
Admin / tax
$84
$91
$7
8.4%
Cost Component
47
% Change 2014 to
2015
Historical Rates in the Blind / Disabled
and COPES Rate Groups
• The following graph shows
that the annual projected
rate trend from July 2012
to December of 2016 is
+2.9%
• The initial MCO contract to
serve blind and disabled
clients saved over $100
million in 2012 over feefor-service
48
Components of 2014 to 2015 AH
Cost Increases
Projected Per Member Per
Month (PMPM) Costs
Rate Component
TOTAL
Hospital Inpatient
Physician
Drugs
Hospital Outpatient
Administration
Pass-through
Other Medical
2014
$289
$65
$64
$48
$47
$32
$23
$9
2015
$302
$65
$64
$59
$47
$35
$24
$9
49
Dollars
$14
-$1
$0
$11
$0
$3
$1
$0
Change 2014 to 2015
Percent of Total
Percent
Change
4.7%
100.0%
-0.9%
-4.4%
-0.6%
-3.0%
22.3%
78.9%
0.4%
1.2%
9.3%
22.0%
2.5%
4.3%
1.3%
0.9%
Potential Challenges
• Integration of services (behavior and physical health)
• Network adequacy
– Distance, time and count
•
•
•
•
Provider contracting and payment expectations
Non-participating providers
Encounter data quality
Transition from fee-for-service to managed care
– Contractual arrangements
• Voluntary service areas
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Network Adequacy Federal
Requirements
Requires the State to ensure:
•
42 CFR § 438.207(d)
– (a) Basic rule. The State must ensure, through its contracts, that each MCO, PIHP, and PAHP
gives assurances to the State and provides supporting documentation that demonstrates that
it has the capacity to serve the expected enrollment in its service area in accordance with the
State's standards for access to care under this subpart
•
42 CFR §438.206(a)(b)
– (a) Basic rule. Each State must ensure that all services covered under the State plan are
available and accessible to enrollees of MCOs, PIHPs, and PAHPs
– (b) Delivery network. The State must ensure, through its contracts, that each MCO, and each
PIHP and PAHP consistent with the scope of the PIHP's or PAHP's contracted services, meets
the following requirements:
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Network Adequacy Washington State Law
Requires the MCO:
•
WAC 182-538-067(1)(c) Managed care provided through MCO’s
– (1) Managed care organizations (MCOs) may contract with the department to provide prepaid
health care services to eligible clients. The MCOs must meet the qualifications in this section
to be eligible to contract with the department. The MCO must:
• (a) Have a certificate of registration from the office of the insurance commissioner (OIC) that allows
the MCO to provide the health care services;
(b) Accept the terms and conditions of the department's managed care contract;
(c) Be able to meet the network and quality standards established by the department; and
•
WAC 284-43-200(1)(4) Network Adequacy
– (1)A health carrier shall maintain each plan network in a manner that is sufficient in numbers
and types of providers and facilities to assure that all health plan services to covered persons
will be accessible without unreasonable delay….
– (4) The health carrier shall establish and maintain adequate arrangements to ensure
reasonable proximity of network providers and facilities to the business or personal residence
of covered persons……
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Monitoring Health Plans Networks
•
•
Monitoring Activities
― Various statistics weekly – call center, outreach activities, assessments (CMS monitoring
calls)
― Network adequacy reports
― Quarterly, upon a material change to the network or based on HCA request
― HCA uses Geo Access for analysis
― MCO’s that fail to meet standards do not receive assignment
― MCO’s are required to report loss of material providers
― HCA evaluates impacts and will take action as necessary
– Monitor complaints to resolution
— MCOs required to report on enrollee/provider complaints regarding access to care
Onsite technical assistance monitoring annually with required corrective action plans
– Includes reviewing provider contracts
– Contractually required MCO quarterly quality assurance review
• Review 25% of combined network
– Verify contact information, address, phone number etc. Open or closed panels
• Report to HCA biannually
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Analysis of Network
Assignment
•
•
•
Enrollment only
•
•
•
Inadequate network
•
Demonstrates sufficient
provider network to
receive all eligible
enrollees
Plan name appears on
enrollment form
HCA auto-enrolls
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
Does not demonstrate a
sufficient provider
network to receive eligible
enrollees. Plan name will
not appear on enrollment
form
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Top 6 provider categories include:
1. Hospital
2. Primary Care Provider
3. Pharmacy
4. Obstetric/Gynecologist
5. Pediatrics
6. Behavioral Health
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
Sample Network Summary
COLUMBIA
COWLITZ
DOUGLAS
FERRY
FRANKLIN
GARFIELD
100.00 100.00 100.00
0.00 16.44 99.89
99.76 100.00 100.00
82.12 99.25 97.62
92.54 93.72 100.00
100.00 100.00 100.00
70.37 98.93 99.45
98.39 98.39 98.39
99.81 100.00 100.00
99.99 97.47 94.96
78.73 45.70 94.08
99.79 100.00 44.01
0.00 100.00 100.00 100.00 100.00
12.15 16.44 99.29 99.26 97.71
99.71 100.00 95.84 99.82 100.00
25.53 99.25 73.90 82.12 95.85
93.37 93.72 93.72 99.22 100.00
23.94 100.00 100.00 100.00 100.00
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Behavioral
Pediatric
OB
Pharmacy
PCP
79.77
99.76
99.81
99.99
51.48
50.05
Hospital
74.11
98.46
99.86
94.85
56.60
99.64
Behavioral
Pediatric
81.91 99.51
99.76 99.76
99.81 100.00
99.99 99.99
51.48 99.79
50.05 100.00
PCP
OB
70.98
98.39
99.81
97.47
45.70
0.00
MCO B
Pharmacy
County
ADAMS
ASOTIN
BENTON
CHELAN
CLALLAM
CLARK
Hospital
MCO A
99.51 89.05 99.45 92.21
99.76 98.46 98.39 98.39
100.00 100.00 100.00 99.81
99.99 97.42 94.96 99.99
99.79 95.43 94.08 78.73
100.00 100.00 44.01 100.00
100.00
0.00 100.00
99.89 99.65 97.71
100.00 100.00 100.00
97.62 25.23 95.85
100.00 98.91 100.00
100.00 11.27 100.00
95.94
99.56
95.84
78.79
99.22
37.46
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
56
Current Initiatives
• Current Initiatives
– State Innovation Grant
• Healthier Washington
– Behavioral Health Organizations
• Chemical Dependency and Mental Health Services
– Fully Integrated Care in Southwest Washington
– Regional Service Areas
• Regional networks and purchasing
• Accountable Communities of Health
– Earlier Enrollment
– Foster and Adoption Support Children enrolled in a single statewide
Managed Care plan
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State Innovation Grant
• Reduce avoidable use of intensive services and settings—such as
acute care hospitals, nursing facilities, psychiatric hospitals,
traditional long term services and supports and jails
• Improve population health—focusing on prevention and
management of diabetes, cardiovascular disease, pediatric obesity,
smoking, mental illness, substance use disorders, and oral health
• Accelerate the transition to value-based payment—while ensuring
that access to specialty and community services outside the Indian
Health System are maintained for Washington’s tribal members
• Ensure that Medicaid per-capita cost growth is two percentage
points below national trends—Washington’s Medicaid costs are
historically well below the national average
58
State Innovation Test Models
• Early Adopter of Medicaid Integration (Payment Model 1)
– The state will test the degree to which integrated financing can bring together physical
and behavioral health services to deliver whole-person care
• Encounter-based to Value-based (Payment Model 2)
– The model will test how increased financial flexibility can support promising models that
expand care delivery options such as email, telemedicine, group visits and expanded
care teams
• Accountable Care Program and Multi-Purchaser (Payment Model 3)
– Washington will work with the University of Washington Accountable Care Network, and
the Puget Sound High Value Network LLC to test a new accountable delivery and
payment model, known as the Accountable Care Program
• Greater Washington Multi-Payer (Payment Model 4)
– Washington will test integrated data platform capacity to allow providers to coordinate
care, share risk and engage a sizeable population across multiple payers
59
Behavioral Health Organizations
• Chemical dependency and mental health
services provided by a managed care entity
• High needs clients who meet established
access to care standards
• Transition step to fully integrated care in 2020.
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Fully Integrated Care
• Goal is to integrate physical health, mental health
and substance use disorder services statewide under
MCOs by 2020
– Includes separate crisis services contract
• Early adopter region set to go live April 2016
• Statewide health care performance measures used
across systems
– 52 measures that will help determine how well the health
care system is performing in both quality and cost
61
Regional Service Areas
• Effective April 2016 Washington will divide the
state Medicaid services into 10 Regional
Service Areas (RSA)
• Accountable Communities of Health will be
established
– Establish collaborative decision-making on a regional basis to improve
health and health systems, focusing on social determinants of health,
clinical-community linkages, and whole person care
– Drive physical and behavioral health care integration by making
financing and delivery system adjustments, starting with Medicaid
62
Regional Service Areas Map
63
Earlier Enrollment
• HCA currently enrollees clients into managed care
prospectively, thus resulting in fee-for-service
expenditures
• Applicants can shop for plans on the State exchange
when applying
• In April 2016, HCA will enroll clients into managed
care the day they are determined eligible
– Improve continuity of care
– Reduce churn
– Reduce auto-assignments
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Foster and Adoption Support into
Managed Care
• The HCA is procuring a single managed care
entity to provide services under a single plan
– To provide a system of consistent, coordinated health care
services.
• Physical health care services starting April
2016
• Fully integrated services effective October
2018
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References
• Health Care Authority (HCA) www.hca.wa.gov
• HCA Managed Care
http://www.hca.wa.gov/medicaid/healthyoptions/pages/healthyoptions.a
spx
• HCA Managed Care Contract
http://www.hca.wa.gov/medicaid/healthyoptions/Pages/contracts.aspx
• HCA Managed Care Reports
http://www.hca.wa.gov/medicaid/healthyoptions/Pages/reports.aspx
• [email protected] 360-725-1786
66
THANK YOU
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