Medicaid Managed Care 101:
A Framework for Cost-Conscious,
Quality Care
Joan Alker
Tricia Brooks
Sarah Somers
Kelly Whitener
Ruth Kennedy
CCF Annual Conference 2015
Today
What we’ll talk about….
What we’ll defer to MC 201….
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Consumer Information
Enrollment
Disenrollment
Plan choice
Types of managed care
Benefits and EPSDT
Network adequacy
Consumer protections
Quality
The State perspective
Payment methodologies
Actuarial soundness
Rate setting
Contract requirements
Approaching Our Work on Managed Care
What do
children and
their
families
need?
What do
they need to
know?
How do we
make sure
that kids
and families
are well
served?
POPULATIONS
ENROLLMENT
CONSUMER INFORMATION
Tricia Brooks
Share of Medicaid Enrollees in Managed Care
• Historically children
and low income
families
• Recent shifting of
duals and disabled to
achieve better cost
controls and care
coordination for high
need, high cost
populations
• All expansion adults
80%
74.22%
71.70%
70%
63%
57.58%
60%
50%
40%
29.4%
30%
20%
14%
10%
3%
0%
1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011
Voluntary vs. Mandatory
Voluntary
enrollment can be
offered to anyone
in Medicaid
Non-exempt
groups can be
mandated to
enroll in managed
care
Waiver is required
to enroll exempt
populations
Low voluntary enrollment can result in inadequate
numbers of enrollees
•
•
•
Particularly true for high risk, high cost populations
Issues can sometimes be addressed through welldesigned payment arrangements
States more often move toward mandatory coverage
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Populations
State Plan
Amendment
• Children
• Parents
• Non-disabled
Adults
Need 1915(b) Waiver to
Mandate Exempt Groups:
• Children with special health care
needs or disabilities
• Children receiving foster care or
adoption assistance
• American Indians
• Dual eligibles (poor elderly
eligible for Medicare)
7
CONSUMER ISSUES THAT STATES
MUST ADDRESS IN BUILDING
DELIVERY SYSTEMS THAT INCLUDE
MANAGED CARE
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Choice
Voluntary
• Choice of FFS or voluntary
enrollment in a managed
care plan
Mandatory
• Risk-based managed care
plans
– Choice of plans
• Exception for rural areas
where choice of primary care
provider is required
• Other protections also exist
• Primary care case
management
– Choice of providers
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Plan Selection vs. Auto-Assignment
• Goal for states is as to enroll as quickly as possible
• Some states require that enrollees select a plan
upfront when applying
• Others wait until after eligibility has been
determined
• All must have auto-assignment (default enrollment)
process for those who do not choose
• Number of plans to choose from varies by state and
region
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Auto-Assignment (Default Enrollment)
• Must preserve existing provider arrangements or
relationships with providers that have traditionally
served Medicaid
• If not possible, must distribute “equitably” among
plans
• In practice, states assign
based on a variety of
NPRM would codify
factors (e.g., proximity to
additional criteria to
providers, enrollment of family
members, and performance
based measures)
use in default
enrollment,
including quality
11
Other Enrollment Issues
• No current enrollment provisions relating to
voluntary managed care
- Many states enroll directly and offer opt-out
• No minimum period of
time allowed for plan
selection
– Varies, by state, from a number
of days to months
– sometimes longer for disabled
populations
NPRM addresses
both
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Enrollment Brokers
• States often contract with external enrollment
brokers to provide choice counseling and conduct
enrollment activities (438.810(a))
• Must be independent from the managed care
entities and free from conflict of interests
• Mixed evidence of the effectiveness
of enrollment brokers
NPRM requires choice
counseling and
establishes broader
requirement for
beneficiary support
system
13
Disenrollment
Requested by Plan
• May not disenroll based on
utilization, change in health
status, special needs
• Contract should specify
reasons plans may use for
requesting disenrollment
Requested by the Enrollee
• First 90 days
• At least once every 12 months,
with 60 day notice
• At any time for cause
• May require enrollee to seek
redress through grievance
system before disenrolling
• Effective no later than the first
of the second month following
the month of the request
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Cause for Disenrollment
• Enrollee moves out of service area
• Plan does not cover service based on moral or
religious objections
• Enrollee needs related services to be performed at
same time that are not available
• Others, including but not limited to, poor quality, lack
of access to covered services or qualified providers
15
Consumer Education
• Health insurance literacy
• Low-income uninsured may
have little or no experience
with managed care
• May be transitioning from
FFS to MC
Enrollment
Drugs
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Notices and Written Information
• All notices and informational or instructional
materials must:
- Be in an easily understood language and format
- Be available in prevalent languages and alternative formats
needed by those with special needs (e.g. limited vision,
limited reading proficiency)
- Inform enrollees and potential enrollees of the availability
and how to access alternative formats
• Provided upon eligibility determination in
time to support plan selection
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Language Support
• States must…
• Identify prevalent languages spoken by a significant
number or percentage of enrollees and potential enrollees
• State and plans must…
• provide written information in all prevalent languages
• provide oral interpretation for all non-English languages
• must inform enrollees and potential enrollees of
availability and how to access language supports
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State Responsibilities
• Mechanism to help
enrollees and potential
enrollees understand
managed care
• Must ensure that
managed care plans
fulfill their
responsibilities
• Information must
include:
– Basic features of managed
care
– Which groups are…
• Able to enroll voluntarily
• Excluded from enrollment
• Required to enroll
– Disenrollment rights
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MC Plan Responsibilities
• Mechanism to help
enrollees and potential
enrollees understand
plan requirements and
benefits
NPRM has new and
very detailed
information
requirements
• Information must
include:
– Benefits and how to
access
– Cost-sharing
– Service area
– Provider information
– Restrictions on choice of
provider
– When services of
covered out of network
– Grievances and appeals
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Marketing Restrictions
• Distribution of materials must be approved by state
in consultation with Medical Care Advisory
Committee
• Must distribute to everyone in service area
• Can’t sell other products
• Info must not be fraudulent, misleading or confusing
• Cold-calling is prohibited
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Other Beneficiary Protections
• Access to emergency services without prior
authorization
• Defines emergency medical conditions,
services, and out-of-network access
• No restrictions on patient-provider
communications
• Liability for payment
• Anti-discrimination
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Roll Out of New MC Implementation
• No Standards but….
- Must be adequate time for system development
- Sufficient resources to ensure smooth transition
- Phased-in approach may work best
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TYPES OF MANAGED CARE ENTITIES
BENEFITS AND EPSDT
NETWORK ADEQUACY AND ACCESS
STANDARDS
Sarah Somers
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Medicaid Managed Care – Key Terms
• Contract, RFP
- Risk contract
• Capitation
- PMPM
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Medicaid Managed Care Entities
• MCO – Managed Care Organization
• PIHP, PAHP – Prepaid Health Plan
- (Inpatient or Ambulatory)
• PCCM – Primary Care Case Management
- “Managed’ fee for service
• PACE – Program of all-inclusive care for the elderly
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NPRM Adds New Definitions
• PCCM Entity – Primary care case management
entity
• NEMT PAHP – Non-Emergency Transportation
Prepaid Ambulatory Health Plan
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Benefits
• Basic requirement:
- States must ensure that all services covered under
Medicaid state plan are “available and accessible”
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Adequacy of Services/Networks
• MCOs/PHPs must:
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Make covered services available to the same extent they
are available to other beneficiaries
Assure that they have adequate capacity to serve
expected enrollment, including services and providers
• PCCM contracts must provide for
arrangements/referrals to sufficient numbers of
providers to ensure prompt service delivery
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Services for Enrollees with Special Health
Care Needs
• States must:
- Identify such persons* to plans
- Assess individual needs (using appropriate
health care professionals)
- Allow direct access to specialists
• Require plans to produce a treatment plan
(optional)
- Developed by provider with enrollee input
- Approved by plan
*as defined by the state
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Network Adequacy
• No specific federal standards
- Contracts
- State law
• Example: Virginia Contract (pp. 39, 245)
• Example: California Regulations (28 Cal. Code.
Regs.1300.67.2)
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Early and Periodic, Screening, Diagnosis
and Treatment (EPSDT)
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Required for beneficiaries under age 21
Outreach and informing
“Screens” (check ups)
Treatment
Assistance with accessing services
Great Resource
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Policy Reasons for EPSDT
Low-income children are more likely to have:
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Vision, hearing and speech problems
Untreated tooth decay
Elevated lead blood levels
Sickle cell disease
Behavioral Health problems
Anemia
Asthma
Transportation barriers
And more . . .
36
EPSDT Requirements: Mandatory Screenings
Medical Screens
Other Screens
 Health and
developmental history
 Unclothed physical
exam
 Immunizations
 Lab tests, including lead
blood tests
 Health education
 Vision, including
eyeglasses
 Hearing, including
hearing aids
 Dental, including relief
of pain, restoration of
teeth and maintenance
of dental health
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EPSDT Requirements: Treatment
• All services that could be covered under state
Medicaid plan (mandatory and optional)
• All Medicaid-covered services necessary to
“correct or ameliorate physical and mental
illnesses and conditions,” even if the service is
not covered under the state plan
• CMS Guidance: no hard limits on hours/visits
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EPSDT Requirements: Outreach and Informing
• Effective and aggressive
- Oral and written
- Translated
- Targeted (e.g. pregnant teens, non-users)
• Transportation and appointment assistance
(prior to screen due date)
• Coordination with other entities
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EPSDT: Issues in Managed Care
• Non-coverage of services
- Carve outs, failure of state to ensure services are
provided
• Limits on number of visits/hours
• Prior authorization for screens, delaying
services
• Stricter medical necessity definition than state
uses
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Questions?
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GRIEVANCES AND APPEALS
Sarah Somers
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Medicaid Due Process: Legal Authority
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Constitution
Medicaid statute
Federal regulations
State law
Contracts (MC)
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What triggers right to hearing?
• Denial of application for benefits/failure to act
with reasonable promptness
• Agency has taken an action erroneously
• Reduction, suspension, termination of service
• PASRR, transfer or discharge from NF
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Right to Appeal, cont’d
• “Action” of MCO:
- Denying, reducing, terminating or otherwise
limiting services or denying payment for services
- Failing to timely provide services
- Denying request for disenrollment or exemption
- “otherwise adversely affecting the individual”
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Notice
• Must include:
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Action taken
Reasons for action
Right to file appeal
Right file state hearing request
Expedited resolution
Continued benefits
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Grievance
• An expression of dissatisfaction about any matter
other than an action
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Continued Benefits
• Must continue pending final hearing decision
if hearing is requested w/in 10 days of action
- When MCO appeal taken and beneficiary loses,
must again request services continue pending fair
hearing decision
- Beneficiary can be required to pay for benefits if
he ultimately loses
• ISSUE – no continued benefits beyond
authorization period
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QUALITY MEASUREMENT AND
IMPROVEMENT
Tricia Brooks
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Quality Assessment and Improvement
Strategy
• Current regulations focus
quality measurement and
improvement strategies on
MCO’s and PIHP’s.
NPRM expands quality
requirements to all
delivery systems, including
FFS and all types of MC
entities
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Each State Contracting with an MCO or
PIHP must….
• Have a written strategy for assessing and
improving quality
• Obtain public input
• Ensure plan compliance
• Review effectiveness and update the strategy
• Submit strategy to CMS, as well as updates and
reports on implementation and effectiveness
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Required Elements of Quality Strategy
• Assess the quality and appropriateness of care to
everyone, and to those with special health needs
• Identify and provide to plans at enrollment, the race,
ethnicity, and primary language of each enrollee
• Monitor and evaluate plan compliance
• Incorporate national performance measures if
applicable
• Arrange for annual independent external quality
review (EQR)
• Ensures adoption and dissemination of practice
guidelines
52
MC Entity Must Conduct Performance
Improvement Projects
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Use objective measurements
Assess clinical and nonclinical areas
Implement system interventions to improve care
Evaluate effectiveness
Submit state or CMS specified performance
measurement data
• Identify both underutilization and overutilization of
services
• Assess quality and appropriateness of care for enrollees
with SHCN
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External Quality Review (EQR)
• Applies to MCO, PHIP, HIO
• EQR organization must meet federal standards
• Analyzes and evaluates aggregated information on
quality, timeliness, and access to health care
services
• Reports must be submitted to CMS but vary across
states in organization and level of detail due to
differing interpretation of the regulations
http://www.healthlaw.org/issues/medicaid/managed-care/EQROverview06162014pdf#.VQ7JvBDF_2w
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EQR?
Validates performance measures and improvement programs :
Mandatory EQR Activities
Optional EQR Activities
- Evaluate quality, timeliness,
and access to care
- Assess plan’s strengths and
weaknesses, and
recommend quality
improvement project
- Appraise how well each
plan responded to previous
QI recommendations
- Validate encounter level data
- Administer or validate
consumer or provider surveys
- Calculate state-required
performance measures
- Conduct detailed PIP reviews
- Conduct focused, one-time
studies
NPRM adds network
adequacy validation to
mandatory activities
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Common Issues Across EQR Reports
• Data collection methods vary
• No federally required measures; states can pick and
choose but tend to use most common
• Challenging to compare across states or plans
• MCO’s come and go, so difficult to form a picture of
system performance
• Comprehensiveness of the reporting to CMS is
improving
NPRM lays foundation for
alignment and more consistent
reporting on quality
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CHIP
Kelly Whitener
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CHIP Managed Care Rules
• The Children’s Health Insurance Program
Reauthorization Act of 2009 (CHIPRA) applied several
Medicaid managed care provisions to CHIP at section
2103(f)(3) of the Social Security Act:
- Section 1932(a)(4): Process for enrollment and termination and
change of enrollment
- Section 1932(a)(5): Provision of information
- Section 1932(b): Beneficiary protections
- Section 1932(c): Quality assurance standards
- Section 1932(d): Protections against fraud and abuse
- Section 1932(e): Sanction for noncompliance
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CHIP Managed Care Rules
• CMS provided initial guidance on these rules
in two State Health Official (SHO) letters
- SHO#09-008 offered guidance on implementing the new
requirements generally, including submitting CHIP
managed care contracts to CMS for review for the first
time
- SHO#09-013 offered additional guidance on the quality
provisions in particular
- Both letters indicated more information was forthcoming,
and it arrived on June 1 this year, proposing managed care
regulations in CHIP for the first time!
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How is CHIP managed care different?
Contracts & Rates
Beneficiary Enrollment
• Contracts are typically not
reviewed by CMS, and they
do not have to be
approved prior to
implementation
• Capitation rates are not
reviewed by CMS and they
do not have to meet
actuarial soundness
requirements
• There is no requirement
for beneficiaries to have a
choice of plans at
enrollment, but must have
another option if they
choose to disenroll from
the managed care plan
• Beneficiaries can be
required to pay premiums
prior to enrollment
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THE STATE
PERSPECTIVE
Ruth Kennedy
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QUESTIONS AND
DISCUSSION
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Resources
• CMS “Medicaid Managed Care Enrollment Report,” July 2011
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Dataand-Systems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdf
• CMS Medicaid Managed Care Web Pages
http://www.medicaid.gov/medicaid-chip-program-information/by-topics/deliverysystems/managed-care/managed-care-site.html
• MACPAC “The Evolution of Managed Care in Medicaid,” June
2011 http://www.mhpa.org/_upload/MACPAC_June2011_web.pdf
• Kaiser Family Foundation “A Profile of Medicaid Managed
Care Programs in 2010: Findings from a 50-State Survey”
http://kff.org/medicaid/report/a-profile-of-medicaid-managed-care-programs-in2010-findings-from-a-50-state-survey/
• Kaiser Family Foundation “Medicaid Managed Care Tracker”
http://kff.org/data-collection/medicaid-managed-care-market-tracker/
NHeLP Resources
• “A Guide to Oversight, Transparency, and Accountability in
Medicaid Managed Care” http://www.healthlaw.org/publications/browseall-publications/managed-care-toolkit-march-2015#.VaMGs5NViko
• “Survey of Medicaid Managed Care Contracts: EPSDT Vision
and Hearing Services” http://www.healthlaw.org/publications/searchpublications/managed-care-survey-EPSDT
• Model Provisions: #1 Grievances and Appeals; #2 Enrollment
and Disenrollment; #3 Network Adequacy; #4 Accessibility &
Language Access; #5 Reproductive Health
http://www.healthlaw.org/publications/search-publications
• Network Adequacy in Medicaid Managed Care:
Recommendations for Advocates
http://www.healthlaw.org/publications/search-publications/network-adequacy-inmedicaid-managed-care#.VaMJdJNViko
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Contact
Sarah Somers
[email protected]
www.healthlaw.org
Joan Alker
[email protected]
Tricia Brooks
[email protected]
Kelly Whitener
[email protected]
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