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The KanCare Transition Kansas Association of Counties Annual Conference November 13, 2012. Martie Ross Pershing Yoakley & Associates, PC. What Is Medicaid?. Federal-state program to provide care for vulnerable populations State determines program structure within specified standards - PowerPoint PPT Presentation
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The KanCare TransitionKansas Association of Counties
Annual ConferenceNovember 13, 2012
Martie RossPershing Yoakley & Associates, PC
Page 2November 13 , 2012
Prepared for Kansas Association of Counties
What Is Medicaid?• Federal-state program to provide care for vulnerable
populations– State determines program structure within specified standards– Approved State Plan
• Shared cost– $2.8B total; $1.1B SGF (KS FMAP = 56.5%) – 18% of SGF– 2nd largest state expenditure
Page 3November 13 , 2012
Prepared for Kansas Association of Counties
What Is Medicaid?• ≈ 300,000 Kansans covered
– Children, pregnant women, adults with children ≤ 30% FPL ($5600/year for family of four)
• 2/3 of beneficiaries, but only 25% of cost• Primarily in managed care (capitated payment to private insurance
company)– Elderly and persons with physical/mental disability
• 1/3 of beneficiaries, but more than 75% of cost• Medicaid pays almost 50% of long-term care costs for elderly • Primarily in fee-for-service (state pays providers directly)
Page 4November 13 , 2012
Prepared for Kansas Association of Counties
KanCare
• Governor Brownback’s plan for reforming Kansas Medicaid program
• Announced in Nov. 2011; effective on Jan. 1, 2013• Achieve $853 million ($368M SGF) over five years
5-year Total
Savings FY13 FY14 FY15 FY 16 FY 17
All Funds 29,060,260 113,513,129 198,041,997 235,439,877 277,004,864 853,060,127
SGF 12,522,066 48,912,807 85,336,296 101,451,043 119,361,396 367,583,609
Page 5November 13 , 2012
Prepared for Kansas Association of Counties
Savings• Does not reduce eligibility• Does not reduce covered services• Does not reduce provider payments• Savings achieved through outcomes-focused,
person-centered care coordination model
Page 6November 13 , 2012
Prepared for Kansas Association of Counties
Page 7November 13 , 2012
Prepared for Kansas Association of Counties
Four Pillars of Health Reform
Focus on wellness and prevention
Focus on quality of care
Promote clinical integration
Promote community-based
solutions
Page 8November 13 , 2012
Prepared for Kansas Association of Counties
Big Picture – Track 1 • Contract with 3 MCOs to run Medicaid program for
per-member fixed rate• Move (nearly) all Medicaid beneficiaries to managed
care• Establish safety net care pools
– Large public teaching hospital; border city children’s hospitals; uncompensated care; CAHs
• Develop Medicaid off-ramps (pilot projects)
Page 9November 13 , 2012
Prepared for Kansas Association of Counties
Big Picture – Track 2• Global waiver• Per capita block grant with performance
standards (quality measures)• “Ready to move forward as early as 2015”
Page 10November 13 , 2012
Prepared for Kansas Association of Counties
Role of MCOs• State’s contract with MCO impose standards of
performance and oversight• MCOs create provider networks to deliver services to
their members– MCOs’ provider contracts establish terms of service delivery
and payment
Page 11November 13 , 2012
Prepared for Kansas Association of Counties
MCO Selection and Network Development
• State has contracted with three for-profit, national health insurance companies – Sunflower State Health Plan (Centene)– AmeriGroup (to be acquired by WellPoint)– United HealthCare
• State-approved standard provider agreement and provider manuals (and any future changes)
• MCOs to have provider networks in place by 11/01/12
Page 12November 13 , 2012
Prepared for Kansas Association of Counties
MCO Selection and Network Development
• Beneficiaries to receive auto-enrollment notice from State in November– Equal distribution?
• Beneficiary may change MCO within first 45 days, annually thereafter– Federal waiver
• MCOs assume administrative duties on 01/01/13 (non-medical services for developmentally disabled delayed to 01/01/14)
Page 13November 13 , 2012
Prepared for Kansas Association of Counties
Provider Network Requirements• Must provide statewide coverage for all services • Must include sufficient number of providers to meet
specified access to care requirements• Must include PCPs, pharmacies, and hospitals located
in every county in which members reside• Must offer contract to all FQHCs, RHCs, and CAHs• Must make “every effort” to permit member to continue
with current provider
Page 14November 13 , 2012
Prepared for Kansas Association of Counties
Provider Network Requirements• Hospital
– Usual and customary transport time (≤ 30 in urban areas)
• Emergency Care– Immediate at the nearest available facility regardless of
network or MCO contract
• PCP – 30 miles/minutes (rural), 20 miles/30 minutes (urban);
patient load ≤ 2500 for physician or ≤ 1500 for mid-level; ≤ 3 weeks for regular appointments, 48 hours for urgent; wait times ≤ 45 minutes
Page 15November 13 , 2012
Prepared for Kansas Association of Counties
MCOs and LHDs
• MCOs to make “reasonable effort” to subcontract with providers receiving Title V or Title X funding– Maternal & child health; family planning; STDs, TB; WIC
• MCOs to coordinate with LHDs “to ensure prevention and limit the spread of” STDs/TB– Contracts with LHDs must include language “regarding the
coordination of care and reporting of” STDs and TB• MCOs “expected to subcontract or coordinate” with
LHDs regarding WIC program (referrals and information sharing)
Page 16November 13 , 2012
Prepared for Kansas Association of Counties
Provider Network Management• Must credential network providers per NCQA guidelines• Must maintain State-approved provider manual• Must maintain compliance program• Must satisfy timely claims processing requirements• Must maintain utilization management program
• Establish prior authorization procedures– No PA for “emergency services”
• Establish and disseminate written review standards
Page 17November 13 , 2012
Prepared for Kansas Association of Counties
Network Provider Payments• State-published fee schedule sets minimum rates for
network providers– Initial fee schedule = current Medicaid FFS rates– Primary care add-on payments (?)– MCO may pay less than minimum if opportunity for
incentive payments (e.g., quality scores)• Alternative payment arrangements only if proposed
by network provider and approved by State
Page 18November 13 , 2012
Prepared for Kansas Association of Counties
Out-of-Network Providers• MCO must provide member access to OON provider if
“appropriate services” not available from network providers
• State will consider OON provider appeals regarding whether service is medically necessity, is an emergency, or is an appropriate screening
Page 19November 13 , 2012
Prepared for Kansas Association of Counties
Out-of-Network Provider Payments • Hospitals and nursing facilities entitled to 3 reasonable
offers; OON paid 90 percent of FFS rates– Other providers not afforded same protection
• OON services negotiated on single-case arrangements– OON providers cannot balance bill beneficiaries
Page 20November 13 , 2012
Prepared for Kansas Association of Counties
Person-Centered Coordinated Care• Demonstrated care coordination capabilities
– Use of HIT/HIE– Track preventive care services for each member– Address misuse of ERs– Program to reduce hospital readmissions
• Initial health risk assessment– Done by “appropriate health care professionals”– Specified elements– Information shared among providers and with the State
• Annual physical exams and/or health education
Page 21November 13 , 2012
Prepared for Kansas Association of Counties
Person-Centered Coordinated Care• Health literacy• Value-added services• Advanced directives• Care management for high-risk, high-service
utilizers, and other high-cost Members • Case management, disease management,
discharge and transition planning
Page 22November 13 , 2012
Prepared for Kansas Association of Counties
Health Homes• ACA appropriates additional monies to states to
establish Medicaid “health homes”• Similar to medical home, but greater emphasis on
community and social services resources• MCO requirements
– Members with diabetes and/or mental illness assigned to health homes by 01/01/14
– Members with other chronic diseases assigned to health homes by 01/01/15
Page 23November 13 , 2012
Prepared for Kansas Association of Counties
Home and Community-Based Services• Kansas is No. 6 in percentage of seniors living in nursing
homes• KanCare forces transition away from institutional care
and toward services provided in individuals’ homes and communities
• Outcome measures will include lessening reliance on institutional care
Page 24November 13 , 2012
Prepared for Kansas Association of Counties
Pay for Performance: P4P• RFP lists operational measures for Contract Year 1;
initial quality measures for Years 2 and 3 • State withholds 3 to 5% percent of total payments
until operational/quality thresholds are met • Quality thresholds increase each year to encourage
continuous quality improvement• RFP “encourages the adoption of innovative,
evidence-based provider payment mechanisms that incorporate performance and quality initiatives”
Page 25November 13 , 2012
Prepared for Kansas Association of Counties
The Kentucky Experience• Transition began in November 2011• Similar fixed-rate MCO contracts• Between 11/11 and 02/12, State paid MCOs
$708 million, MCOs paid out $420 million• Patient and provider complaints
Page 26November 13 , 2012
Prepared for Kansas Association of Counties
Auditor’s Recommendations• Agreed-upon metrics for measuring and
reporting timeliness of payments– Monitoring and corrective action plans
• Use of automated systems • Well-defined appeals process• Consideration of relevant information prior to
denying claims
Page 27November 13 , 2012
Prepared for Kansas Association of Counties
LHD Opportunities• Specific LHD programs identified in RFP• Beneficiary enrollment facilitation• Specific services (e.g., immunizations)• Care coordination services• Initial health risk assessments (EPSDT)• Primary care• Partnerships with local providers
Page 28November 13 , 2012
Prepared for Kansas Association of Counties
Medicaid Expansion• Starting in 2014, state that expands Medicaid eligibility
to 133% FPL will receive higher FMAP for newly eligible– 100% in 2014-16; 95% in 2017; 94% in 2018; 93% in 2019; 90%
in 2020+ – Administrative costs still 50/50
• Coverage must be at least as good as the minimum essential health benefits available through Exchanges
Page 29November 13 , 2012
Prepared for Kansas Association of Counties
SCOTUS ACA Decision
Majority No. 1 (Justices Roberts, Scalia, Kenney, Thomas, and Alito): Congress lacks authority under Commerce Clause to impose individual mandate.
Majority No. 2 (Justices Roberts, Ginsburg, Breyer, Sotomayor, and Kagan): Congress has authority under Taxing and Spending Clause to impose penalty on persons without health insurance coverage.
Page 30November 13 , 2012
Prepared for Kansas Association of Counties
SCOTUS ACA DecisionMajority No. 1 (+ Justices Breyer and Kagan): Congress lacks authority to withhold all Medicaid funding for state that does not expand Medicaid coverage.
Majority No. 2 Entire ACA does not fall due to unconstitutionality of Medicaid expansion penalty.
Page 31November 13 , 2012
Prepared for Kansas Association of Counties
Medicaid Expansion“No, Thanks”
• 365,000 uninsured in Kansas (13.3%)• 141,000 eligible under Medicaid expansion • 38,000 between 100-133% FPL eligible for exchange
subsidies• 103,000 left out if Kansas opts out
Page 32November 13 , 2012
Prepared for Kansas Association of Counties
Medicaid ExpansionImpact on Hospitals
• Less-than-expected decline in uncompensated care• Reductions in disproportionate share payments
– Medicaid DSH reduced 50% by 2019oHHS has not yet published methodology
– Medicare DSH reduced 75% in 2014 (with some amount returned based on documented uncompensated care)
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