Apple Health (Medicaid) Managed Care Program Overview Preston W. Cody, Division Director Health Care Services November 16, 2015

Apple Health (Medicaid) Apple Health (Medicaid) Managed Care Program OverviewManaged Care Program Overview

Preston W. Cody, Division DirectorHealth Care ServicesNovember 16, 2015

IntroductionIntroduction

Preston Cody, Division Director Health Care Services Division

Washington State Health Care Authority

2

OverviewOverview• Introduction• Overview• Objectives• What is Managed Care?• Managed Care History• Managed Care in

Washington• Demographics• Managed Care Churn• Managed Care Quality

and Contract Monitoring

• Rate Setting• Potential Challenges

• 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 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 What is Medicaid Managed Care? 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

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Some Facts about the Some Facts about the History of Managed Care 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

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Medicaid Managed Care in Medicaid Managed Care in Washington 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

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Medicaid Managed Care in Medicaid Managed Care in Washington Today 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)

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Role of MCOs in Role of MCOs in Washington 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)

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Building Provider Building Provider Networks 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 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

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MCOsMCOs’’ Role and Role and Contributions to ACHs 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

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Care Management 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

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Leveraging Data and Leveraging Data and Technology Technology

• Advanced healthcare analytics and data. • Information Exchange and Interoperability • Examples:

– Claims-based data– Link4Health (Clinical Data Repository) – Real-time ED/admission based data

(Pre-Manage/EDIE) – Patient registry – Shared cost savings analysis

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DemographicsDemographicsManaged Care Eligibles and Managed Care Enrollees by County – October 2015Managed Care Eligibles and Managed Care Enrollees by County – October 2015

Reflects Enrollees OnlyReflects Enrollees Only

Garfield

Pend Oreille

Spokane

Walla Walla

AsotinColumbia

Stevens

Whitman

Ferry

Lincoln

Franklin

Adams

DouglasGrant

Benton

Yakima

Klickitat

Chelan

San Juan

Whatcom Okanogan

Skagit

King

Kittitas

Snohomish

Lewis

Pierce

Skamania

Clallam

Island

Clark

Cowlitz

Kitsap

Mason

Wahkiakum

Pacific

Jefferson

Grays Harbor

County enrollment in managed care is voluntary. 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.

Thurston

7,580

7708

98%

4,714

5046

93%

42,803

44,831

95%

19,564

20,278

96%

3,746

4,058

92%

91,487

95,346

96%

824

904

91%

26,531

28,852

92%

10,180

10,467

97%

1,258

1,392

90%

27,247

28,251

96%

27,723

28,896

96%

17,524

19,104

92%

10,934

11,476

95%

5,669

6,036

94% 309,239

324,931

95% 7,616

7,908

96%

2,265

2,403

94%

19,066

20,717

92%

12,578

13,372

94%

11,324

11,983

95%

4,713

5,033

94%

3,003

3,297

91%

163,425

173,665

94%

26,981

28,217

96%

179

156

115%

122,276

127,198

96%115,799

123,263

94%

9,657

10,397

93%

775

826

94%

12,641

13,303

95%

38,922

40,887

95%

5,898

6,077

97%

85,156

88,718

96%

2,342

2,504

94%

46,787

49,622

94%

38,811

41,549

93%

471

499

94%

2936

2,981

98%

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January-September 2015 January-September 2015 Enrollment Trends Enrollment Trends

Apple Health Demographic Analysis, October, 2015

The charts display enrollment over a 9 month period. Enrollment continues to increase for mostprograms 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%

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AHAC Enrollment AHAC Enrollment (as of November 1, 2015)(as of November 1, 2015)

*Transactions may contain client duplicates and decrease per month due to loss of eligibility, causing retro changes.

AHAC Enrollment November 1, 2015

Enrollment ReasonJan-Dec 2014 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 49,893Client Choice 6,207 721 460 484 410 381 820 1,124 1,156 1,157 1,196 1,452 16 15,584Connecting Family 1,104 238 387 339 297 175 191 137 122 180 218 151 60 3,599Reenrolled 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 32,564 2,304 2,019 3,248 1,886 1,443 1,187 515 449 548 554 595 248 47,560Client Choice 6,180 504 417 502 409 341 611 746 792 820 1,178 1,576 41 14,117Connecting Family 2,488 376 548 555 521 320 272 179 224 264 274 209 88 6,318Reenrolled with Previous Plan 3,284 747 1,557 1,274 1,139 774 479 223 346 410 390 591 94 11,308

CCC Total 44,516 3,931 4,541 5,579 3,955 2,878 2,549 1,663 1,811 2,042 2,396 2,971 471 79,303

Auto Assignment 18,815 2,587 2,180 3,232 1,872 1,448 1,125 870 763 869 903 1,003 410 36,077Client Choice 13,068 982 834 937 793 686 1,348 1,970 2,099 2,004 1,996 2,358 34 29,109Connecting Family 6,779 730 1,016 1,051 861 662 571 442 445 490 503 418 159 14,127Reenrolled with Previous Plan 10,777 959 1,623 1,396 1,111 849 587 261 505 632 630 906 204 20,440

CHPW Total 49,439 5,258 5,653 6,616 4,637 3,645 3,631 3,543 3,812 3,995 4,032 4,685 807 99,753

Auto Assignment 0 0 0 0 0 0 1 0 0 0 0 1 0 2Client Choice 0 515 997 670 545 342 436 514 523 535 557 535 15 6,184Connecting Family 0 5,935 179 228 219 170 158 101 122 115 138 82 36 7,483Reenrolled with Previous Plan 0 3 53 78 125 100 52 13 51 53 76 109 12 725

CUP Total 0 6,453 1,229 976 889 612 647 628 696 703 771 727 63 14,394

Auto Assignment 12,279 3,696 2,831 4,750 2,816 2,063 1,726 1,190 1,087 1,219 1,190 1,383 562 36,792Client Choice 24,402 2,195 2,001 2,186 2,038 1,697 2,903 3,807 4,149 4,314 4,351 5,436 101 59,580Connecting Family 14,454 1,613 2,207 2,089 1,944 1,457 1,303 946 978 1,081 1,279 936 327 30,614Reenrolled with Previous Plan 9,721 1,157 1,988 1,718 1,471 1,258 832 385 794 792 939 1,438 226 22,719

MHC Total 60,856 8,661 9,027 10,743 8,269 6,475 6,764 6,328 7,008 7,406 7,759 9,193 1,216 149,705

Auto Assignment 37,787 2,310 1,968 3,179 1,815 1,339 1,123 784 705 848 794 952 395 53,999Client Choice 9,149 723 651 772 1,026 700 1,305 1,929 2,092 2,241 2,183 2,730 37 25,538Connecting Family 2,152 313 559 534 450 317 364 237 232 308 314 233 102 6,115Reenrolled with Previous Plan 3,417 858 1,704 1,271 1,151 824 552 296 402 497 480 682 132 12,266

UHC Total 52,505 4,204 4,882 5,756 4,442 3,180 3,344 3,246 3,431 3,894 3,771 4,597 666 97,918

*Apple Health Adult Coverage Total 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

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Apple Health Program EnrollmentApple Health Program Enrollment By Health Plan By Health Plan

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*Enrollment as September 1, 2015

Managed Care Program AMG CUP CHPW CCC MHC UHC TotalAHAC 80,354 12,820 98,846 81,723 135,913 94,290 503,946CHIP 2,269 1,391 5,457 3,188 14,047 4,148 30,500HO 49,996 37,518 174,606 85,376 355,038 82,020 784,554HOBD 9,064 2,535 18,673 11,897 30,369 12,718 85,256HOFC 125 128 483 192 1,611 302 2,841

*Manage Care Enrollment Total 141,808 54,392 298,065 182,376 536,978 193,478 1,407,097

Apple Health Demographic Analysis, October 2015

Enrollment By Age BracketEnrollment By Age BracketThe 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.


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Enrollment By Gender Enrollment By Gender

• The distribution of gender patterns across health plans are similar; however, AMG has more male enrollees than female enrollees


• 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

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Gender by Age Group and Program 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


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Enrollment By Race 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”


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Enrollment Breakdown by Race and Enrollment Breakdown by Race and EthnicityEthnicity


• 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

Any Minority African AmericanAmer Indian/

Alaska NatAsian/ Pacific

Islander Hispanic1,422,627 832,613 451,671 113,639 11,650 106,040 305,280

Percentage 59% 32% 8% 1% 7% 21%

Minority GroupsWhite Non-

MinorityApple Health Clients Served

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Managed Care Enrollment By CountyManaged 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


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Enrollment By Preferred Spoken Language Enrollment By Preferred Spoken Language (Other Than English or Spanish)(Other Than English or Spanish)

25

• 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


Health Plan and County Preferred Spoken LanguageHealth Plan and County Preferred Spoken Language

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• 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


Enrollment by Federal Poverty Level (FPL)Enrollment by Federal Poverty Level (FPL)and Income Bracket and Income Bracket

27

• 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 RaceFPL Groupings By Race

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• 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


Average Medicaid Managed Care Average Medicaid Managed Care Client FPL and County Unemployment RateClient FPL and County Unemployment Rate

29

• 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%)

Apple Health Demographic Analysis, October 2015

ChurnChurn

• Without MCO plan lock-in churn can be expected

30

Health Plan Outgoing ChurnHealth Plan Outgoing Churn(September 2015)(September 2015)

31Managed Care Health Plan Churn October, 2015

71

Health Plan Incoming ChurnHealth Plan Incoming Churn(September 2015)(September 2015)

32Managed Care Health Plan Churn October, 2015

33

Health Plan Churn Percentage Per County Health Plan Churn Percentage Per County Based on County EnrollmentBased on County Enrollment

(September 2015)(September 2015)

33

Average Churn .70%

Managed Care Health Plan Churn October 2015

MCO MonitoringMCO 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 CFR/EQR Requirements for States -States -

Mandatory ActivitiesMandatory 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 CFR Requirements for States - States -

Optional ActivitiesOptional 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 Structured Monitoring of MCOsof MCOs

• Areas reviewed based on federal requirements and monitoring protocols: • Availability of services• Coordination and

continuity of care• Program Integrity• Quality assessment and

performance improvement

• Coverage and authorization of services (utilization management)

• Enrollee Rights• Grievance System• Practice Guidelines• Credentialing• Timely Claims Payment• Subcontracts• Enrollment and Disenrollment• Health Information Systems

37

2015 Monitoring Results2015 Monitoring Results

38

2015 Monitoring Report2015 Monitoring Report

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Well-Child Visits – 3-6 Years Well-Child Visits – 3-6 Years of Ageof Age

40

Adolescent Immunizations Adolescent Immunizations

41

CAHPS – Child and Child with CAHPS – Child and Child with Chronic Conditions SurveyChronic Conditions Survey

42

Finance Capacity 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 ProcessRate 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)

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Managed Care Rate Managed Care Rate SettingSetting

• 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

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AH Adult Cost TrendAH Adult Cost Trend

Cost Component 2014 2015Change 2014 to

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%

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Blind / Disabled Cost Blind / Disabled Cost TrendTrend

Cost Component 2014 2015Change 2014 to

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%

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Historical Rates in the Blind Historical Rates in the Blind / Disabled and COPES Rate / Disabled and COPES Rate

GroupsGroups• 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 fee-for-service

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Components of 2014 to 2015 Components of 2014 to 2015 AH Cost IncreasesAH Cost Increases

Rate Component

Projected Per Member Per Month (PMPM) Costs Change 2014 to 2015

2014 2015 Dollars PercentPercent of Total

ChangeTOTAL $289 $302 $14 4.7% 100.0%Hospital Inpatient $65 $65 -$1 -0.9% -4.4%Physician $64 $64 $0 -0.6% -3.0%Drugs $48 $59 $11 22.3% 78.9%Hospital Outpatient $47 $47 $0 0.4% 1.2%Administration $32 $35 $3 9.3% 22.0%Pass-through $23 $24 $1 2.5% 4.3%Other Medical $9 $9 $0 1.3% 0.9%

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Potential ChallengesPotential 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 areas50

Network Adequacy Federal Network Adequacy Federal RequirementsRequirements

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:

51

Network Adequacy Washington State Network Adequacy Washington State LawLaw

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……

52

Monitoring Health Plans Monitoring Health Plans NetworksNetworks

• 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

53

Analysis of Network Analysis of Network

54

Assignment • Demonstrates sufficient provider network to receive all eligible enrollees

• Plan name appears on enrollment form

• HCA auto-enrolls

Enrollment only • 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

Inadequate network • Does not demonstrate a sufficient provider network to receive eligible enrollees. Plan name will not appear on enrollment form

Top 6 provider categories include:1. Hospital2. Primary Care Provider3. Pharmacy4. Obstetric/Gynecologist5. Pediatrics 6. Behavioral Health

Top 10 specialty provider categories include:

1. Cardiologist2. Gastroenterology3. General Surgeon4. Neurologist5. Oncologist6. Ophthalmologist7. Orthopedics8. Otolaryngology9. Physical Medicine Rehab10. Pulmonologist

Sample Network SummarySample Network Summary

55

Managed Care ContractManaged 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 InitiativesCurrent 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 GrantState 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

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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

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Regional Service AreasRegional 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

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Regional Service Areas Regional Service Areas MapMap

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Earlier EnrollmentEarlier 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 Foster and Adoption Support into Managed CareSupport 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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ReferencesReferences• Health Care Authority (HCA) www.hca.wa.gov • HCA Managed Care

http://www.hca.wa.gov/medicaid/healthyoptions/pages/healthyoptions.aspx

• 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

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http://www.hca.wa.gov/



http://www.hca.wa.gov/medicaid/healthyoptions/Pages/contracts.aspx

http://www.hca.wa.gov/medicaid/healthyoptions/Pages/reports.aspx

mailto:[email protected]

THANK YOUTHANK YOU

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Documents

Apple Health (Medicaid) Managed Care Program Overview Preston W. Cody, Division Director Health Care Services November 16, 2015