TA Partnership for Child and Family Mental Health FINANCING SYSTEMS OF CARE Medicaid Managed Care Mary B. Tierney, MD April 15, 2004

TA Partnership for Child and Family Mental Health

FINANCING SYSTEMS FINANCING SYSTEMS OF CAREOF CARE

Medicaid Managed CareMedicaid Managed Care

Mary B. Tierney, MDMary B. Tierney, MD

April 15, 2004April 15, 2004


MEDICAIDMEDICAID

• Federal/State PartnershipsFederal/State Partnerships• State Agency RequirementsState Agency Requirements• EligibilityEligibility• ServicesServices• Payment for Services Payment for Services


MANAGED CAREMANAGED CARE

GENERAL CONCEPTSGENERAL CONCEPTS


HISTORY OF HEALTH INSURANCEHISTORY OF HEALTH INSURANCE

• Originally based upon fire and flood Originally based upon fire and flood insurance models – insure against insurance models – insure against catastrophic losscatastrophic loss

• Growth in all health insurance through Growth in all health insurance through the workplace after World War IIthe workplace after World War II

• Managed Care was a small component Managed Care was a small component of health insurance movement until of health insurance movement until 1970’s 1970’s


HISTORY OF HEALTH INSURANCE HISTORY OF HEALTH INSURANCE AND MANAGED CAREAND MANAGED CARE

• Enactment of the Health Enactment of the Health Maintenance Organization Act of Maintenance Organization Act of 19731973

• In the 1980’s and 1990’s there was In the 1980’s and 1990’s there was continued growth of the private continued growth of the private sector and subsequently, public sector and subsequently, public sector use of Managed Care sector use of Managed Care


DEFINITIONS DEFINITIONS

• Fee for ServiceFee for Service

• Managed CareManaged Care

• Capitation/Per Member Per MonthCapitation/Per Member Per Month

• Risk ContractRisk Contract


GROWTH OF MEDICAID GROWTH OF MEDICAID MANAGED CAREMANAGED CARE

Medicaid Managed Care Enrollment, 1990 - 2002

2.703.63

4.81

7.79

9.80

13.33

15.3516.57

17.7618.79

20.77

23.12

0

5

10

15

20

25

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Years

En

roll

me

nt

in M

illi

on

s


MANAGED CAREMANAGED CARE

LEGISLATIVE AND LEGISLATIVE AND REGULATORY REQUIREMENTSREGULATORY REQUIREMENTS


LEGISLATIVE AND LEGISLATIVE AND REGULATORY HISTORYREGULATORY HISTORY

• From 1965 To 1997 States must obtain From 1965 To 1997 States must obtain waivers for managed carewaivers for managed care

• The Balanced Budget Act (BBA) of 1997 The Balanced Budget Act (BBA) of 1997 allows states to mandate enrollment in allows states to mandate enrollment in managed care without waiversmanaged care without waivers

• The BBA mandates certain protections The BBA mandates certain protections such as quality improvement and such as quality improvement and grievance rights grievance rights


LEGISLATIVE AND LEGISLATIVE AND REGULATORY HISTORYREGULATORY HISTORY

• June 14, 2002, managed care June 14, 2002, managed care regulations (except external quality regulations (except external quality improvement) finalized, became improvement) finalized, became effective, June 14, 2003effective, June 14, 2003

• January 24, 2003, external quality January 24, 2003, external quality improvement regulations finalized, improvement regulations finalized, become effective January 24, 2004become effective January 24, 2004


ORGANIZATIONS COVERED BY ORGANIZATIONS COVERED BY THE REGULATONSTHE REGULATONS

• Managed Care Managed Care Organizations Organizations (MCO)(MCO)

• Primary Care Case Primary Care Case Management Management (PCCM)(PCCM)

• All 1915 (b) All 1915 (b) waiverswaivers

• Most 1115 Most 1115 waiverswaivers

• ContractorsContractors• State Plan State Plan

amendmentsamendments


Regulatory RequirementsRegulatory Requirements

• Limits on Enrollment Limits on Enrollment • Guaranteed EligibilityGuaranteed Eligibility• Protection of MCO membersProtection of MCO members• Restrictions and Regulations on Restrictions and Regulations on

MarketingMarketing• Solvency RequirementsSolvency Requirements• Fraud and Abuse SanctionsFraud and Abuse Sanctions• Quality ImprovementQuality Improvement


LIMITS ON ENROLLMENT LIMITS ON ENROLLMENT

• Individuals also Eligible for MedicareIndividuals also Eligible for Medicare• Native AmericansNative Americans• Categories (Katie Beckett)Categories (Katie Beckett)• Foster Care or Out-of Home Placement Foster Care or Out-of Home Placement • Children under age 19 years who are:Children under age 19 years who are:

- On SSI- On SSI

- Other Special Needs - Other Special Needs


GUARANTEED ELIGIBILITYGUARANTEED ELIGIBILITY

• States have the option to States have the option to guarantee 6 months eligibility for guarantee 6 months eligibility for Medicaid if enrolled in an MCOMedicaid if enrolled in an MCO

• This guarantee applies even if one This guarantee applies even if one loses Medicaid through TANF, SSI loses Medicaid through TANF, SSI or other eligible groups or other eligible groups


PROTECTION OF MEMBERSPROTECTION OF MEMBERS

• Complaints and Complaints and Grievance Grievance ProceduresProcedures

• Protection against Protection against liability for payments liability for payments to providers in case to providers in case of insolvency of the of insolvency of the MCOMCO

• ConfidentialityConfidentiality

• Communication Communication requirements requirements including use of clear including use of clear concise language concise language

• Translation into other Translation into other prevalent languagesprevalent languages

• Distribution of Distribution of “Rights and “Rights and Responsibilities” Responsibilities”


MARKETING MARKETING RESTRICTIONSRESTRICTIONS

• Marketing Materials Receive State Marketing Materials Receive State ApprovalApproval

• Distribution to Entire Service AreaDistribution to Entire Service Area• No Door to Door, Telephone, Cold-No Door to Door, Telephone, Cold-

CallsCalls• Accurate Information Provided Accurate Information Provided


SOLVENCY SOLVENCY REQUIREMENTSREQUIREMENTS

• Must Comply with State-wide Must Comply with State-wide Solvency Requirements Used by Solvency Requirements Used by the State Insurance Commissionerthe State Insurance Commissioner

• Members May Not be Held Liable Members May Not be Held Liable for Debts Incurred by MCO in the for Debts Incurred by MCO in the Case of Insolvency Case of Insolvency


FRAUD AND ABUSEFRAUD AND ABUSE

• Range of Sanctions Must be Range of Sanctions Must be Available Available

• Monetary SanctionsMonetary Sanctions

• Cancellation of the ContractCancellation of the Contract


QUALITY IMPROVEMENTQUALITY IMPROVEMENT

• Internal Quality ImprovementInternal Quality Improvement

• External Quality ReviewExternal Quality Review


INTERNAL QUALITY INTERNAL QUALITY IMPROVEMENTIMPROVEMENT

• Use of Clinical Use of Clinical Practice Practice GuidelinesGuidelines

• Measure Measure Performance Performance using Objective using Objective IndicatorsIndicators

• Systems Systems Intervention to Intervention to Improve QualityImprove Quality

• Evaluation of Evaluation of Effectiveness of Effectiveness of InterventionsInterventions

• Planning and Planning and Initiation of Initiation of Activities for Activities for Increasing or Increasing or Sustaining Sustaining ImprovementImprovement


EXTERNAL QUALITY EXTERNAL QUALITY REVIEW/MANDATORYREVIEW/MANDATORY

• Independent External Independent External Organization with Organization with Expertise in QI Expertise in QI ReviewReview

• Validation of MCO Validation of MCO Internal QI Activities Internal QI Activities

• Validation of Validation of Performance Performance Measures and Measures and Compliance with Compliance with MeasuresMeasures

• Review of Previous Review of Previous Activities to Activities to Determine Determine Compliance with QI Compliance with QI PlanPlan


EXTERNAL QUALITY EXTERNAL QUALITY REVIEW/OPTIONALREVIEW/OPTIONAL

• Validation of Encounter DataValidation of Encounter Data• Administration or Review of Administration or Review of

Member Satisfaction Surveys and Member Satisfaction Surveys and Other ActivitiesOther Activities

• Conduction of Quality Improvement Conduction of Quality Improvement Activities in Addition to Those of Activities in Addition to Those of the MCO the MCO


OPPORTUNITIES FOR OPPORTUNITIES FOR SYSTEM OF CARE SYSTEM OF CARE

COMMUNITIESCOMMUNITIES


OPPORTUNITIESOPPORTUNITIES

• Contracting with MCO’s for:Contracting with MCO’s for:- “Case-Management”- “Case-Management”- Wrap-Around- Wrap-Around- Provision of Mental Health - Provision of Mental Health Services Services

• Contract Requiremements Contract Requiremements including the Regulations, including the Regulations, Licensure Licensure


OPPORTUNITIESOPPORTUNITIES

• Participation in Quality Participation in Quality Improvement ActivitiesImprovement Activities

- Clinical Practice Guidelines- Clinical Practice Guidelines- Assist in Development of - Assist in Development of

Quality Indicators Quality Indicators- Measuring Effectiveness of - Measuring Effectiveness of

Wrap-Around and Other Wrap-Around and Other Activities Activities


TAKE HOME MESSAGETAKE HOME MESSAGE

WHAT GETS MEASURED GETS WHAT GETS MEASURED GETS MANAGEDMANAGED


CAN WE TALK?CAN WE TALK?

Documents

TA Partnership for Child and Family Mental Health FINANCING SYSTEMS OF CARE Medicaid Managed Care Mary B. Tierney, MD April 15, 2004