Understanding Medicaid Managed Long Term Care Contracting

September 11, 2013

LeadingAge New YorkFinancial Managers Annual Conference

Michael H. LewensohnManagerHealth Care Medical Reimbursement Servicesmlewensohn@odpkf.com

Discussion Topics

DefinitionsContract assessment Facility specific costs and potential data

resourcesCommunicationOther Issues

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• Managed Care• MLTC (Managed Long Term Care)• MCO (Managed Care Organization)• Capitation• Coordination of Care• FIDA (Fully Integrated Duals Advantage)• SNP (Special Needs Plan)

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Definitions

Definitions (continued)

• PACE (Program of All-Inclusive Care for the Elderly)

• Evergreen Agreement• Dual Eligible• Formulary• Included Services• Excluded Services• Capitation / Fee-For-Service

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• Rates– Multiple levels of care, based on patient needs and

assessment• Identify documentation requirements by level of care

• Included and Excluded Services– Pharmacy formulary– Rehabilitation– Medical services– Medical Diagnostic Testing (Labs, X-Ray, Supplies)

Contract AssessmentContract Assessment

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Contract Assessment (continued)(continued)

• Billing Protocols– Identify billing submission period – Identify the billing appeals process

• Care Requirements– Delivery of care and documentation requirements– Patient assessments to support level of care/payment

• Credentialing of Facility Professionals– Medical staff, Rehabilitation, Testing & Supplies

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Contract Assessment (continued)(continued)

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Effective Term. Term of Rate Rate Rate Service Claim Filing Appeal Filing Quality CareMLTC MAP Date Date Agreement Level I Level II Level III Type Included Excluded Period (Days) Period (Days) Payment Other

ABC MLTC No 4/1/2013 N/A 1 Year $75.00 $150.00 $225.00 Medical X 90 Days 180 Days Yes N/ASpecialty Medical XRehabilitation XO/P Mental Health XAmbulance XTransportation XER Services XDME (Equipment) XProsthetics XDiagnostic Testing XPharmacy XHearing Services XVision Services XOther: N/A N/A

Contract Assessment (continued)(continued)

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Mental Vision Hearing Equipment / Diagnostic MLTC MAP Rate Medical Pharmacy Rehab Health Services Services Transpotation ER Orthotics Testing Other

MLTC 1 No $100.00 Excluded Included Included Included Included Included Included (not amb) No Included, limited Included N/A

MLTC 2 Yes $100.00 Included Included Included Excluded Excluded Included Ambulance Only Yes Excluded Excluded $500 Mental Health Deductible

MLTC 3 No $75.00 Included Excluded Excluded Included Included Included Excluded Yes Included Included Pre-Auth Required - Excluded Svs

MLTC 4 No $100.00 Excluded Included Included Included Included Included Included (not amb) No Included Excluded N/A

MLTC 5 No $100.00 Excluded Included Included Included Included Included Included (not amb) No Included Included N/A

MLTC 6 No $100.00 Included Included Included Included Included Included Included (not amb) No Excluded Included N/A

MLTC 7 No $100.00 Excluded Included Included Included Excluded Included Included (not amb) No Included Excluded Pre-Auth Required - Excluded Svs

MLTC 8 No $100.00 Included Included Included Included Included Included Included (not amb) No Excluded Excluded N/A

MLTC 9 No $100.00 Excluded Included Included Included Included Included Included (not amb) No Included Excluded Pre-Auth Required - Excluded Svs

Identifying Facility Specific Costs: Potential Data Resources • Medicare and Medicaid cost reports• Internal facility reports• Vendor historical data• Available “public information” about

neighboring providers• Information available through trade

organizations

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Communicating MLTC Issues

• Staff training and ongoing communication of contractual changes

• Vendors• Apprise vendors of when bills should be sent to

the Facility versus other 3rd party payers• Patients and Families

• Apprise patients and or families of costs which they may be responsible to pay

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Other Issues• Facility Admission Agreement: the Facility’s

contract with patients• The MLTC agreement versus the Facility Admission

Agreement

• Avoid Evergreen Contracts• Request specific start and end dates of

agreements• Identify when re-negotiation period begins

• Consult legal counsel

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