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Coming to a State Near You: What You Need to Know About Medicaid Managed Care Changes Eric Carlson Amber Cutler Fay Gordon Thursday, June 30, 2016
Coming to a State Near You: What You Need to Know About Medicaid Managed Care Changes
Eric Carlson
Amber Cutler
Fay Gordon
Thursday, June 30, 2016
• All participants are on mute. Use the Questions or Chat function for substantive questions or technical concerns.
• Problems with webinar, email [email protected]
• Slides are available on our website at justiceinaging.org. A recording of the webinar will be available on our website in 24 hours. See also the chat box for a link to the slides.
Justice in Aging is a national organization that uses the
power of law to fight senior poverty by securing access
to affordable health care, economic security, and the
courts for older adults with limited resources.
Since 1972 we’ve focused our efforts primarily on
populations that have traditionally lacked legal
protection such as women, people of color, LGBT
individuals, and people with limited English proficiency.
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• Published: May 6, 2016• 81 Federal Register 27498 –
27901• Two sections: Medicaid
Managed Care and CHIP requirements
https://www.gpo.gov/fdsys/pkg/FR-2016-05-06/pdf/2016-09581.pdf
Final Medicaid Managed Care Rule
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Major themes in the proposed rule
• Alignment with other programs (QHP, Medicare
Advantage, private market)
• Beneficiary Protections
• Addresses LTSS
• Modernizing and Improving Quality of Care
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Key Terms • Managed Care Organizations (MCO) – managed care entities
that offer comprehensive benefits; plan is paid a fixed,
prospective, monthly payment for each enrollee known as
capitation.
• Prepaid Inpatient Health Plans (PIHP) – managed care entities
that receive capitated payments for a limited array of services.
• Prepaid Ambulatory Health Plans (PAHP) – same as above
• Primary Care Case Management (PCCM) – managed care
entities that link beneficiaries to Primary Care Physicians
• Rating Period – twelve month period for which capitation rates
are developed under a managed care contract
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Timeline for Implementation
Effective Immediately
2 Provisions
60 Days After Implementation
July 5, 2016
74 Provisions
No Later than Rating Period
Starting on or after 7/1/17
55 Provisions
No Later than Rating Period
Starting on or after 7/1/18
11 Provisions
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Timeline for Implementation
No Later Than 7/1/18
8 Provisions
No Later than Rating Period Starting on or
after 7/1/19
1 Provision
Rating Period Starting after Release
of CMS Guidance
1 Provision
No Later than 3 years from Date of Final
Notice Published in Federal Register
1 Provision
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Enrollment§ 438.54
• Establishes a minimum level of beneficiary protections and consistency across programs.
• Rule attempts to promote active choice.
• Flexibility for states to create enrollment systems.
The rules establish for the first time ever standards governing enrollment into managed care programs.
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Enrollment
• States must have an enrollment system for its program –voluntary and mandatory as appropriate
• States can utilize a voluntary or passive enrollment process
• Leaves discretion to state in setting a time period for enrollment into managed care
• Beneficiaries must receive informational and confirmation notices
• Default enrollment process must seek to preserve existing provider-patient relationships
• Prohibition on enrollment discrimination (§438.3(d))
Key Provisions
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Disenrollment§ 438.56
Key Provisions
• If State limits disenrollment, beneficiaries must be able to disenroll as follows:
• Without cause
• Within 90 days of initial enrollment
• At least once every 12 months
• Upon automatic reenrollment if disenrolled for loss of eligibility
• When State imposes sanction on plan
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Disenrollment§ 438.56
Key Provisions• With cause
• Beneficiary moves out of service area
• Plan due to moral or religious objections will not cover service enrollee seeks
• The enrollee needs related services to be performed at the same time that are not all available within the provider network and PCP or other provider determine receiving separately would subject to unnecessary risk
• For enrollees that use MLTSS, the enrollee would have to change their residential, institutional, or employment supports (effective 7/1/2017)
• Other: poor quality of care, lack of access to covered services, or lack of access to providers experienced with dealing with enrollee’s special needs.
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LTSS Definition§ 438.2
Key Provisions
First ever definition of long-term services and supports in managed care:
LTSS means services and supports provided to beneficiaries of all ages who have functional limitations and/or chronic illnesses that have the primary purpose of supporting the ability of the beneficiary to live and work in the setting of their choice which may include the individual’s home, a worksite, a provider-owned or controlled residential setting, a nursing facility, or other institutional setting.
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LTSS Definition§ 438.2
Key Provisions
All agesFunctional limitations
and/orChronic illness
Live and work Setting of choice
Primary purpose to support ability to
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Nondiscrimination§ 438.3(a)
Key Provisions-Discrimination Prohibited
Enrollment discrimination prohibited:
The MCO will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability and will not use any policy or practice that hs the effect of discriminating on that basis.
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Nondiscrimination§ 438.3(a)
Preamble:
• Prohibiting discrimination is necessary to protect access
• Decline to include protection for individuals in the criminal justice system
• Includes explicit protection for sexual orientation (compare to Section 1557)
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MCO Sanctions § 438.700
Key Provisions-Sanction Findings
State must establish sanctions that it may impose on the MCO for certain violations.
State bases determination on findings from:
Onsite surveys Enrollee or other complaints
Financial status Other sources
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MCO Sanctions § 438.700
Key Provisions-Sanction Causes
State may sanction MCO for:
Failure substantially to provide medical service
Imposing premiums or chargesin excess of what Medicaid
allows
Discriminates based on health status or need for
services
Misrepresents or makes up information to CMS, state,
enrollee or health care provider
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MCO Sanctions § 438.702
Key Provisions-Sanction Types
Types of immediate sanctions:
• Civil money penalties• Appointing temporary management• Granting individuals right to terminate enrollment without
cause • Suspension of all new enrollment, including default
enrollment • Suspension of payment for beneficiaries enrolled after the
date of sanction
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Beneficiary Support System What is it?
An independent system to provide choice counseling and assist enrollees post enrollment.
Provides: choice counseling, assistance understanding managed care, and outreach to all beneficiaries.
Note: This part NOT effective 7/5/2016
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Beneficiary Support System § 438.816
Key Provisions-Payment Requirements
BSS not required to be set up by July 5. However,
clarity on state expenditures for BSS goes into effect
on July 5:
• BSS expenses are eligible for FFP match when:
• Costs do not duplicate payment for activities
that are being offered
• Persons providing choice counseling services
meet conflict of interest requirements
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Enrollment Broker Services§ 438.810
Key Provisions-Choice Counseling
Clarifies Enrollment Broker activities (current and future in the BSS):
• Choice counseling services and/or• Enrollment activities
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Enrollment Broker Services§ 438.810
Key Provisions-Conflict of Interest
Enrollment broker must meet two conditions:
1) Independent from MCO where broker provides services
2) Freedom from direct or indirect financial interest in any entity or health care provider in the state
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Access and Cultural Considerations§ 440.262
Key Provisions-State Must Have Culturally Competent Methods
State requirement
• State must have methods to promote access and service delivery in a culturally competent manner to allbeneficiaries
• Methods must ensure beneficiaries have access to covered services that are delivered in a manner that meets their unique needs
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Questions
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Non-Institutional Settings for HCBS§ 438.3(o)
Broad Coverage
HCBS settings rules apply to any services that “could be authorized” through
• HCBS waiver,• HCBS state-plan program, or• Community-First Choice program.
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HCBS Settings Rules
Outlines of Rule
Requires integration with the community.
Additional standards for residential settings.
States currently implementing HCBS rule, with deadline of March 2019 for complete implementation.
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Enrollee Rights§ 438.100
Broad Description of Rights
Re-statement of existing regulatory rights:
• Honoring rights of dignity and privacy.• Participation in treatment decisions, including right to
refuse treatment.• Right to be furnished health care in accordance with
federal regulations governing managed care quality of care.• Availability of services, adequate capacity, continuity of
care, etc.
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Provider-Enrollee Communications§ 438.102
Provider Cannot Be Muzzled By MCO
MCO cannot restrict provider from advising or advocating on enrollee’s behalf relating to:
• Treatment options,• Information needed to make treatment decision,• Risks and benefits of treatment, or• Enrollee’s right to participate in decision-making.
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Marketing§ 438.104
State Approval; No Cold-Call Approaches
• State approval prior to distribution.
• Distribution to entire service area.
• No cold-call techniques.
• Door-to-door selling, phone calls,
e-mail, texts, etc.
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Cost Sharing§ 438.108
Consistent with Fee-for-Service Rules
• Enrollee cost sharing must be consistent with fee-for-service cost-sharing rules.
• Protection must be established through contract between State and MCO.
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Emergency Services§ 438.114
Relaxed Network Provider Requirements
• Emergency services must be covered with regard to whether the provider was in the network.
• Applies if• Emergency condition, or• MCO representative instructed
enrollee to seek emergency services.
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Choosing Network Providers§ 438.214
State Credentialing Policies• Each MCO must have written policy for
selecting network providers.• Each state must have uniform credentialing
policy for• Acute,• Primary,• Behavioral,• Substance use disorders, and • LTSS.
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Credentialing for LTSS
Standards for Self-Directed Care
• Preamble addresses credentialing in self-directed care:• Beneficiary-defined parameters, and• State-wide criteria such as
• Criminal background check, or• Age requirements.
• See 81 Fed. Reg. at 27,655.
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Grievance and Appeal Systems§ 438.228
Details to Be Implemented in Future
• Each MCO must have grievance and appeal system that complies with the federal regulations.
• Substantive grievance and appeal regulations (§§ 438.400- 438.424) won’t be effective until rating period on or after June 1, 2017.
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Grievance and Appeal Systems§ 431.200
Terminology Update
• One of several sections updating “action” to “adverse benefit determination”
• Here, applies to adverse benefit determination by an MCO providing opportunity for a State Fair Hearing
Medicaid Managed Care Tool
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Available at: http://www.justiceinaging.org/medicaid-managed-care-tool
Additional Resources
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• Medicaid.gov
• National Health Law Program Medicaid Managed Care Issue Briefs
• Maximus Webinar Series
• Justice in Aging: justiceinaging.org• Email Us: Eric Carlson, [email protected]
Amber Cutler, [email protected] Gordon, [email protected]
