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Managed Care Changes Basic Health and Healthy Options Alison Robbins Washington State Health Care Authority September 18, 2012.

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Presentation on theme: "Managed Care Changes Basic Health and Healthy Options Alison Robbins Washington State Health Care Authority September 18, 2012."— Presentation transcript:

1 Managed Care Changes Basic Health and Healthy Options Alison Robbins Washington State Health Care Authority September 18, 2012

2 Procurement Process Conducted in 2011 – 2012 New contracts signed March 2012 Program changes implemented July 1, 2012 Exiting Plans: Group Health Cooperative, Regence BlueShield, Asuris NW Health, Kaiser, Columbia United Providers. 2

3 Healthy Options Plans for Amerigroup/Real Solutions Community Health Plan of Washington Coordinated Care Corporation Molina Healthcare of Washington UnitedHealth Care Community Plan

4 Effective Service Areas for Healthy Options, Childrens Health Insurance Program, Healthy Options Blind/Disabled, and Healthy Options Foster Care Programs as of Garfield Pend Oreille Spokane Walla Asotin Columbia Stevens Whitman Ferry Lincoln Franklin Adams Douglas Grant 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 AMG CCC CHP MHC UHC CCC CHP MHC UHC CCC CHP MHC UHC CHP CCC MHC UHC CCC CHP MHC UHC CCC MHC UHC CHP MHC UHC CCC CHP MHC UHC AMG CCC CHP MHC UHC CCC CHP MHC UHC AMG CCC CHP MHC UHC CHP MHC AMG CCC MHC UHC CCC UHC CHP CCC MHC UHC AMG AMG CCC CHP MHC UHC MHC AMG CCC CHP MHC AMG CHP MHC AMG CCC CHP UHC AMG CCC CHP MHC UHC CCC UHC CHP MHC UHC CCC CCC CHP MHC UHC CHP MHC CCC UHC AMG CCC CHP MHC UHC CCC CHP MHC UHC AMG CHP MHC UHC AMG County enrollment in managed care is voluntary. Thurston CCC UHC AMG CHP MHC CCC AMG CCC CHP MHC UHC AMG CCC MHC UHC AMG MHC UHC CCC CHP MHC UHC AMG CCC CHP MHC UHC CCC, CHP, MHC, UHC AMG CCC MHC

5 Division of Developmental Disabilities Enrollment in Healthy Options will not impact: – The services you are currently receiving from DDD – Your case management with DDD – Your eligibility for DDD 5

6 Medicaid Healthcare Services Fee for Services Healthy Options managed care 6

7 Medicaid Managed Care 7 Health Plans must ensure: – Guaranteed access to a Primary Care Provider – Choice of multiple Primary Care Providers and Specialists – 24/7 access to a Nurse Advice Line – Coordination of care among providers and systems of care: for example, between medical and mental health systems – Prescription coverage

8 Ensuring plan readiness Comprehensive readiness reviews of each health plan Examination of contractual and quality requirements Bi-weekly plan training sessions Bi-weekly individual health plan meetings Ad hoc meetings as requested Bi-weekly network development assessment Agency staff response to plan questions Review of plan materials 8

9 New Eligible Clients New population added to managed care: Categorically Needy SSI Blind and Disabled : Medicaid Only Mandatory Enrollment – must enroll in managed care unless client meets exemption requirement Voluntary enrollment for foster care children Foster children may enroll but are not required to enroll 9

10 Exempt from Managed Care Medicaid Only, Blind/Disabled clients will enroll except clients: Living in institutional settings Enrolled in Chronic Care Management Programs Enrolled in the Program of All-Inclusive Care for the Elderly (PACE) On hospice American Indians/Alaska Natives Enrolled in the Washington Medicaid Integration Partnership (WMIP) Enrolled in the Medically Intensive Childrens Program (MICP) Third Party Insurance 10

11 Healthy Options enrollment process Clients receive: Notice of enrollment in a health plan and instructions on how to change plans; Enrollment Handbook with information about Healthy Options Enrollment form Enrollments effective the first of the following month: Changes for November 1 can be made until October

12 How you can help Know what to tell clients Check eligibility for Healthy Options Find out which plan(s) each doctor or specialist contracts with: Help determine appropriate plan Help enrolling in or changing plans Help clients contact providers or plan for help coordinating care Report issues to the plan and/or HCA 12

13 Care Management Expectations of Plans Stronger contractual requirements To assist new enrollees: Rxs written prior to enrollment Get care from non-par providers or new PCP Transitional care requirements to mitigate risk of re-hospitalization/re-institutionalization Care coordination with focus on integrated care between physical and behavioral health 13

14 Care Management Expectations Intensive Care Management for enrollees with special health care needs (ESHCN) Identification of ESHCN Initial Health Screen-Initial Health Assessment Treatment plans Quality Assurance and special programs 14

15 Managed Care Facts Enrollees: – May change plans every month – most dont – Are allowed to get second opinions through the plan – New Enrollees: May keep current prescriptions, care plans and providers for 90 days or until accessed by the new plan – There is no balance billing; no co-pays for Medicaid clients 15

16 Exemption/Disenrollment WAC currently undergoing revision; Requests reviewed on case by case basis by HCA medical consultant Clients who contact MACSC will be directed to work with the plan to receive services 16

17 Third Party Insurance What is Third Party Insurance –Third party insurance provides insurance benefits comparable to Healthy Options – it may be Medicare, TriCare, or an insurance like Group Health or Premera Clients with third party insurance are exempt from enrollment in Healthy Options Call ext Monday 7:30 – 4:30 Tuesday – Friday 7:30 – 1:00 17

18 How to Enroll Medicaid clients can make plan choices now by using the ProviderOne system https://www.waproviderone.org/client Call the IVR at

19 Health Plan Contact Information Customer Service: Website: Provider Line Website: Customer Services: Website: Provider line Website: Customer Service: Website: Provider line Website: Customer Service: Website: Provider line Website: Customer Service: Website: Provider line - Phone: Website: 19

20 Questions Basic Health and Healthy Options Managed Care Healthy Options Basic Health Contact us: Managed Care mailbox: 20


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