Presentation on theme: "Managed Care Changes Basic Health and Healthy Options"— Presentation transcript:
1Managed Care Changes Basic Health and Healthy Options Alison RobbinsWashington State Health Care AuthoritySeptember 18, 2012
2Procurement Process Conducted in 2011 – 2012 New contracts signed March 2012Program changes implemented July 1, 2012Exiting Plans: Group Health Cooperative, Regence BlueShield, Asuris NW Health, Kaiser, Columbia United Providers.
3Healthy Options Plans for 2012 Amerigroup/Real SolutionsCommunity Health Plan of WashingtonCoordinated Care CorporationMolina Healthcare of WashingtonUnitedHealth Care Community Plan
4County enrollment in managed care is voluntary. Effective Service Areas for Healthy Options, Children’s Health Insurance Program, Healthy Options Blind/Disabled, and Healthy Options Foster Care Programs as ofAMG CHP MHCCCCWhatcomOkanoganFerryStevensPend OreilleAMG CCC CHP UHCAMG CHP MHCCHP MHCUHC CCCCHP MHCUHCAMGCCC CHP MHC UHCAMGSkagitSan JuanAMG CCC CHP MHCCHP MHCChelanClallamIslandSnohomishMHCAMG CCC CHP MHC UHCCCCCHPMHCUHCSpokaneAMG CCC CHP MHCUHCJeffersonCCCCHPMHCUHCLincolnAMG CCC CHP MHC UHCCCC UHCCCCMHCUHCMasonKitsapAMG CCC CHP MHC UHCGrays HarborAMGCCCMHCUHCDouglasHere is the latest version of which plans are located in each county.Blue highlighted counties indicate voluntary enrollment in managed care.CHPCCCMHCUHCAMGGrantKittitasCHPMHCUHCCHPCCCMHCUHCKingAdamsWhitmanAMG CCC CHP MHC UHCCCC CHP MHCUHCAMG CCC MHC UHCAMG CCC CHP MHC UHCThurstonPierceYakimaCCCCHPMHCUHCPacificLewisAMG CCC CHP MHC UHCFranklinCCC CHP MHC UHCAMGGarfieldCCCCHPMHCUHCAMG CCC MHCBentonColumbiaCCCCHPMHCUHCCCCCHPMHCUHCWahkiakumCowlitzCHPMHCSkamaniaAMG CCC CHP MHC UHCAMGMHCUHCCCCUHCCCC UHCWalla WallaAsotinKlickitatCCCUHCClarkCCC, CHP, MHC, UHCCounty enrollment in managed care is voluntary.
5Division of Developmental Disabilities Enrollment in Healthy Options will not impact:The services you are currently receiving from DDDYour case management with DDDYour eligibility for DDD
6Medicaid Healthcare Services Fee for ServicesHealthy Options managed care
7Medicaid Managed Care Health Plans must ensure: Guaranteed access to a Primary Care ProviderChoice of multiple Primary Care Providers and Specialists24/7 access to a Nurse Advice LineCoordination of care among providers and systems of care: for example, between medical and mental health systemsPrescription coverage
8Ensuring plan readiness Comprehensive readiness reviews of each health planExamination of contractual and quality requirementsBi-weekly plan training sessionsBi-weekly individual health plan meetingsAd hoc meetings as requestedBi-weekly network development assessmentAgency staff response to plan questionsReview of plan materialsThese are some of the activities HCA has embarked upon to ensure contract readiness for the July 1 start date.HCA conducted Readiness Reviews of all 5 plans. Each plan was required to submit documentation showing HCA that it could fulfill contractual and federal Medicaid managed care requirements. Federal protocols were used to assess plans in 13 areas. Each new plan also had a 2 day on-site visit consisting of staff interviews. The 2 existing plans had a 2 day on-site visit with 1 day devoted to readiness review-related staff interviews.
9New Eligible Clients New population added to managed care: Categorically Needy SSI Blind and Disabled:Medicaid OnlyMandatory Enrollment – must enroll in managed care unless client meets exemption requirementVoluntary enrollment for foster care childrenFoster children may enroll but are not required to enrollWith the departure of the five health plans – Group Health; Regence/Asuris; CUP and KaiserThe Number of displaced clients to be reassigned to new plans is approximately 138,000 throughout the state; Group Health and CUP are no longer contracted with Basic Health. CHP recently reached a subcontracting agreement with CUP; MHC recently reached agreements with GHC and Kaiser.
10Exempt from Managed Care Medicaid Only, Blind/Disabled clients will enroll except clients:Living in institutional settingsEnrolled in Chronic Care Management ProgramsEnrolled in the Program of All-Inclusive Care for the Elderly (PACE)On hospiceAmerican Indians/Alaska NativesEnrolled in the Washington Medicaid Integration Partnership (WMIP)Enrolled in the Medically Intensive Children’s Program (MICP)Third Party InsuranceInstitutional Settings include: SNF, ICF/ID, state hospitals, etc.
11Healthy 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 OptionsEnrollment formEnrollments effective the first of the following month: Changes for November 1 can be made until October 30.The ProviderOne enrollment process is a little more streamlined and efficient than the old method. In the old system enrollment took approximately days. Today the process is simpler. The client still gets a choice of health plans after the system enrolls the client into one. A client then has days to decide if the plan they are enrolled is OK or if they need to change plans.
12How you can help Know what to tell clients Check eligibility for Healthy OptionsFind out which plan(s) each doctor or specialist contracts with:Help determine appropriate planHelp enrolling in or changing plansHelp clients contact providers or plan for help coordinating careReport issues to the plan and/or HCANone of this is new information, however it is still vitally important information in terms of helping people navigate the system. Read through last bullets. Highlight reporting issue for resolution; contact information for plans and HCA to follow.
13Care Management Expectations of Plans Stronger contractual requirementsTo assist new enrollees:Rxs written prior to enrollmentGet care from non-par providers or new PCPTransitional care requirements to mitigate risk of re-hospitalization/re-institutionalizationCare coordination with focus on integrated care between physical and behavioral healthIn moving the blind and disabled population consisting of children and adults into managed care, HCA undertook a number of contract strengthening requirements aimed at improving care coordination and integration for enrollees with special health care needs.
14Care Management Expectations Intensive Care Management for enrollees with special health care needs (ESHCN)Identification of ESHCNInitial Health Screen-Initial Health AssessmentTreatment plansQuality Assurance and special programsSpecial requirements for children in foster care who voluntarily enroll in managed care chiefly involve coordination activities with the Fostering Well Being Care Coordination Unit. Plans are required to assist with care coordination across fee-for-service covered programs, too.
15Managed Care Facts Enrollees: May change plans every month – most don’tAre allowed to get second opinions through the planNew Enrollees: May keep current prescriptions, care plans and providers for 90 days or until accessed by the new planThere is no balance billing; no co-pays for Medicaid clients
16Exemption/Disenrollment WAC currently undergoing revision;Requests reviewed on case by case basis by HCA medical consultantClients who contact MACSC will be directed to work with the plan to receive servicesWAC is currently undergoing revision (estimated completion by November) so that meeting the definition of a child with special health care needs is no longer a reason in and of itself for exemption or disenrollment from managed care. Requests are handled on a case by case basis with heavy involvement of the MCO to determine exactly why an MCO cannot meet an enrollees health care needs. Refer to 3 handouts:Healthy Options Disenrollment Process: high level process flowHealthy Options Disenrollment Requests: describes exemption-disenrollment process in greater detailHealthy Options Disenrollment Form: information the plan completes documenting enrollee care needs and MCO efforts to provide/coordinate needed care.
17Third 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 PremeraClients with third party insurance are exempt from enrollment in Healthy OptionsCall extMonday 7:30 – 4:30Tuesday – Friday 7:30 – 1:00HCA’s policy has always been that enrollees with TPL are exempted from managed care. This is still the case and is a reminder.
18How to EnrollMedicaid clients can make plan choices now by using the ProviderOne systemhttps://www.waproviderone.org/clientCall the IVR atProviderOne Client PortalIVR systemCall CenterVerify Eligibility in ProviderOne before providing services
19Health Plan Contact InformationCustomer Services:Website:Provider line Website:Customer Service:Website:Provider line Website:Customer Service:Website:Provider line Website:Customer Service:Website:Provider line - Phone: Website:Customer Service:Website:Provider Line Website:
20Questions Basic Health and Healthy Options Managed Care Healthy OptionsBasic HealthContact us:Managed Care mailbox:questions on Managed Care to