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Managed Care Changes Basic Health and Healthy Options

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Presentation on theme: "Managed Care Changes Basic Health and Healthy Options"— 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.

3 Healthy Options Plans for 2012
Amerigroup/Real Solutions Community Health Plan of Washington Coordinated Care Corporation Molina Healthcare of Washington UnitedHealth Care Community Plan

4 County 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 of AMG CHP MHC CCC Whatcom Okanogan Ferry Stevens Pend Oreille AMG CCC CHP UHC AMG CHP MHC CHP MHC UHC CCC CHP MHC UHC AMG CCC CHP MHC UHC AMG Skagit San Juan AMG CCC CHP MHC CHP MHC Chelan Clallam Island Snohomish MHC AMG CCC CHP MHC UHC CCC CHP MHC UHC Spokane AMG CCC CHP MHC UHC Jefferson CCC CHP MHC UHC Lincoln AMG CCC CHP MHC UHC CCC UHC CCC MHC UHC Mason Kitsap AMG CCC CHP MHC UHC Grays Harbor AMG CCC MHC UHC Douglas Here is the latest version of which plans are located in each county. Blue highlighted counties indicate voluntary enrollment in managed care. CHP CCC MHC UHC AMG Grant Kittitas CHP MHC UHC CHP CCC MHC UHC King Adams Whitman AMG CCC CHP MHC UHC CCC CHP MHC UHC AMG CCC MHC UHC AMG CCC CHP MHC UHC Thurston Pierce Yakima CCC CHP MHC UHC Pacific Lewis AMG CCC CHP MHC UHC Franklin CCC CHP MHC UHC AMG Garfield CCC CHP MHC UHC AMG CCC MHC Benton Columbia CCC CHP MHC UHC CCC CHP MHC UHC Wahkiakum Cowlitz CHP MHC Skamania AMG CCC CHP MHC UHC AMG MHC UHC CCC UHC CCC UHC Walla Walla Asotin Klickitat CCC UHC Clark CCC, CHP, MHC, UHC County enrollment in managed care is voluntary.

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

6 Medicaid Healthcare Services
Fee for Services Healthy Options managed care

7 Medicaid Managed Care 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 These 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.

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 With the departure of the five health plans – Group Health; Regence/Asuris; CUP and Kaiser The 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.

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 Children’s Program (MICP) Third Party Insurance Institutional Settings include: SNF, ICF/ID, state hospitals, etc.

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 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.

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 None 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.

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 In 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.

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 Special 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.

15 Managed Care Facts Enrollees:
May change plans every month – most don’t 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

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 WAC 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 flow Healthy Options Disenrollment Requests: describes exemption-disenrollment process in greater detail Healthy Options Disenrollment Form: information the plan completes documenting enrollee care needs and MCO efforts to provide/coordinate needed care.

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 HCA’s policy has always been that enrollees with TPL are exempted from managed care. This is still the case and is a reminder.

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 ProviderOne Client Portal IVR system Call Center Verify Eligibility in ProviderOne before providing services

19 Health Plan Contact Information 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: Customer Service: Website: Provider Line Website:

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


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