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1 Provider Town Hall Presentation Managed Medical Assistance (MMA) & Child Welfare (CW) 2014.

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Presentation on theme: "1 Provider Town Hall Presentation Managed Medical Assistance (MMA) & Child Welfare (CW) 2014."— Presentation transcript:

1 1 Provider Town Hall Presentation Managed Medical Assistance (MMA) & Child Welfare (CW) 2014

2 Agenda 2 Sunshine Health & Managed Medical Assistance (MMA) Overview Child Welfare (CW) Program Overview Continuity of Care for Transitioning Members Cenpatico Behavioral Health Contracting Covered Services & Expanded Benefits Q & A

3 3 Sunshine Health & Managed Medical Assistance (MMA) Overview Mark Barrett VP, Network Development & Contracting MMA & CW 2014

4 Sunshine Health Overview Sunshine Health is a wholly-owned subsidiary of Centene Corporation and has provided Medicaid Managed Care services in Florida since 2009. Products: Medicaid; Long Term Care; HealthyKids; Medicare SNP; and Health Insurance Exchange Number of Florida employees: 1,200+ Number of Florida physicians: 18,500+ 4

5 History and Scope of Centene Established in 1984 in Milwaukee, WI Headquartered in St. Louis, MO Fortune 500 company (#303) Employs approximately 8,700 individuals Serves government sponsored healthcare programs in 21 states Provider network includes over 190,000 physicians and 1,900 hospitals Centene Overview “Better Health Outcomes, Lower Cost” 5 MA D-SNP (6 States) MA D-SNP (6 States) Medicaid (19 States) Medicaid (19 States) Exchanges (9 States) Exchanges (9 States) ~2.6M Members Correctional (3 States) Correctional (3 States)

6 Bringing Medicaid Leadership Experience to New Markets 1984 1995 2004 20061999 2006 2009 2011 20122011 2012 2007 2012 2013 2010 Partnering with 19 State Medicaid Agencies* 6 Starting Q4 2014* * Fidelis SecureCare is subject to certain acquisition closing conditions including regulatory approvals

7 Specialty Company Resources and Expertise Integrated Approach Total Solution Integration physical health, behavioral health, pharmacy services, and ancillary services Total Solution Integration physical health, behavioral health, pharmacy services, and ancillary services 7 Telehealth Services Provider of In-Home Services Vision Benefits Case Management Software HCBS for I/DD Populations Pharmacy & Specialty Pharmacy Benefits Life, Health & Wellness Behavioral Health & Specialty Therapies Centurion is a correctional healthcare joint venture between Centene and MHM Services Inc. Currently has contracts in MA, MN, and TN.

8 Managed Medical Assistance (MMA) 2014 Rollout of MMA Regions 2, 3, 4 - May 1 Regions 5, 6, 8 - June 1 Regions 10, 11 - July 1 Regions 1, 7, 9 - August 1 8 Sunshine Health was selected to provide managed care services for Medicaid recipients in Regions 3 through 11 for a five year period.

9 Managed Medical Assistance (MMA) & Managed Care The goals of Florida MMA are to provide: Coordinated health care across different health care settings A choice of the best managed care plans to meet recipients’ needs The ability for health care plans to offer different, or more, services The opportunity for recipients to become more involved in their health care 9

10 Medicaid Managed Care There are two different components that make up the Statewide Medicaid Managed Care (SMMC) program: Long Term Care (LTC) Managed Medical Assistance (MMA) Medicaid recipients who qualify and become enrolled in the Florida LTC managed care program will receive LTC services through a LTC managed care plan. Medicaid recipients who qualify and become enrolled in the Florida MMA program will receive all health care services other than LTC through a managed care plan. 10

11 AHCA’s List of Statewide Comprehensive Plans 11 RegionComprehensive Plans Available 1None available 2 3Sunshine, United 4 5Sunshine 6 7Molina, Sunshine, United 8Sunshine 9 10Humana, Sunshine 11Amerigroup, Coventry, Humana, Molina, Sunshine, United

12 12 Child Welfare (CW) Overview MMA & CW 2014 Cathy Sharp Manager, Provider Partnership

13 Through a competitive bid process, the Agency for Health Care Administration (AHCA) selected Sunshine Health as the only specialty managed care plan to provide managed care services for children in the CW system for a five year period. Child Welfare (CW) 13 2014 Rollout of CW Regions 2, 3, 4 - May 1 Regions 5, 6, 8 - June 1 Regions 10, 11 - July 1 Regions 1, 7, 9 - August 1

14 Sunshine Health is the sole specialty plan in Florida for the child welfare population, serving approximately 30,000 children statewide. CW includes three primary partners: Sunshine Health Cenpatico Behavioral Health Community Based Care Integrated Health (CBC-IH) Child Welfare (CW) 14

15 Sunshine Health is contracted with Community Based Care – Integrated Health (CBC-IH) to provide support and care coordination for all Sunshine Health CW Members statewide. Sunshine Health’s contract with CBC-IH is an innovative partnership designed to ensure that all behavioral or physical health care related services are coordinated with the CBC agencies. Our staff provide care and utilization management through an integrated team of professionals focused on meeting the overall needs of each child. Community Based Care (CBC) 15

16 16 CBC-IH is assisting Sunshine Health in gathering information for the new CW members’ Health Risk Screenings (HRS). The HRS includes questions regarding physical health, behavioral health, dental, and pharmacy authorizations or appointments during the 90 day CW continuity of care period. CBC-IH will identify a PCP for each child in the Sunshine Health CW Plan, and at go-live, it is anticipated that Sunshine Health will have the designated PCP on its provider list. This will greatly reduce the need for auto-assignment and ensure uninterrupted transition of care. Child Welfare (CW)

17 17 Continuity of Care MMA & CW 2014 Cathy Sharp Manager, Provider Partnership

18 New Members 18 Sunshine Health ensures continuous care for new members receiving an active course of treatment through their previous health plan or Medicaid Fee-For-Service (FFS), provided the services were prior authorized before enrollment with Sunshine Health. These services include: Prior existing orders Provider appointments (dental appointments, surgeries, etc.) Prescriptions (including those at non participating pharmacies) Behavioral health services

19 Continuity of Care Period 19 Sunshine Health provides continuity of care for all new members for the following time periods following the enrollment date or until the member’s new PCP or behavioral health provider reviews the member’s treatment plan: MMA members up to 60 calendar days CW members up to 90 calendar days Sunshine Health ensures new members who are pregnant and have initiated a course of prenatal care, regardless of the trimester, continuity of care with their current OB/GYN until the completion of postpartum care Sunshine Health also ensures, in conjunction with Medicaid eligibility, continuity of care for active orthodontia until the completion of care and reimbursement to providers, regardless of provider network

20 20 In the event a new enrollee is receiving a prior authorized treatment with an out-of-network provider, Sunshine Health will: Continue to pay for the course of treatment through the continuity of care timeframes, regardless of whether the services are provided by participating or non-participating providers Adjudicate claims submitted by out-of-network providers between the date of service and the date of the clean claim submission, unless that period exceeds 365 days Authorization & Payment

21 21 Sunshine Health adopted AHCA’s Preferred Drug List (PDL) formulary for the first year of MMA and CW. Sunshine Health’s Pharmacy Benefit Manager (PBM), US Script, will continue to manage the pharmacy network and process PA or step edit requests Sunshine Health’s specialty drug company, Acaria will continue to process requests for specialty drugs Age, gender, and quantity limits along with the drugs that require a PA will mirror those on AHCA’s PDL. This information can be accessed through a link on Sunshine Health’s website to the AHCA website PA forms and criteria can be accessed through US Script or Sunshine Health’s website Any changes made by AHCA will be adopted to the PDL by Sunshine Health Pharmacy Management

22 22 A Sunshine Health case manager is assigned to all members needing continuity of care services. Case managers and other team members will follow these members and facilitate the care coordination process by: Contacting the member/caregiver to obtain information on the member’s providers, dates of appointments, and provided services Providing additional clinical information to utilization management Helping the member make appointments with their Sunshine Health PCP or behavioral health provider Helping the member transition to a participating provider, if needed Case Management Support

23 23 We encourage providers who have new Sunshine Health patients transitioning from Medicaid FFS or another heath plan with approved authorizations, or in ongoing treatment plans, to contact Sunshine Health’s Utilization Management staff as soon as possible by calling: 1-866-796-0530 Contact Us

24 24 Cenpatico Behavioral Health MMA & CW 2014 Kristie Cavins Provider Relations Cenpatico Behavioral Health

25 25 Service Area and Provider Types Cenpatico contracts with an extensive provider network that contracts with the following: Community Mental Health Centers (CMHCs) Independent Practitioners (MDs, PhDs, LPC, LCSW, and LMFTs) Institutes for Mental Disorders (IMD) General Hospitals offering psychiatric and/or substance use services Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Primary Care Clinics (PCCs) Statewide Inpatient Psychiatric Programs (SIPP)

26 26 Cenpatico emphasizes its commitment to quality of care for Sunshine Health members by ensuring our providers adhere to the following: Provide members with a professional level of care and efficiency that is consistent with community standards Prepare and maintain complete medical records and other required documents for all member care Participate in quality improvement activities, utilization review activities, orientations, continuing education, and other medical management components Abide by ethical principles of their profession Cenpatico will communicate with providers to inform them of their participation responsibilities, credentialing and application status, and network requirements. Provider Participation Responsibilities

27 27 Provider Training Program Cenpatico will offer a series of trainings for providers specific to behavioral management services for members including: Motivation interviewing Trauma informed care Privacy/HIPAA Behavioral health screening tools Integration of Care IMPACT – depression model – PCP focused A schedule of upcoming training events will be available at: SunshineHealth.com SunshineHealth.com

28 28 Network Participation Agreements Cenpatico wants to extend an agreement to your organization if you are not already contracted with us. For those existing network providers, an amendment to your existing contract to incorporate the expanded behavioral health outpatient benefits and applicable modifiers for MMA and CW may be necessary. For additional information, contact Dawn Kinkead at: dkinkead@cenpatico.com or 727-434-4139 dkinkead@cenpatico.com

29 29 Contracting MMA & CW 2014 Bridget Jones Contract Negotiator

30 Medical 168 Hospitals 5,500+ Primary Care Physicians 13,000+ Specialist Physicians Behavioral 100+ Psychiatric Community Hospitals & Crisis Stabilization Units 650+ Psychiatrists 3,100+ Behavioral Health Providers Dental 1,000+ Dentists 100+ Oral Surgeons Pharmacy 4,300+ Retail Pharmacies 30 Sunshine Health Network Snapshot

31 31 Participating Hospitals in Region 5 Morton Plant Northbay Hospital6600 Madison StNew Port Richey34652727-842-8468Pasco5 Community Hospital/Medical Center of Trinity9330 State Road 54Trinity34655727-834-4000Pasco5 Regional Medical Center Bayonet Point14000 Fivay RoadHudson34667727-819-2929Pasco5 Florida Hospital Wesley Chapel 2600 Bruce B Downs BlvdWesley Chapel33543813-929-5000Pasco5 Florida Hospital Zephyrhills7050 Gall BlvdZephyrhills33541813-788-0411Pasco5 Bayfront Health Dade City13100 Fort King RdDade City33525352-521-1100Pasco5 Mease Countryside Hospital3231 Mcmullen Booth RdSafety Harbor34695727-725-6111Pinellas5 Mease Dunedin Hospital601 Main StDunedin34698727-733-1111Pinellas5 Morton Plant Hospital300 Pinellas StClearwater33756727-462-7000Pinellas5 St. Anthony's Hospital1200 7th Ave NSt Petersburg33705727-825-1100Pinellas5 Bayfront Medical Center701 6th StSt. Petersburg33701727-823-1234Pinellas5 Florida Hospital North Pinellas 1395 South Pinellas AvenueTarpon Springs34689727-942-5000Pinellas5 Edward White Hospital2323 9th Avenue NorthSt. Petersburg33713727-323-1111Pinellas5 Largo Medical Center201 14th Street SWLargo33770727-588-5200Pinellas5 Northside Hospital6000 49th Street NorthSt. Petersburg33709727-521-4411Pinellas5 St. Petersburg General Hospital6500 38th Avenue NorthSt. Petersburg33710727-384-1414Pinellas5 All Children's Hospital501 6th Ave SSt. Petersburg33701727-898-7451Pinellas5 Largo Medical Center - Indian Rocks2025 Indian Rocks RdLargo33774727-581-9474Pinellas5

32 32 Participating Hospitals in Region 6 * Letter of Intent Completed & Agreement Pending Florida Hospital Wauchula533 West Carlton StreetWauchula33873863-773-3101Hardee6 Florida Hospital Lake Placid1210 US Hwy 27 NorthLake Placid33852863-465-3777Highlands6 Florida Hospital Heartland Medical Center4200 Sun n' Lake BlvdSebring33872863-314-4466Highlands6 Highlands Regional Medical Center3600 S Highlands AveSebring33870863-385-6101Highlands6 Brandon Regional Hospital119 Oakfield DrBrandon33511813-681-5551Hillsborough6 St. Joseph's North Hospital4211 Van Dyke RoadLutz33558813-443-7000Hillsborough6 South Florida Baptist Hospital301 N Alexander StPlant City33563813-757-1200Hillsborough6 South Bay Hospital4016 Sun City Center Blvd Sun City Center33573813-634-3301Hillsborough6 Florida Hospital Carrollwood7171 N. Dale Mabry HighwayTampa33614813-932-2222Hillsborough6 Florida Hospital Tampa3100 E. Fletcher Ave.Tampa33613813-971-6000Hillsborough6 Shriners Hospitals for Children- Tampa12502 USF Pine DrTampa33612813-972-2250Hillsborough6 St. Joseph's Hospital 3001 W Dr Martin Luther King Jr BlvdTampa33607813-870-4000Hillsborough6 St. Joseph's Women's Hospital 3030 W Dr Martin Luther King Jr BlvdTampa33607813-879-4730Hillsborough6 Tampa General Hospital1 Tampa General CirTampa33606813-844-7000Hillsborough6 Blake Medical Center2020 59th St WBradenton34209941-792-6611Manatee6 Lakewood Ranch Medical Center8330 Lakewood Ranch BlvdBradenton34202941-782-2100Manatee6 Manatee Memorial Hospital206 Second Street EastBradenton34208941-746-5111Manatee6 Bartow Regional Medical Center2200 Osprey BlvdBartow33830863-533-8111Polk6 Heart of Florida Regional Medical Center40100 U.S. 27Davenport33837863-422-4971Polk6 Lakes Wales Medical Center410 S 11th StLake Wales33853863-676-1433Polk6 Lakeland Regional Medical Center1324 Lakeland Hills BlvdLakeland33805863-687-1100Polk6 Winter Haven Hospital200 Avenue F NEWinter Haven33881863-293-1121Polk6

33 Contractual agreements must be in compliance with the terms of the Managed Care Plan’s AHCA contract. 55 required contract checklist provisions Template agreements must be approved by AHCA Providers must be eligible for participation in the Medicaid Program Fully completed application, including updated CAQH credentials, will expedite the credentialing process Who do I contact about an agreement? Contracting Representatives are on site today Contracting Overview 33

34 34 Covered Services, Expanded Benefits & Program Incentives MMA & CW 2014 Cathy Sharp Manager, Provider Partnership

35 MMA Covered Services Advanced registered nurse practitioner services Ambulatory surgical treatment center services Chiropractic services Dental services Early periodic screening & treatment services Emergency services Family planning services Healthy start services Hearing services Home health agencies services Hospice services Hospital inpatient services Hospital outpatient services Laboratory & imaging services Medical equipment & prostheses Mental Health services Nursing care Optical services Optometrist services Physical, occupational, respiratory, and speech therapy Podiatric services Physician services, including physician assistant services Prescription drugs Renal analysis services Respiratory equipment & supplies Substance abuse treatment Transportation to access covered services 35

36 Sunshine Health Expanded Benefits (Limitations and Authorizations may apply) 36 BenefitDescriptionMMACW Expanded Adult DentalTwo (2) exams a year and two (2) cleanings a year. Routine and diagnostic x-rays every two (2) years. Targeted dental outreach to non-compliant members. Postcard referrals for dental check ups provided to PCPs for distribution to members. YesPart of standard benefits Expanded VisionAn additional dollar allowance towards glasses, lenses, or frames. Yes Expanded HearingAdult members will receive one (1) hearing exam per year and one hearing aid every two (2) years. YesPart of standard benefits Over-the-Counter/ Mail Order A $25 per family per month benefit to purchase health related items such as vitamins, aspirin, and first aid supplies. Yes

37 37 BenefitDescriptionMMACW Unlimited Primary Care Visits Unlimited office visits for general services such as family practice or pediatric when medically necessary. Yes Home Health Visits Up to four (4) intermittent visits per day for non ‐ pregnant adults age 21 and older (additional home health visits are already covered for children and pregnant adults). The visits can be any combination of licensed nurse and home health aide visits when medically necessary. Yes Home VisitsTwo (2) home visits per month by a physician or physician extender for supervision of chronic conditions. Yes Sunshine Health Expanded Benefits (Limitations and Authorizations may apply)

38 38 BenefitDescriptionMMACW Expanded Perinatal Visits Unlimited office visits with participating maternity providers for prenatal and postpartum care. Yes Expanded Outpatient Hospital Visits Outpatient hospital services covered up to $1,500 per year for members over the age of 21; excluding Region 3 which covers up to $1,800. YesPart of standard benefits Waived Co-paymentsNo co-payments.Yes Adult Pneumonia, Influenza, and Shingle Vaccines No charge for certain vaccines for members age 21 and older. YesPart of standard benefits Post-Discharge MealsUp to ten (10) home-delivered meals for members who are discharged from the hospital and participating in Sunshine Health’s Transitional Care Program. Yes Nutritional CounselingUp to 3 outpatient visits per year with a participating dietician for nutritional counseling. Yes Sunshine Health Expanded Benefits (Limitations and Authorizations may apply)

39 39 BenefitDescriptionMMACW Art TherapyDelivered in an outpatient setting in conjunction with other behavioral health services. Yes Medically Related Lodging and Food Up to $100 per day for up to 21 days to cover lodging and up to two (2) meals per day for family members when a member’s approved specialized hospital stay is 150 miles or more from home. Yes CircumcisionCircumcision is covered for newborn males during the initial hospitalization. Yes Sunshine Health Expanded Benefits (Some limitations and authorizations may apply)

40 40 BenefitDescriptionMMACW NurseWiseA 24/7 nurse advice line to answer healthcare questions. Assistance is offered in English, Spanish, and other languages per request. Yes Peer Support ServicesPeer Support Services for members with mental health conditions provided by Certified Peer Support Specialists in mental health recovery who are trained in delivering effective peer support. Yes Care GrantsCare Grants up to $150 a year to cover expenses not covered by Medicaid. Examples include athletic uniforms, athletic equipment, school trips, and college application fees. Requests for Care Grants can be made through a referral from a Provider, CBC Dependency Care Manager, or a Sunshine Health staff member. N/AYes Children’s Follow-Up Incentive Program Children under age 21 who have a follow-up outpatient appointment within seven (7) days of discharge from a Behavioral Health inpatient hospitalization will receive an incentive to increase compliance with discharge plans. Provides educational materials along with a $10 gift card following confirmation that they attended their appointment. Yes Sunshine Health Program Incentives

41 Questions 41


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