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Facilitated by Alabama Primary Health Care Association Medicaid Transformation.

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Presentation on theme: "Facilitated by Alabama Primary Health Care Association Medicaid Transformation."— Presentation transcript:

1 Facilitated by Alabama Primary Health Care Association Medicaid Transformation

2 Session Overview Statutory RCO Requirements RCO Planning Principles Statewide RCO regions Timeline and Anticipated Next Steps

3 Medicaid System Transformation “Will not expand Medicaid under the current system”…Governor Robert Bentley Alabama Legislature – SB 340 Provides for the delivery of medical services to Medicaid beneficiaries on a managed care basis through regional care organizations or alternate care providers

4 Medicaid System Transformation Managed Care (Risk Based) Medicaid will contract with qualified organizations (RCO or ACP) where the organization assumes risk for the cost of services covered under the contract and incurs loss if the cost of services exceeds the payment under the contract (10/1/2016)

5 Medicaid System Transformation Regional Care Organizations An organization of health care providers that contracts with Medicaid to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of the state and meets requirements of enabling statute

6 Medicaid System Transformation Alternative Care Providers (ACP) A contractor, other than a RCO that agrees to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of the state pursuant to a risk contract; traditional commercial MCO

7 Medicaid System Transformation ACP Triggers Medicaid may contract with an alternate care provider if: – The RCO fails to meet contract requirements – If no organization has been certified as an RCO or probationary RCO by October 1, 2016 – If no RCO is willing to accept the contract

8 Medicaid System Transformation Collaborators Private health carriers, third party purchasers, provider, health care center, health care facility, state and local gov. entity, or other public payers, corporations, individuals and consumers who are expecting to collectively cooperate, negotiation or contract with another collaborator or RCO

9 Statutory RCO Requirements Medicaid Responsibilities 1.Establish statewide managed care regions 2.Establish policy and process for application and certification as collaborators; certify qualified collaborators 3.Establish criteria for probationary and full certification of RCOs; certify qualified RCOs

10 Statutory RCO Requirements Medicaid Responsibilities 4.Establish quality standards and minimum service delivery network requirements 5.Establish and support statutory quality assurance and improvement provisions 6.Establish requirements for HIT, data analytics, quality of care, quality improvement measurement and standards

11 Statutory RCO Requirements Medicaid Responsibilities 7.Conduct initial readiness audits and ongoing financial audits 8.Monitor federal Medicaid regulatory compliance throughout implementation and management to assure FFP is maintained

12 Statutory RCO Requirements Medicaid Responsibilities 9.Establish procedures to safeguard integrity of claims payment and protect against wrongful denial of claims 10.Establish policy and process to address grievances of enrollees and RCO or ACP

13 Statutory RCO Requirements Governance Structure 12 members risk-bearing members 8 non-risk bearing (statutory) members 3 community representatives

14 Statutory RCO Requirements Governance Risk-bearing Members (12) Participants bear risk by contributing cash, capital, or other assets to the RCO or contract to treat Medicaid beneficiaries at a capitated rate per beneficiary even if the RCO does not reimburse the participant

15 Statutory RCO Requirements Governance Non-Risk-bearing Members (8) Participants that do not represent risk bearing members include 5 medical professionals providing care to Medicaid patients in that region 3 of these will be primary care physicians; 1 from APHCA/ALNMA, 2 from regional board of health

16 Statutory RCO Requirements Remaining 2 medical professionals include an optometrist and pharmacist None of the non-risk bearing professionals can be risk bearing or be employed by a risk bearing organization

17 Statutory RCO Requirements Governance Community Representatives (3) Participants shall include: Chair of the citizens’ advisory committee Another citizens’ advisory committee member elected by the committee (must be member of AL Arise or AL Disabilities Leadership Coalition Business executive nominated by Chamber of Commerce in the region

18 Statutory RCO Requirements Citizens’ Advisory Committee Committee will advise the Board on ways the organization may be more efficient in providing quality care and carry out other functions and duties assigned to it by the RCO and approved by Medicaid At least 20% shall be Medicaid patients enrolled in the RCO

19 Planning Principles 1.Any Willing Provider - A provider may contract with any RCO to provide services in a Medicaid region if the provider is willing to accept the payments and terms offered comparable providers

20 Medicaid Redesign Principles 2.Provider Reimbursement Floor – established by AMA for providers inside and outside of the region; may be higher for in region providers, but must be at least the Medicaid floor (current rate?) to prevent RCOs from unfairly excluding providers outside of the region

21 Medicaid Redesign Principles 3.Every RCO will contract with Children’s Hospital of Birmingham, UAB Hospital, & other hospitals as necessary to ensure specialty services remain available 4.Maternity Care Program will be included in RCO services and capitation 5.PCN scope of case management will be included in RCO services and capitation

22 Medicaid Redesign Principles 6.Capitation amount for each region will be region specific ,000 out of 900,000 Medicaid patients will be covered by RCOs 8.Family planning and dentistry will not participate in RCOs during phase 1 9.LTC will not be included in RCOs

23 Statewide Medicaid Regions 1.Market demand will determine the number of RCOs per region; each will have a minimum of 60,000 eligibles; larger regions help to minimize risk 2.Regions not modeled after any existing government regions or districts; other Medicaid regions will transition into RCO regions (i.e., maternity care)

24 Statewide Medicaid Regions 3.Regional organization intended to maintain hospital and physician referral patterns/patient relationships; minimize border crossover issues (also, see any willing provider) 4.Patient residence establishes basis for RCO assignment and capitation

25 Draft Map; final adoption to occur by October 1, 2013 Public Hearing

26 Timeline and Next Steps Public comments for policies through Administrative Procedures Act (35 days for public comment) Opportunity for Public Hearing

27 Timeline and Next Steps October 1, Establish/Adopt Medicaid Managed Care Regions October 1, Organizations seeking to become a RCO must have governing board and structure approved by Medicaid April 1, Probationary RCOs must demonstrate ability to establish adequate medical service delivery network

28 Timeline and Next Steps October 1, Probationary RCOs must meet financial requirements October 1, Probationary certification expires; must demonstrate capability of providing services pursuant to a risk contract

29 Timeline and Next Steps Next Steps Rules around Collaboration – possible emergency rule submitted in September Provisional Certification – possible rules submitted by January 2014 (requirements, application content, risk bearing tests)

30 Timeline and Next Steps Next Steps RCO Certification – final rules possible by April 2014 AMA open to RCO applications for provisional status possibly from April – August 2014

31 Provider Activities 1.Understand RCO system design, requirements, timeline 2.Internally assess your role within the planning, development, implementation of RCO and ongoing program 3.Collaborate as allowed under statute with others at appropriate time 4.Educate patients at appropriate time

32 Questions

33 Alabama Primary Health Care Association Sharon Parker, RN CVRN, CHTS-CP Chief Quality Officer


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