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Medicaid Transformation: A Changing System.
NCAPSE Spring Conference Julia Adams Scheurich
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How Medicaid funds flow to NC today
NCGA HHS – Federal Health and Human Services CMS - Centers for Medicaid Services (Federal) DHHS – Department of Health and Human Services (State of NC) LME - Local Management Entities/ MCOs - Managed Care Organizations (County/Local) Service Providers (of which UNC, Autism Society, etc. are one of many) NC Medicaid /Division of Voc Rehab/Division of MH/DD/SAS (State) Reminder and level setting Explain the flow and the NCGA (i.e. waiver slots and PMPM)
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Vision for Medicaid Managed Care - DHHS
“Improving the health and well-being of North Carolinians through an innovative, whole-person centered and well- coordinated system of care that addresses both medical and non-medical drivers of health.” Vision for Medicaid Managed Care - DHHS
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Medicaid Transformation = Change is coming
Requires Medicaid to move to an at risk, capitated, managed care 1115 waiver 1115 waiver is the federal authority used to accomplish the foundations set forth in the state law We currently operate under the 1915b/c waiver Moves away from a fee for service model for services outside of the LME/MCO. Vision of reform is to deliver whole-person care through coordinated physical health, behavioral health, intellectual/developmental disabilities and pharmacy products and care models. Includes Social Determinants of Health. Address the full set of factors that impact health, uniting communities and health care systems Medicaid Transformation = Change is coming At risk, capitated, managed care BILLIONs of dollars –hospitals, MDs, and the Behavioral Health system
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Other huge piece of 1115 – exploration to address health barriers, pilots/grants to come out soon around Employment, Housing, Food Insecurity, transportation, personal safety. Grants to come out for these soon also. DSS having to step up, everyone having to prove their value.
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2015: Session Law 2015-245 directs the Department to transition to managed care
: Extensive collaboration with and feedback from stakeholders Aug 2018: RFP released Oct 2018: CMS approves 1115 waiver Feb 2019: Contracts Awarded to PHP. How did we get here?
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PHPs for NC Medicaid Managed Care for Standard Plans
Statewide contracts AmeriHealth Caritas North Carolina, Inc. Blue Cross and Blue Shield of North Carolina, Inc. UnitedHealthcare of North Carolina, Inc. WellCare of North Carolina, Inc. Regional contract – Regions 3 & 5 Carolina Complete Health, Inc.
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NC Medicaid Managed Care Regions and Rollout Dates – DHHS Standard Plans
NOV. 2019 REGION 4 NOV. 2019 REGION 6 FEB. 2020 ALLEGHANY ASHE SURRY NORTHAMPTON STOKES ROCKINGHAM CASWELL PERSON GRANVILLE WARREN GATES VANCE REGION 1 FEB. 2020 HALIFAX HERTFORD WATAUGA WILKES YADKIN FORSYTH ALAMANCE AVERY GUILFORD ORANGE DURHAM FRANKLIN BERTIE ALEXANDER IREDELL NASH MADISON YANCEY CALDWELL DAVIE EDGECOMBE DAVIDSON MARTIN WASHINGTON TYRRELL BURKE CHATHAM WAKE DARE WILSON BUNCOMBE MCDOWELL CATAWBA ROWAN RANDOLPH HAYWOOD PITT BEAUFORT SWAIN LINCOLN JOHNSTON RUTHERFORD LEE GREENE HYDE HENDERSON CABARRUS GRAHAM HARNETT WAYNE JACKSON POLK CLEVELAND GASTON STANLY MOORE LENOIR CRAVEN CHEROKEE MACON TRANSYLVANIA MECKLENBURG MONTGOMERY CLAY REGION 3 FEB. 2020 RICHMOND HOKE CUMBERLAND SAMPSON JONES PAMLICO UNION ANSON DUPLIN SCOTLAND ONSLOW CARTERET ROBESON BLADEN PENDER REGION 5 FEB. 2020 COLUMBUS BRUNSWICK Rollout Phase 1: Nov – Regions 2 and 4 Rollout Phase 2: Feb – Regions 1, 3, 5 and 6
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Feb March April 2019 May June 3RD July Aug Sept Oct Nov 1ST Dec
Initial letter sent to beneficiaries in 2 counties Address verification letter sent to remaining counties 2019 Flyers posted at DSS Address corrections to DSS 2nd letter to members Member Outreach activities Public Service Announcements PHP marketing materials June 3RD EB Call Center Open Welcome Packets mailed SOFT LAUNCH July Aug Sept Oct Open Enrollment Begins - July 15th Open Enrollment Ends - Sept 13th Members auto assigned to PHPs based on algorithm • Member ID cards Member Handbooks Nov 1ST Day 1 - Regions 2 & 4 Managed Care Launch- Phase 1 Dec Member feedback Evaluation of materials, process
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June 3RD July 2019 Aug Sept 2 Oct Nov Dec Jan 2020 Feb 1st March nd
EB Call Center Open Outreach Activities Flyers posted at DSS Address corrections to DSS Letters to members Member Outreach activities SOFT LAUNCH Sept 2 nd Enrollment Welcome Packets Oct Nov Dec Jan Open Enrollment Begins- Oct 14th Open Enrollment Ends- Dec 13th 2020 Day 1 - Regions 1, 3, 5 & 6 • Member ID cards Member Handbooks Feb 1st Managed Care Launch- Phase 2 March Member feedback Evaluation of materials, process
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How will people know which plan we are in?
This Photo by Unknown Author is licensed under CC BY-NC-ND
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Maximus: The Role of the Enrollment Broker
Independent of the PHPs. Will help people decide which plan they should be in. There is an auto assignment into the plans but there is choice. Won an RFP to do this work in NC. Maximus: The Role of the Enrollment Broker
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Beneficiary Experience – Auto Assignment
Beneficiaries who don’t choose a health plan will be assigned one automatically, consistent with the following components in this order: Where the beneficiary lives. Whether the beneficiary is a member of a special population (e.g. member of federally recognized tribes or BH I/DD Tailored Plan eligible). If the beneficiary has a historic relationship with a particular PCP/AMH. Plan assignments of other family members. If the beneficiary has a historic relationship with a particular PHP in the previous twelve (12) months (e.g.,“churned” off/into Medicaid Managed Care). 9
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The Prepaid Health Plans: Benefits
Both Standard Plans and BH I/DD Tailored Plans will be integrated managed care products and will provide a robust set of physical health, behavioral health, long-term services and supports, and pharmacy benefits. Create single point of accountability for care and outcomes for Medicaid. Standard Plans Tailored Plans Beneficiaries benefit from integrated physical & behavioral health services “Primary care” behavioral health spend included in PHP capitation rate Phased implementation – Nov & Feb. 2020 Specialized managed care plans targeted toward populations with significant BH and I/DD needs Access to expanded service array Behavioral Health Homes Projected for July 2021 3
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Standard Plan Medical services: physician healthcare. Pharmacy.
PT, OT, Speech Therapy. Dietician services. Behavioral Health. (Low to moderate) Substance Use Disorder Services. (Low to moderate) EPSDT Autism Services Under State Plan
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Tailored Plan All Medicaid benefits (minus dental, LEA, PACE) PLUS
Residential treatment facility services Child and adolescent day treatment services Intensive in-home services Multi-systemic therapy services Psychiatric residential treatment facilities (PRTFs) Assertive community treatment (ACT) Community support team (CST) Substance abuse non-medical community residential treatment Substance abuse medically monitored residential treatment • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID) WAIVER SERVICES TBI waiver services • Innovations waiver services • 1915(b)(3) services ALL STATE-FUNDED BH & I/DD SERVICES STATE-FUNDED TBI SERVICES
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Tailored Plan Design and Launch Timeline
Until early 2020, DHHS will be conducting intensive planning for both Standard Plans (SPs) and TPs. After SPs launch, DHHS will continue implementation planning for Tailored Plans. Aug. Jan. Feb. Nov. May July 2018 2019 2020 2021 BH I/DD TP design (8/2018-2/2020) BH I/DD TP implementation planning (2/2020-7/2021) SP implementation planning (8/2018-2/2020) DHHS awards BH I/DD TP contracts (tentative) DHHS released SP RFP SPs launch in initial regions BH I/DD TPs launch (tentative) SPs launch in remaining regions; DHHS releases BH I/DD TP RFA (tentative) DHHS issues SP contracts MCAC BH/IDD SUBCOMMITTEE, FEB. 4, 2019
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Tailored Plan Eligibility
Qualifying I/DD diagnosis Innovations and TBI Waiver enrollees and those on waitlists Qualifying Serious Mental Illness (SMI) or Serious Emotional Disturbance (SED) diagnosis who have used an enhanced service Those with two or more psychiatric inpatient stays or readmissions within 18 months Qualifying Substance Use Disorder (SUD) diagnosis and who have used an enhanced service Medicaid enrollees requiring TP-only benefits Transition to Community Living Initiative (TCLI) enrollees Children with complex needs settlement population Children ages 0-3 years with, or at risk for, I/DDs who meet eligibility criteria Children involved with the Division of Juvenile Justice of the Department of Public Safety and Delinquency Prevention Programs who meet eligibility criteria NC Health Choice enrollees who meet eligibility criteria
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Tailored Plan Simplified
What services are in the standard plan for people with I/DD, MH or SUD? Behavioral Health Urgent Care • Outpatient Plus • Rapid Care Services • Behavioral Health Crisis Assessment and Intervention • Child First Outpatient EPSDT (both plans) RBBHT –State Plan Services for children and young adults with Autism. Age This is ABA. (both plans) Care management. SDOH through NCCARES 360, Healthy Opportunities Pilots, and what the PHPs have internally that they will bring to NC. Tailored Plan Simplified
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Tailored Plan Simplified
What services will remain in the tailored plan? Innovations waiver. B3. ILOS (except for ones that are specifically for the standard plan) Behavioral Health Urgent Care • Outpatient Plus • Rapid Care Services • Behavioral Health Crisis Assessment and Intervention • Child First Outpatient State dollar services. ICF/IDD Intensive services for mental health, substance use disorders, PRTF, residential. Tailored Plan Simplified
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Tailored Plan Simplified
Is there choice in which plan a person can enroll in? Yes and No Can I go to the standard plan and stay on the Innovations waitlist? Yes. You will not loose your place on the waitlist. Can I go to the standard plan and keep my Innovation waiver, B3, ILOS, or Single Stream Services? No. You would loose your tailored plan services. Tailored Plan Simplified
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How can I learn more about the tailored plans?
DHHS has a lot of information: Behavioral Health/IDD Tailored Plan: idd-tailored-plans Has link to all the previous webinars including the slides and a transcript of the presentations. Link to the Eligibility and Enrollment Paper: FinalPolicyGuidance-Final pdf Next white paper from DHHS will be on care/case management.
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