MAXIMUS Webinar Series

Transcription

1 MAXIMUS Webinar Series What the Provider Enrollment Rule Means Operationally for States and MCOs, Including Network Adequacy Continuing the Discussion on the CMS Rule for Medicaid & CHIP Managed Care June 23,

2 Introductions Jan Ruff Senior Vice President MAXIMUS Health Services Heidi Robbins-Brown Principal HMA 2

3 Agenda Overview of Regulatory Environment Impacts of New Screening and Enrollment Requirements Related Areas Provider Directories Network Adequacy Take-Away Messages 3

4 Goals of the New Rule The new Medicaid Managed Care Rule endeavors to achieve four primary goals: 1. Support state delivery system reform efforts 2. Improve the consumer experience and key consumer protections 3. Strengthen program integrity by improving accountability and transparency 4. Align key rules with those of other health coverage programs Improving accountability means: Identifying minimum standards for provider screening and enrollment Expanding managed care plan responsibilities in program integrity efforts 4

5 No one has it all figured out yet! 5

6 Provider Screening and Enrollment Effective Dates ACA & MCO September 25, 2016: ACA Reenrollment and Site Visits July 1, 2018: MCO Initial Provider Enrollment and Screening No later than rating period for contracts starting on or after July 1, 2018 Key Dates Ahead 6

7 Harmonization between ACA & the Rule The new Medicaid Managed Care Regulations bring all of the Affordable Care Act Provider Screening and Enrollment Provisions to the Medicaid Managed Care Delivery System Creates cohesive requirements across Medicare, Medicaid Fee-for- Service (FFS) and Medicaid Managed care Common goals are accountability, transparency and ensuring program integrity 7

8 The GAO concluded that, as part of an overall effort to enhance program integrity and reduce fraud risk, effective enrollment and screening procedures are essential to make sure that ineligible or potentially fraudulent providers and suppliers do not enroll in the program and that CMS has taken steps to develop and implement such procedures. Source: CMS Fact Sheet Strengthening Provider and Supplier Enrollment Screening 8

9 Current Medicaid Screening & Enrollment Laws Mandatory enrollment in the Medicaid program for both Fee-For-Service and Managed Care providers and suppliers Screening criteria: Review ownership and control disclosures submitted by the MCOs Perform routine checks with federal databases Perform periodic revalidation of all MCO providers Divides provider types into three categories of risk Assigns different screening requirements depending on risk level 9

10 Limited Risk Provider Types & Screening Activities Provider Type Risk Categories Physicians Non-physician practitioners Medical groups and clinics Ambulatory surgical centers (ASCs) Audiologists Federally qualified health centers (FQHC) Hospitals, including critical access hospitals Indian and Tribal Health Services facilities End stage renal disease facilities Mass immunization roster billers Occupational therapists enrolling as individuals or as group practices Pharmacies Radiation therapy centers Rural health clinics (RHC) Skilled nursing facilities Speech language pathologists 10 Screening Activities Verification of provider-specific requirements, including but not limited to the following: License verification National Provider Identifier (NPI) verification Federal and state database checks Ownership/controlling interest information verification

11 Moderate Risk Provider Types & Screening Activities Provider Type Risk Categories Screening Activities Ambulance service suppliers Community mental health centers Outpatient rehabilitation facilities Independent clinical laboratories Independent diagnostic testing facilities Hospice organizations (CSHCN Services Program only) Physical therapists enrolling as individuals or as group practices Portable X-ray suppliers Currently enrolled (re-enrolling) home health agencies Currently enrolled (re-enrolling) DMEPOS providers Comprehensive outpatient rehabilitation facilities License verification National Provider Identifier (NPI) verification Federal and state database checks Ownership/controlling interest information verification, AND Unannounced site visits before and after enrollment or re-enrollment 11

12 High Risk Provider Types and Screening Activities Provider Type Risk Categories Screening Activities Prospective (newly enrolling) home health agencies Prospective (newly enrolling) Durable Medical Equipment, Prosthetics and Orthotics Services providers License verification National Provider Identifier (NPI) verification Federal and state database checks Ownership/controlling interest information verification Unannounced site visits before and after enrollment or re-enrollment, Submission of fingerprints for all individuals with ownership in the entity of five percent or more (Fingerprint submission guidelines are being developed) 12

13 Re-enrollment Re-enrollment standards vary by provider type and risk; most providers require re-enrollment no longer than every five years Section 6401 of the Affordable Care Act of 2010 (ACA) requires Durable Medical Equipment Prosthetics and Orthotics Service (DMEPOS) providers to re-enroll every three years 13

14 Provider Fees State Medicaid programs must require an application fee for institutional providers Amount of the application fee is subject to change every calendar year The fee for calendar year 2016 is $554 Application fee is required for any newly enrolling or re-enrolling institutional provider, including providers that are applying for a new practice location Excludes Physicians and non-physician providers and their medical groups and clinics 14

15 New Ownership Disclosures Medicaid must capture both the Employer Identification Number (EIN) and Social Security Number (SSN) of: Each provider or supplier Each person with ownership or control interest in the provider or supplier Any subcontractor in which the provider or supplier directly or indirectly has a 5 percent or more ownership interest Any managing employees including directors and officers of corporations and non-profit organizations and charities Information is captured through the Disclosure of Ownership and Control Interest Statement Providers must attest to having a compliance program in place 15

16 New Mandatory Disclosures for MCOs Implement procedures providing for the prompt referral of any potential fraud, waste, or abuse Report changes to enrollees eligibility status and to a provider s ability to participate Report to the State within 60 calendar days when it has identified overpayments in the capitated payments 16

17 Impacts of New Screening & Enrollment Requirements States will differ in the number and magnitude of impacts experienced States must update MCO contracts to reflect its compliance and oversight strategies Cumulative administrative burden on state agencies, plans and providers 17

18 Impacts of New Screening & Enrollment Requirements Direct enrollment or oversight of MCO enrollment will be time consuming and costly for states to implement Significant state resources needed to build, test and implement an enrollment tool or oversight tools Potentially longer enrollment times could stress the providers, health plans and state relationships Mitigation: 120-Day temporary contracts Inconsistencies between the regulation and the guidance on state role vs ability to delegate to other entities must be addressed 18

19 Impact of New Screening & Enrollment Requirements Disparate federal databases already an ACA barrier and will be exacerbated by enrollment of health plan providers One PI (will address current issues with PECOS) Monthly PI checks Site Visits for moderate and high risk providers Fingerprinting for high risk providers 19

20 2016 OIG Audit Plan OIG will review: State and CMS screening and enrollment activities and processes regarding oversight of: Provider ownership collection and verification; database checks; and comprehensive review of information submitted across payers and OIG States experience in implementation of enhanced screening and reenrollment efforts, including site visits 20

21 Audience Poll What do you think? What do you think is the best option to ensure accountability while also meeting the new Screening and Enrollment (S&E) requirements for your state? 1. 1 Have Medicaid staff perform the new work 2. 2 Have Medicaid Staff continue to perform S&E for plans 3. 3 Delegate this work to a (non FI/MCO) third party 4. 4 Delegate this work to the MCO 21

22 MCO Regulation Provider Directories Effective Date: July 1,

23 Provider Directories Attempt to harmonize Medicare, Medicaid and Marketplaces Provider Directories are required to be updated within the same timeframes: Electronic Directories: Up to every 30 days or more frequently Paper Directories: Monthly updates and need only be available by request 23

24 Provider Directories Impacts Both states and Health Plans must post accurate and timely provider directories on their websites Requires timely exchanges of data and updates to provider files and provider access tools and even mobile apps Requires validation and oversight Supports member access and satisfaction 24

25 How to Synchronize & Streamline Directories State provider enrollment data MMIS How to synchronize and streamline? MCO directories Enrollment Broker provider directories 25

26 MCO Regulation Network Adequacy Effective Date: July 1, 2018 No later than rating period for contracts starting on or after July 1,

27 Network Adequacy High expectations for health plans to ensure access to services for beneficiaries Access includes building and maintaining an adequate network Each state must adopt time and distance standards Each state obligated to verify provider network adequacy in relation to their state s standards 27

28 Network Adequacy Impacts States must update MCO contracts to communicate new network adequacy standards States must validate MCO network adequacy reporting and member access Network adequacy and relationship to timeliness of provider enrollment processes 28

29 Take-Away Messages Medicaid Programs and MCOs need to understand their new regulatory environment which includes the blending of the new Managed Care Rule and the previous ACA provisions States can tailor their approach to enhance accountability and checks and balances while minimizing MCO administrative costs and duties to create better MLR across all MCOs Centralize administrative functions Offload to third parties CMS will provide ongoing technical assistance that will bring further clarification to the regulations for both states and health plans 29

30 Take-Away Messages State are still in the process of fully meeting ACA requirements and will now need to meet the new MCO requirements as well New MCO timelines fall right on top of many states current FFS revalidation efforts MMIS systems and staff are impacted by the totality of the ACA and MCO regulations and support the entire Medicaid ecosystem States may consider a phased in approach to compliance beginning with delegated functions to ease the burden 30

31 Questions Discussion 31

32 Thank You! Want to discuss further? Contact: To view the recording of this webinar and others, please visit: 32