DHCS Update: Major Initiatives and Strategies Towards Standardization

Transcription

1 DHCS Update: Major Initiatives and Strategies Towards Standardization Javier Portela, Division Chief Managed Care Operations Department of Health Care Services ICE 2016 Annual Conference December

2 Presentation Outline 1. Managed Care Final Rule 2. Program Updates Whole Person Care Access Assessment FQHC Alternative Payment Methodology Pilot Coordinated Care Initiative 3. Questions/Open Discussion 2

3 Managed Care Final Rule 3

4 Final Rule Overview Background First major overhaul of the managed care regulations since 2002 Response to the major shift to the managed care delivery system nationwide Directed at states to ensure compliance with Medicaid managed care plans and downstream effects to beneficiaries Aligns the Medicaid managed care program with other health insurance coverage Recurring Themes programs (i.e., Marketplace, Medicare Advantage) Adds many consumer protections to improve the quality of care and beneficiary experience Improves State accountability and transparency Inclusion of Long Term Services and Supports (LTSS) needs Implementation Dates Effective July 5, 2016 Some provisions effective July 5, 2016 (IMD and in-lieu-of services) Phased implementation over three years, starting with the July 1, 2017 contract rating period 4

5 July 1, 2018 contract rating year 2019 and beyond July 1, 2017 contract rating year No later than July 1, 2018 Major Provisions Beneficiary Information Requirements Grievances and Appeals Managed Care Quality Strategy Cultural Competency Network Adequacy Care Coordination Quality Improvement Program Prescription Drugs Utilization Review Provider Screening and Enrollment Annual Network Certification Beneficiary Support System EQRO Validation of Network Adequacy Quality Rating System Program Integrity Annual MCP Report 5

6 Internal research Implementation Strategy Conducted gap analysis of Final Rule provisions in contrast with current requirements to identify impact Consulted with areas across the Department for input on policy and operational considerations External Stakeholder Input Engage the Medi-Cal managed care health plans (MCPs) and stakeholder groups including the DHCS Stakeholder Advisory Committee, Managed Care Advisory Group, topic-specific workgroups, and external partners Collaborate on development of materials, deliverables, and/or processes prior to implementation Plan Guidance Provide guidance to assist MCPs with implementation on each of the activities via All Plan Letters and contract amendments Provide deliverables requirements to the MCPs on a flow basis throughout the implementation phases Roll out contract amendments per implementation year 6

7 Key 2017 Provisions Beneficiary Information Requirements Grievances and Appeals Access and Cultural Competency Care Coordination Quality Improvement Program and text communication State operated website that provides specific plan information Model handbook and notice templates Non-English taglines in beneficiary materials Timeframes for resolution of appeals shortened to 72 hours Requires that appeals are exhausted at the plan level before proceeding to a State Fair Hearing Requires gender identity be included as a component of culturally appropriate care Apply to all appropriate settings including behavioral health settings and LTSS MCP Performance Improvement Projects (PIPs) must include mechanisms to assess beneficiaries using LTSS and/or with special health care needs 7

8 Key 2017 Provisions Drug Utilization Review (DUR) Program Integrity Annual MCP Report Health Information Systems MCP Accreditation Status MCPs must have DUR requirements as defined in 42 CFR 456, Subpart K and report its DUR program activities to the State annually Encounter data and financial data audit CEO/CFO certification of data submissions Federal database checks Posting MCP performance online, including financial, encounter data reporting, enrollment, grievances and appeals, corrective action plans, and others MCP encounter data submissions to the State must be per CMS specifications Web posting of each plan s accreditation status Treatment of recoveries New Annual Program Assessment Report due to CMS (2018) 8

9 Key 2018 Provisions Quality Strategy Network Adequacy Encounter Data Provider Enrollment and Screening Beneficiary Support System New elements include plan to identify and reduce health disparities, transition of care policy, and a plan to identify individuals needing LTSS or with special health care needs Time and distance standards for specialized provider types Annual Network Certification Federal Financial Participation (FFP) is contingent on encounter data submission per CMS specifications All Medi-Cal providers be screened and enrolled by the State Choice counseling and assistance to beneficiaries postenrollment, including LTSS 9

10 2019 and Beyond Network Adequacy Quality Rating System New mandatory EQRO activity to validate network adequacy Plan rating system based on a common set of performance measures 10

11 Final Rule Strategies Towards Standardization Model handbook and template notices Beneficiary Support System website requirements to be posted: Model handbook, provider directory, drug formularies, MCP accreditation status, quality ratings, quality measures and performance outcomes, Quality Strategy, MCP reports (audits, data, etc.) Inclusion of Long-Term Services and Supports 11

12 Program Updates 12

13 Whole Person Care (WPC) 13

14 Whole Person Care (WPC) Overarching goal: Coordination of health, behavioral health, and social services Comprehensive coordinated care for the beneficiary resulting in better health outcomes WPC Pilot entities collaboratively: Identify target populations Share data between systems Coordinate care real time Evaluate individual and population progress 14

15 WPC by Numbers 5 year program $1.5B total federal funds $300M annual available 2 application rounds 18 applicants for Round 1 15

16 First Round Applications Counties with < 1,000 sq. mi. (7) Counties between 1,001 3,000 sq. mi. (4) Counties between 3,001 5,000 sq. mi. (4) Counties with > 5,000 sq. mi. (3) Alameda Contra Costa Santa Clara Los Angeles Kern Napa San Joaquin Monterey Orange Riverside San Francisco Placer San Diego San Mateo Solano Ventura Shasta San Bernardino 16

17 Services and Interventions: PMPM Bundle Example Care Management Bundle Ensures that all Medi-Cal eligible high utilizers across multiple systems (HUMS) and homeless individuals have access to comprehensive care coordination through a consistent countywide complex care management system Two tiers one for those not facing homelessness will have a 1:35 provider-to-patient ratio; the homeless will have a 1:30 ratio Administered by the Medi-Cal managed care plans and provided by a network of Community Based Care Management Entities (CB- CMEs) 17

18 Housing Bundle Services and Interventions: PMPM Bundle Example Enhanced housing transition service bundle which is provided by housing navigators who provide intensive care management, address housing barriers, housing search and application assistance and move-in support Housing and tenancy sustaining services bundle which provides residency retention services for patients in permanent supportive housing Skilled Nursing Facility Housing Transitions program provides SNF residents with intensive housing navigation services that complement the housing bundles 18

19 FFS Items Services and Interventions: FFS Items Examples Sobering Center Housing education and legal assistance program to help low-income and high utilizing populations to maintain housing Substance Use Disorder (SUD) Diversion Behavioral health consultations with PCPs that are not included as Medi-Cal benefits Street outreach to link all unsheltered chronically homeless individuals to care Community Living Facilities Quality Improvement to improve the quality of low income housing facilities Client Move-In Fund for Housing Navigators to assist patients with move-in expenses 19

20 Data Sharing Approach Example Streamlined data sharing across multiple systems Continuity of Care document to allow physicians to send electronic medical information to other providers Data Sharing Workgroup Agreed-upon data elements using the Common Meaningful Use Data Set as a base format Dedicated server and data repository supported by reporting tools Care management applications will be used by care managers and other end users 20

21 Access Assessment 21

22 Access Assessment Objectives Evaluate primary, core specialty, and facility access to care for Medi-Cal managed care beneficiaries based upon requirements set forth in the Knox Keene Act and MCP contracts with DHCS Consider State Fair Hearing, Independent Medical Review (IMR) decisions, and grievances and appeals/complaints data Advisory Committee The Advisory Committee will provide recommendations into the Assessment design and the structure of the Access Assessment Report. The Advisory Committee is comprised of MCPs, plan and provider associations, advocates, and beneficiaries. 2 The first Advisory Committee meeting will be held in November

23 Access Assessment Process Post the Governor signing SB 815, DHCS has 90 days to amend its External Quality Review Organization (EQRO) contract to direct the EQRO to conduct the assessment. o Following amendment of the contract, DHCS has 6 months to submit the Access Assessment design to CMS for approval. The EQRO has 10 months post CMS approval to conduct the assessment and produce an initial draft report. o DHCS will post the draft report for a 30-day public comment period after it has incorporated feedback from the Advisory Committee. The EQRO will complete a final report that includes a comparison of health plan network adequacy compliance across different lines of business, as well as recommendations in response to any systemic network adequacy issues identified. o DHCS will submit the final Access Assessment Report to CMS. 23

24 FQHC Alternative Payment Methodology (APM) Pilot 24

25 APM Pilot Authority SB 147 (Chapter 760, Statutes of 2015) established a 3-year pilot program Description Payment to FQHCs would transition wholly from the State to Medi-Cal managed care plans Moves away from a per-visit payment Instead, clinics will receive a monthly capitation payment The per member per month (PMPM) capitation payment would be equivalent to what the Prospective Payment System (PPS) reimbursement would have otherwise been 25

26 APM Pilot Timeline Summer 2016 Fall 2016 Winter 2016 Spring 2017 Summer 2017 October 2017 Finalize pilot concept paper; submit to CMS for review Finalize SPA; submit to CMS for approval Notify all clinics of pilot; start the application process Plans/clinics reconcile data; Mercer develops wrap cap Release draft rate to plans/clinics Begin readiness activities with plans/clinics Notify plans/clinics of final rates; submit rates to CMS Pilot begins 26

27 Coordinated Care Initiative (CCI) 27

28 CMC Enrollment Data As of October 1,

29 Enrollment Updates Passive enrollment complete in all CCI counties Orange County complete in July 2016 Santa Clara County complete in December 2015 Beneficiaries newly eligible for Medi-Cal still select an MLTSS plan Dual eligible beneficiaries who are currently in Fee For Service will be enrolled into an MLTSS plan with option enrollment into Cal MediConnect during January and February

30 Comprehensive Strategy Streamlined enrollment Updated Cal MediConnect and MLTSS Resource Guide and Choice Book New Beneficiary Toolkit Updated Provider Toolkit Standardization of referrals to LTSS services Improved Continuity of Care policy Sharing of best practices among Cal MediConnect health plans 30

31 CCI Evaluations Rapid Cycle Polling Project University of California Evaluation 31

32 Data Analysis Doing our own data analysis and working with many partners to better understand who is opting out and why as well as how the program is working for enrollees o DHCS analysis of opt out enrollees o Stratify data by language, ethnicity, and geographic region to identify where there are potential target areas o SCAN funded efforts and evaluation o Rapid Cycle Polling Project Showed that most beneficiaries were generally satisfied with their health services and that those who encountered issues were similar to those of opt-outs and beneficiaries in non-participating counties: aves1-3rapidcyclepolling_final.pdf o Cal MediConnect Evaluation Reported that most CMC beneficiaries are satisfied with their care coordinators but don t value Health Risk Assessments (HRAs): alcmckeyfindings_final.pdf 32

33 Whole Person Care Resources Access Assessment FQHC APM CCI 33

34 Questions/Open Discussion