Select Topics in Implementing an Integrated Medicaid Managed Long-Term Care Program

Transcription

1 Select Topics in Implementing an Integrated Medicaid Managed Long-Term Care Program

2 TennCare Overview Tennessee s Medicaid Agency Tennessee s Medicaid Program Managed care demonstration implemented in 1994 Operates under the authority of an 1115 waiver Uses managed care to cover persons otherwise not eligible for Medicaid Entire Medicaid population (1.2 million) is in managed care Medical, behavioral and now long-term care services are administered by two (2) At-Risk Managed Care Organizations (MCOs) located in each region of the state (mandatory enrollment in managed care) TennCare Select manages care statewide for certain special populations (e.g., children receiving SSI, children in State custody, persons enrolled in MR waiver programs) via an ASO (i.e., modified risk) arrangement Prescription drugs administered by a statewide Pharmacy Benefits Manager Dental Services for children under 21 administered by a statewide Dental Benefits Manager

3 Key Design Elements Began as a legislative initiative: Long-Term Care Community Choices Act of 2008 Integrates TennCare nursing facility (NF) services and HCBS for the elderly and adults with physical disabilities into the existing managed care delivery system (roughly $1 billion); MR services remain carved out Amended 1115 demonstration waiver authority 1-year approval process; existing 1915(c) waiver folded into 1115, including same benefit package (with minor modifications) and individual cost neutrality cap based on cost of NF care Enrollment target for HCBS supports controlled growth while developing sufficient community infrastructure to provide care (persons transitioning from a NF and certain persons at risk of NF placement are exempt) Cost and utilization managed via individual benefit limits and individual cost neutrality cap Specific requirements regarding NF diversion and NF-to-community transition Consumer directed options for core HCBS using a prior authorization model Electronic Visit Verification system assures quality of care and program integrity State leadership, collaboration, and strong contract requirements are key; CRA available at:

4 Contracting Considerations Amended contracts with existing MCOs selected via competitive bid process Existing TennCare recipients remained with their currently selected MCO which became responsible for LTC services upon CHOICES implementation TennCare members do not change MCOs when LTC services are needed Blended capitation payment for all physical, behavioral and LTC services (NF and HCBS) with separate rate cells for duals/non-duals aligns incentives to rebalance MCOs at full risk for all services, including NF (not time-limited) Risk-adjustment for non-ltc component of the rate based on health plan risk assessment scores John Hopkins ACG Case-Mix System using MCO encounter data at start date of operations and annually thereafter (or upon significant circumstances) with adjustment for a +/- change greater than 3%, 2%, or 1% during each of the first 3 years, respectively Risk-adjustment for LTC component of the rate based on mix by setting at implementation and open enrollment periods with adjustment for a +/- change greater than 1/2 of 1%

5 Contracting Considerations for Members Freedom of choice of NF/HCBS Continuity of care provisions to ensure as seamless a transition as possible Receive same services specified in NF/HCBS Plan of Care for at least 30 days Utilize existing NF/HCBS Waiver providers (in or out-of-network) Continue pending comprehensive assessment and development/implementation of new comprehensive person-centered plan of care Care coordination processes, timeframes, tools, and staffing Comprehensive Care Coordination provided by MCOs Each member has an assigned Care Coordinator nurses/social workers Comprehensive ongoing needs assessment /person-centered care planning Coordination of physical, behavioral, functional and social support needs Management of chronic conditions and care transitions On the ground and face-to-face with minimum contact requirements

6 Contracting Considerations for Members Care coordination Prescriptive processes (in contract requirements and protocols) Member referrals, new members, NF-to-community transitions Standardized forms and informational materials Specific time frames, e.g., 6 days to process referrals (screening, intake, needs assessment, POC) 10 days to process new members (intake, needs assessment, POC, initiate svcs) 14 days ea. to conduct transition screening, assessment, develop transition plan Greater flexibility in tools and staffing May use proprietary instruments; must include minimum State-specified elements No minimum staffing ratios Prescriptive processes and timelines with minimum contacts, depending on setting

7 Contracting Considerations for Members Consumer Direction State contracts with a single statewide fiscal employer agent to perform fiscal intermediary and supports brokerage functions for all CHOICES members Consumer direction provides members (or qualified representative) with employer authority MCO authorizes a fixed amount of services based on need Members assessed to need a service available through consumer direction must be given opportunity to receive services thru consumer direction or traditional provider agency Member/rep, using fiscal/employer agent, is the employer of record and must be able to perform CD responsibilities Member/rep sets the reimbursement rates for the worker from list of available rates set by the State and signs a Service Agreement with each qualified worker Members may also self-direct certain health care tasks as part of consumer directed services

8 Contracting Considerations for Members Electronic Visit Verification System State pass-through for individual MCO contracts with EVV vendor Services scheduled and authorized in accordance with member needs Providers for most HCBS (including Consumer Directed workers) log in and out at each visit Tracks the provision of services, including start time, duration, worker, and basic functions performed Immediate notification to provider, MCO Care Coordinator and for Consumer Direction, Supports Broker, if worker does not arrive as scheduled Ability to resolve service gaps immediately Completed visits used to generate a file that can be used for claims submission Increased financial accountability and program integrity

9 Contracting Considerations for Providers State sets rates of reimbursement (LTC services only) Non-par reimbursement set at 80% of the lowest rate paid by the MCO to participating network providers for the same service Stringent prompt pay requirements 90% of clean electronic claims within 14 day 99.5% of clean electronic claims within 21 days Enhanced training and technical assistance for LTC providers Nursing Facility-specific MCOs required to contract with all current Medicaid certified Nursing Facilities for first three years State continues to make level of care determinations MCOs must authorize LTC services based on State s LOC determination (level of reimbursement and duration)

10 Readiness Review Desk review of key deliverables Policies, procedures, processes and plans Onsite review of critical processes and operating functions Comprehensive test case scenarios re: needs assessment and care planning Videotaped intake/assessment Outputs, including required documentation and forms, signed plan of care, and service authorizations State participation in training activities for care coordinators, providers, EVV training for staff, providers and FEA, and FEA training Care coordinator ride-alongs Demonstration of critical MCO systems including LTC service authorizations to contract providers and the FEA, member referrals to the FEA, EVV system functionality and claims processing systems using actual test cases Validation of provider networks

11 Readiness Review Milestone deliverables for service authorizations 50% of service authorizations loaded 6 weeks prior to go-live 75% of service authorizations loaded 4 weeks prior to go-live 90% of service authorizations loaded 2 weeks prior to go-live 100% of service authorizations loaded prior to go-live Milestone deliverables for provider network files 50% of current NFs and 50% of current HCBS providers (or equivalent) contracted, credentialed and loaded and 50% of access standards met 7 weeks prior to go-live 75% of current NFs and 50% of current HCBS providers (or equivalent) contracted, credentialed and loaded and 75% of access standards met 4 weeks prior to go-live 90% of current NFs and 50% of current HCBS providers (or equivalent) contracted, credentialed and loaded and 90% of access standards met 2 weeks prior to go-live

12 Monitoring Compliance Reporting (Section 2.30) on a daily, weekly, monthly, quarterly, semi-annual, annual, on request and ad hoc basis Eligibility, enrollment and disenrollment Specialized services Disease management Service coordination Provider networks/ agreements/payment Utilization management QM/QI Customer service/provider service Member complaints Fraud and abuse Financial management Claims management Information systems Administrative requirements Subcontract HIPAA Non-discrimination Terms and conditions

13 Monitoring Compliance Site inspections Inspections of work performed/audits Independent review - EQRO

14 Assuring Compliance Corrective Action Plans Liquidated Damages Level A pose a significant threat to patient care or the continued viability of the TennCare program Level B pose a threat to the integrity of the TennCare program, but do not imperil patient care Level C pose threats to the smooth and efficient operation of the program, but do not imperil patient care or the integrity of the program

15 Assuring Compliance Capitation payment withhold Monthly withhold distributed in the next monthly payment, unless retained for non-compliance 10% for first 6 months of operation and any 6 months following notice of deficiency 5% for 2 nd 6 months of operation (if no notices of deficiency) 2.5% thereafter (if no notices of deficiency) Months withheld for non-compliance are not payable pending correction of identified deficiencies Payments retained for 6 consecutive months without correction of identified deficiencies are no longer payable to the MCO and MCO may be declared ineligible for future distribution of 10% withhold Contract termination