ICRC Study Hall Call: State Monitoring and Oversight of Managed Long- Term Services and Supports Care Programs September 23, 2014 2:00-3:00 PM Eastern Phone: 1-800-273-7043; Access Code: 596413 The Integrated Care Resource Center, an initiative of the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination Office, provides technical assistance for states coordinated by Mathematica Policy Research and the Center for Health Care Strategies.
Participants Michelle Herman Soper Senior Program Officer Center for Health Care Strategies Jenna Libersky Researcher Mathematica Policy Research Rudy Villarreal Director Health Plan Management Texas Health and Human Services Commission 2
I. Welcome, Introductions, and Roll Call II. State Oversight of Medicaid Managed Long- Term Services and Supports (MLTSS) III. Texas Oversight of Medicaid MLTSS IV. Questions and Discussion V. Concluding Remarks 3
Jenna Libersky Mathematica Policy Research The Integrated Care Resource Center, an initiative of the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination Office, provides technical assistance for states coordinated by Mathematica Policy Research and the Center for Health Care Strategies.
About this presentation This presentation will inform states pursuing integrated care and managed long-term services and supports (MLTSS) programs about key oversight practices across states with MLTSS The information draws largely from a 2012 survey of eight states with MLTSS experience See: Lipson, D., J. Libersky, R. Machta, L. Flowers, and W. Fox-Grage. Keeping Watch: Building State Capacity to Oversee Medicaid Managed Long-Term Services and Supports. Report no. 2012-06. Washington, DC: AARP Public Policy Institute, July 2012. Available at http://www.aarp.org/ health/medicare-insurance/info-07-2012/keeping-watch-building-statecapacity-to-oversee-medicaid-managed-long-term-services-andsupports-aarp-ppi-health.html. 5
Many state oversight activities for MLTSS are similar to those used for other Medicaid managed care programs that only cover acute and primary services But because LTSS users have greater needs, MLTSS oversight needs to be more frequent and population-specific Monitoring must include additional provider types For example: nursing homes, personal care attendants, adult day health centers, social service providers Services should be monitored more often, ideally in real time For example: through electronic verification systems Travel and accessibility requirements must account for beneficiary needs For example: provider network time-to-travel standards should account for mobility impairments, and language requirements for member education materials should accommodate people with intellectual disabilities For Medicare-Medicaid beneficiaries ( dual eligible individuals ), oversight of Medicaid services should be coordinated with Medicare 6
7 States oversight practices vary, even among experienced states Variation is due to the length of time operating MLTSS, number and range of contractors/beneficiaries/services, staff knowledge and skills, coordination and communications practices, staff turnover, technology, etc. The following slides present norms and promising practices from eight states that have operated MLTSS programs for more than two years Oversight activities fall into five categories: 1. Organization and staffing 2. Contract monitoring and performance improvement 3. Provider network adequacy and access to services 4. Consumer rights 5. Quality assurance and improvement
8 Over time, many states integrate LTSS oversight functions into agencies or units dedicated to all Medicaid managed care programs Integration provides a comprehensive view of services and promotes efficient use of staff States also train or repurpose existing staff, or hire new staff with oversight skills Examples include contract negotiation, knowledge of managed care operations, consensus building, and data analytics
Contract monitoring and performance improvement On-site readiness reviews for new managed care contractors and regular on-site reviews for continuing contractors 1 Strong partnership with MCOs, characterized by frequent communication about contract issues Financial incentives to drive performance For example, savings for MCOs that exceed targets for use of HCBS as opposed to institutional care Provider network adequacy and access to services Medicaid agency or mystery shoppers to verify that provider offices are open and accepting new patients 1 For more information on readiness reviews activities in AZ, MN, TN, TX, and WI, see: Flowers, Lynda. Ready, Set, Go! The Readiness Review Process for Care Coordination and Provider Network Adequacy in Five States. Washington, DC: AARP Public Policy Institute, December 2013. Available at http://www.aarp.org/health/medicare-insurance/info-12-2013/the-readiness-review-process-aarp-ppiltc.html. 9
10 Consumer rights Ombudsman investigates MLTSS member problems Critical incidents are monitored daily Member grievances and appeals are regularly reviewed and discussed with MCO managers Quality assurance and improvement Electronic visit verification systems are used to monitor home care services in real time Dashboard of quality indicators presents a comprehensive picture of performance Encounter data are used to construct quality measures and to monitor performance Care management activities are reviewed, usually through a sample of records
11 Monitoring care coordination can help identify system-wide problems Gaps in provider networks, inaccessible sites of care, poor-quality services, need for specific benefit counseling, breach of consumer rights, etc. MLTSS programs that use 1915(c) waivers must follow the same procedures to monitor HCBS and care coordination as they would under fee-or-service (FFS) Oversight activities include: Specifying responsibilities and qualifications for care managers Reviewing a sample of individual care plans to ensure home visits and comprehensive assessments occur on schedule Reviewing training materials for care managers to ensure that the guidance conforms to state standards and policies Surveying a sample of clients by telephone to discuss their experience of care
Receipt of HCBS based on a comprehensive care assessment and care plan within 30 days of enrollment Share of members asked about their care preferences Number of home safety evaluations Screening and treatment for falls Case manager turnover rates Nursing facility diversion rates Plan all-cause readmissions Nursing home readmissions within 30 days of discharge Follow-up after hospitalization for mental illness Medication reconciliation after discharge from inpatient facility Percentage of members with a change in ADLs/IADLs Employment status Member satisfaction 12
Jenna Libersky JLibersky@mathematica-mpr.com 13
Texas Oversight of Medicaid Managed Long- Term Services and Supports (MLTSS) September 23, 2014 Rudy Villarreal
Medicaid Managed Care Initiatives Expand STAR+PLUS to Medicaid Rural Service Areas, 09/01/2014 IDD carve-in of acute services, 09/01/2014 Behavioral health and targeted case management, 09/01/2014 Nursing facilities carve-in 03/01/2015 15
El Paso El Paso Amerigroup, Molina Lubbock Amerigroup, Superior Hudspeth El Paso Culberson Jeff Davis Presidio El Paso Hudspeth Culberson Presidio STAR+PLUS Managed Care (effective March 1, 2012) Hartley Service Areas Jack Titus Yoakum Terry Lynn Garza Kent Stonewall Haskell Throckmorton Young Wise Denton Collin Hunt Hopkins Franklin Morris Cass Camp Palo Rockwall Rains Gaines Dawson Borden Scurry Fisher Jones Shackelford Stephens Parker Tarrant Dallas Wood Marion Pinto Upshur Dallam Sherman Hansford Ochiltree Lipscomb Kaufman Van Zandt Harrison Gregg Hartley Moore Hutchinson Roberts Hemphill Hood Johnson Andrews Martin Howard Mitchell Nolan Taylor Callahan Eastland Erath Ellis Smith Somervell Henderson Oldham Potter Carson Panola Gray Wheeler Rusk Navarro Comanche Hill Loving Winkler Ector Deaf Midland Smith Randall Glasscock Coke Bosque Armstrong Donley Collingsworth Sterling Runnels Coleman Brown Anderson Cherokee Shelby Hamilton Freestone Parmer Castro Swisher Briscoe Hall Childress Tarrant * Nacogdoches Ward McLennan Limestone Mills San Augustine Crane Hardeman Upton Reeves Reagan Tom Green Coryell Bailey Lamb Hale Floyd Motley Irion Cottle Wilbarger Concho Foard Wichita Falls Leon Houston Sabine Angelina McCulloch San Saba Lampasas Clay Trinity Montague Cochran Hockley Lubbock Crosby Dickens King Knox Baylor Archer Cooke Grayson Lamar Fannin Red Bell River Robertson Schleicher Menard Bowie Madison Jasper Delta Pecos Dallas * Jack Burnet Yoakum Terry Lynn Garza Kent Stonewall Haskell Throckmorton Young Wise Denton Collin Franklin Titus Milam Polk Newton Crockett Mason Llano Hunt Hopkins Walker Tyler Morris Williamson Cass Brazos Camp Palo Rockwall Rains Sutton Grimes San Jacinto Gaines Dawson Borden Scurry Fisher Jones Kimble Shackelford Stephens Parker Tarrant Dallas Wood Marion Burleson Pinto Upshur Lubbock Brewster Jeff Davis Cochran Reeves Deaf Smith Parmer Bailey Dallam Oldham Ward Brewster Castro Lamb Hockley Terrell Andrews Loving Winkler Ector Midland Pecos Crane Travis Amerigroup, United Travis Sherman Moore Potter Randall Swisher Hale Lubbock Martin Upton Terrell Bexar Hansford Hutchinson Carson Armstrong Briscoe Floyd Crosby Kaufman Gillespie Van Zandt Travis Harrison Hood Blanco Gregg Lee Montgomery Hardin Johnson Howard Mitchell Nolan Taylor Callahan Eastland Erath Ellis Smith Washington Somervell Henderson Panola Kerr Hays Bastrop Liberty Orange Rusk Navarro Edwards Comanche Hill Glasscock Coke Bosque Kendall Austin Waller Val Sterling Verde Jefferson Runnels Coleman Brown Anderson Cherokee Shelby Real Hamilton Bandera Comal Caldwell Freestone Fayette Harris Chambers Nacogdoches McLennan Limestone Mills Reagan Tom Green Coryell Irion Concho Guadalupe San Augustine Colorado Falls Leon Houston Sabine Angelina Fort Bend McCulloch San Saba Lampasas Bexar Gonzales Trinity Bell Kinney Uvalde Medina Robertson Lavaca Galveston Madison Jasper Schleicher Menard Burnet Milam Polk Crockett Mason Llano Walker Tyler Newton Wharton Williamson Brazos Wilson Brazoria Sutton Grimes San Jacinto De Witt Kimble Burleson Jefferson Gillespie Travis Lee Blanco Montgomery Hardin Zavala Frio Atascosa Karnes Jackson Washington Liberty Bastrop Orange Kerr Hays Victoria Matagorda Edwards Maverick Kendall Austin Waller Val Verde Jefferson Real Bandera Comal Caldwell Goliad Fayette Harris Chambers Kinney Maverick Uvalde Zavala Dimmit Bexar Amerigroup, Molina, Superior Hidalgo Ochiltree Roberts Gray Donley Hall Motley Dickens Lipscomb Hemphill Wheeler Collingsworth Childress Cottle King Webb Hidalgo Dimmit Bexar Medina Frio La Salle Zapata Hardeman Foard Knox Atascosa Jim Hogg Starr Duval Wilbarger Wilson Webb Bee McMullenLive Oak Jim Wells Brooks Guadalupe Gonzales La Salle Hidalgo Baylor Karnes San Patricio Nueces Kleberg Zapata Kenedy Goliad Willacy De Witt Cameron HealthSpring, Molina, Superior Wichita Archer Refugio Colorado Fort Bend Bee McMullen Lavaca Live Oak Wharton Brazoria Victoria Aransas Jim Hogg Starr Jackson Clay Matagorda Calhoun Jim Wells Duval Brooks Nueces Hidalgo STAR+PLUS Service Areas Montague Galveston Refugio San Patricio Nueces Kleberg Kenedy Willacy Cameron Cooke Tarrant Amerigroup, Bravo Aransas Grayson Calhoun Fannin Lamar Delta Harris HHSC, Health Plan Operations September 2010 Red River Nueces Superior, United Bowie Dallas Molina, Superior Jefferson Amerigroup, Molina, United Harris Amerigroup, Molina, United 16 HHSC, Health Plan Operations July 2011 16
HHSC Oversight Process HHSC readiness review process is designed to make sure contracted Managed Care Organizations (MCOs) are prepared to implement all contract provisions Monitoring process is designed to make sure the MCOs are compliant with contract and program goals Key areas include: Administrative functions like provider networks, claims processing and member marketing and communication Financial requirements Utilization review Quality monitoring Technical requirements and data analytics Vendor Drug Program 17
The Command Center At the start of a managed care project, HHSC will implement a Command Center The Command Center is the central point of contact on any particular managed care implementation Issues are emailed to a specific email address established for the managed care project The email box is carefully managed and all items triaged and routed to the appropriate staff who can respond to the question, issue or concern The box may also receive communication from prospective members requesting to remain in fee-for-service Medicaid Prospective member requests are routed to the HPM Resolution team The request will be captured in our proprietary tracking system Staff will contact the prospective member to provide education and to coordinate concerns over health issues with the MCOs 18
Administrative Functions Monitor call center performance Evaluate and trend complaints Identify and address service delivery performance issues Prioritize complaints impacting health and safety of members and resulting in adverse provider impact Monitor MCO complaints, appeals and claims processes Monitor access to care complaints and provider networks Review policies and procedures 19
Provider Complaints Initial point of contact is MCO or dental plan May submit written complaint to HHSC at hpm_complaints@hhsc.state.tx.us HHSC will intervene in issues when MCO is not complying with HHSC contract 20
Provider Networks Analyze MCO provider data Review provider turnover rates Network panel status reports Evaluate geo-access standards Monitor provider directories 21
Technical Assistance Goal: MCOs achieve positive outcomes and comply with required performance standards Technical assistance conference calls: Policy Operations Procedures and Systems (POPS) conference calls Ongoing communication with the MCOs Identify needs for policy clarification Resolve encounter data, member enrollment and premium payment issues Clarify contract requirements Coordinate and/or provide training 22
HHSC utilizes external auditors to assist with regular monitoring efforts Audit targets include: Annual compliance audits Periodic risk assessments Periodic performance audits External Audits 23
Questions & Discussion 24
About ICRC Established by CMS to advance integrated care models for Medicare-Medicaid enrollees and other Medicaid beneficiaries with high costs and high needs ICRC provides technical assistance (TA) to states, coordinated by Mathematica Policy Research and the Center for Health Care Strategies Visit http://www.integratedcareresourcecenter.com to submit a TA request and/or download resources, including briefs and practical tools to help address implementation, design, and policy challenges Send additional questions to: ICRC@chcs.org 25