State roles & responsibilities in Medicaid managed long-term care

State roles & responsibilities in Medicaid managed long-term care Andrea Maresca Director of Federal Policy and Strategy April 24, 2012 Agenda Core State Managed Care Design Considerations Plan Payment Policy Quality and Access Requirements Program Integrity, Data, & Reporting New CMS Requirements

Key Elements Often Drive Policy Vehicle(s) Voluntary versus mandatory enrollment Target populations and consumer priorities Outreach and enrollee education Roll-out Plan choice and auto-assignment Continuity of care Care coordination Access to providers Specialty Long Term Care Payment Monitoring Medicaid Payment Policy Rules are the Same for Plans Federal requirements that Medicaid payments be consistent with efficiency, economy, and quality apply Section 1902(a)(30(A)) 1981 legislation added the requirement that capitation payments to risk-based managed care plans be made on an actuarially sound basis 2002 guidance provided regarding actuarial soundness

2002: CMS Revised Plan Payment Requirements Capitation rates now must be developed in accordance with generally accepted actuarial principles and practices, appropriate for the population and services, and certified by qualified actuaries Four additional requirements Population appropriate base line Adjustments Rate specificity Additional requirements for high cost populations Renewed Focus on Actuarial Soundness Government Accountability Office 2010 Study Found CMS oversight of state compliance and data quality for rate setting could be improved CMS concurred and made an array of changes http://www.gao.gov/products/gao-10-810 New review pursued by Senator Grassley (R-IA) Letter to all State Medicaid Directors requesting information to help determine whether states and CMS are conducting sufficient oversight of Medicaid managed care plan rate setting http://www.grassley.senate.gov/about/upload/2012_02_23-ceg-to- Minnesota-Medicaid-MLR.pdf Next steps: TBD

No Specific Federal Requirements for Provider Network Participants All federal managed care requirements relate to ensuring access to and quality of Medicaid services Provider rates may be set by the state or negotiated by the plans with provider networks with state sign-off Lack of Standard Quality (Outcomes) Measures for LTSS Growing attention to the need and efforts to develop true outcomes measures States rely on process measure requirements to MCOs, including: Demonstrate members have had a LOC determination Provide client a choice between institutional and HCBS services Demonstrate client received visits/services at certain intervals Develop Performance Improvement Projects (PIPs) to establish and monitor progress towards client goals 8

Other Process Measures Proxy for Quality State Access Monitoring Monitoring enrollee feedback and provider and community input Reviewing available data (e.g. ER use) Additional contract reporting requirements Provider Supply Monitoring Assess whether providers listed in a managed care plan s network actually accept new patients Monitor compliance standards specified in managed care plan contracts including network adequacy, provider-to-patient ratios, and geo-access analysis Commonly Used Quality Monitoring Strategies External Quality Review Organizations (EQRO) State must provide for an external, independent review of their managed care plans Healthcare Effectiveness Data and Information Set (HEDIS) Consumer Assessment of Healthcare Provider Systems (CAHPS) Nursing Home Surveys Accreditation National Committee for Quality Assurance Unfolding role for National Commission for Quality Long-Term Care

Examples of MMLTC Quality Improvement Activities Consumer and provider satisfaction surveys Health Outcomes Survey (HOS) EQRO focus study on care coordination HEDIS performance measures Enrollee records reviews Contractor best practice collaborative Protocols and tools for care coordinators Utilization review Provider credentialing Reviews of clinical outcomes Program evaluation States May Include Various Requirements in Contracts with Plans Sufficient and appropriate provider network Assurances that appropriate services are available and readily obtained Care Coordination Assistance with accessing services Additional services for high need populations

Core Federal Accountability Requirements Availability of complete plan records for audit by the federal government and states Prohibition on plan discrimination based on enrollee health status Individuals right to disenroll within the first 90 days without cause and then at least every 12 months thereafter Plans must maintain patient encounter data and provide data to the state Medicaid Managed Care Data is More Limited than FFS Data All states collect some form of encounter data from plans States vary in what and how much of encounter data they report to the federal Medicaid information system States also report information on their managed care plans through the Medicaid Managed Care Data Collection System

New Challenges for Medicaid Program Integrity in Managed Care Programs States responsible for the development and oversight of Medicaid's managed care programs and policy including managing MCO States facing new challenges in their Program Integrity (PI) efforts with the growth in managed care, particularly MLTC States must determine when and how to meet new federal requirements for managed care programs For example: requirements for provider screening and enrollment States may take different approaches to meet this requirement CMS currently updating its Medicaid managed care manual 15 Other State Reporting Requirements Driven by Program Authority State Plan Options Section 1915(a) Section 1932 (a) Medicaid Waivers Section 1915(b) Permits states to mandate enrollment into managed care programs Some services may be carved out of managed care Must demonstrate budget neutrality but does not have to be a statewide program Section 1115 Flexibility given to states to test policies not permitted under Medicaid statute Must demonstrate budget neutrality and must be statewide Regular evaluations of the project Public notice and comment requirements for SPAs and waivers (as of April 2012)

ACA Included New Requirements New Plan Responsibilities Content requirements for the eligibility transaction Meet certain service and performance timeframes for eligibility and claim status transactions New State Responsibilities Must conduct a gap analysis to determine if operational changes are needed to comply with these operating rules and to be able to provide the newly required information States must analyze their current Medicaid information technology (IT) infrastructure to determine if hardware and/or software modifications are needed in order to meet these requirements and the operating rule compliance date of January 1, 2013 http://www.gpo.gov/fdsys/pkg/fr-2011-04-19/pdf/2011-9340.pdf What s Next for States CMCS building out principles/requirements/expectations for states CMCS to identify best practices and technical assistance resources for states as they move forward CMCS and states moving forward with proposals in the meantime 18

Plan Roles and Responsibilities in MMLTC Programs Amy Ingham Medicaid Policy Manager April 23, 2012 19 Medicaid Health Plans of America (MHPA) 108 Members 33 States + DC 20

Our Mission Develop and Advance Public Policy Controlling Costs + Improving Access/Delivery = Quality Health Care 21 36 States and DC Have Medicaid Health Plans WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR NY MI PA OH IN WV VA KY NC TN SC ME VT NH MA RI CT NJ DE MD DC TX LA MS AL GA AK FL HI Current Medicaid Health Plan Penetration

Medicaid Managed Care Options Medicaid Health Plans(full-risk capitation): state contracts with health plan to provide services to enrollees Primary Care Case Management: physician serves as gatekeeper for assigned patients, coordinating care Limited Benefit Plans: state pays plans to provide a fixed set of services Medicaid Health Plans Better Access to coordinated care Quality Assurance and Improvement Delivery System Innovation Predictable Costs Cost Savings Reduced Waste, Fraud and Abuse 24

Enrollment in Medicaid Data Sources: 2010 CMS Medicaid Managed Care Enrollment Report 25 State of Medicaid Managed Care All but two states have managed care programs - Alaska, Wyoming Thirty-six states and the District of Columbia have contracts with private Medicaid managed care plans 31 operate primary care case management programs. 26

States Addressing Special Populations Difficult, high-risk, high-needs, chronically ill populations are focus for states. Dual Eligibles- Integration Complex, High-Risk Patients Aged, Blind and Disabled Long Term Care States Move to Address Complex Health Needs In 2011, Medicaid programs in 15 states reported expanded efforts to coordinate care for individuals with high-cost/chronic/complex medical conditions. In 2012, 20 states began or expanded initiatives. Some of these initiatives were directly tied to new requirements for managed care, or enhanced coordination already occurring in MCOs. 28

States Focus on Aged, Blind and Disabled Together, the aged and/or disabled are 25% of the Medicaid population and account for over 65% of Medicaid spending. Benefits/Services for these populations are costly Many states see benefit in better coordinating care for these populations. Managed Care Plans are making efforts to provide better coordinated care for these populations for example, carving in pharmacy benefits in 2011 and 2012 (NY, OH, TX and IL). 29 Long Term Services and Supports 32 states in 2011 and 33 states in 2012 expanded long term services and support (LTSS). 14 states in 2011 and 11 states in 2012 restricted access to long term care. Many states are looking at integrating acute and long-term care within a managed care delivery system. 30

Long Term Services and Supports Medicaid paid for 62.2% of all LTSS rendered in 2010, which is almost 1/3 of total Medicaid spending. Most LTSS services are rendered on a fee-for-service basis. More states are moving toward managed Medicaid LTSS, which currently is established in 12 states AZ, FL, HI, ID, MA, MN, NM, NY, TN, TX, WA, and WI. Managed Medicaid LTSS relies on a reduction of the use of institutionalized care, such as nursing homes, which is the most expensive component of LTSS, and an increased use of home and community based services (HCBS). 31 Initiatives to Expand Care Coordination Among LTSS Beneficiaries States have historically been able to establish HCBS or LTSS in a managed care through Section 1915(b) waiver Section 1915(c) waiver State Plan Option 1915 (a) 1932 (a) Section 1115 waiver 32

ACA: New Initiatives to Expand Care Coordination Among LTSS Beneficiaries Section 10202: Balancing Incentive Program Section 2703: Health Homes for Individuals with Chronic Conditions Section 2403: Money Follows the Person Section 2701: Adult Health Quality Measures Section 2602: Innovation Center -Financial Alignement Initiative (Dual Eligibles) 33 States Choose Methods States have mainly operated MLTSS programs using a combination of 1915(b) enrollment authority with 1915(c) home and community-based service waiver authority. April 2011, CMS awarded $1 million to 15 states for designing systems to integrate Dual Eligibles. 37 states and DC submitted letters of intent for the Financial Alignment Initiative, announced in July 2011, and 26 of these states are pursuing the capitatedmodel (one of two options). Dual Eligiblesreceive great interest, but states need more direction on non-duals LTSS programs. 34

Plan Responsibility Plan responsibility is subject to particular requirements of the program, state and individual contract, with major responsibilities being to submit encounter data and quality indicators Main responsibilities: Develop/expand care management and coordination practices Ensure access to needed benefits and services Submit encounter data Meet External Quality Review (EQRO) requirements Meet performance measures (HEDIS) 35 Important Responsibilities of Medicaid Health Plans Meeting complex health challenges of the LTSS population Expanding provider networks and ensuring network adequacy Providing robust care management Assessing quality care provided and making improvements Monitoring rates as they impact services and care provided 36

Looking Ahead Medicaid health plans continue to engage with states and CMS on ways to better serve the LTSS population. Plans are taking initiative by reaching out to other plans, providers and state leaders in order to create their own partnerships and initiatives to coordinate for LTSS population and Duals. MHPA plans are well equipped to serve as a working model, providing superior care coordination for LTSS beneficiaries now and into the future. 37 Questions? www.mhpa.org 38

Minnesota Managed Care for Seniors Over 90% of Medicaid Seniors in MN are dually eligible for Medicare Most seniors served through managed care: Minnesota SeniorCare Plus (MSC+) Minnesota Senior Health Options (MSHO) a special needs plan (SNP) program that is a voluntary alternative to MSC+ Managed care for seniors in MN Seniors (65+) have been required to enroll in Medicaid managed care since 1983. The State s Medicaid seniors in all 87 counties are required to choose from health plan options available in their counties. Health plans provide additional member services, transportation, primary care/care system/medical homes, interpreter services, monitoring and facilitation of access to services above what is normally provided in fee for service. Department of Human Services contracts with 8 health plans to serve seniors statewide.

Option #1: MSHO The Minnesota Senior Health Options MSHO program integrates Medicare and Medicaid primary, acute, drugs, home care, and other long term care services as well as Elderly Waiver (EW) services and the first 180 days of care in a nursing facility. MSHO plans provide all Medicare services including Part D drugs. Enrollment is voluntary. Enrollees do not pay a premium to join. Nation s first dual demo in 1995 Operates under 1915 (a) and 1915 (c) Medicaid waivers Option #2 MSC+ The Minnesota Senior Care Plus (MSC+) programs, implemented in June 2005, provides eligible seniors, age 65 and older residing in participating counties, their acute care, home care, Elderly Waiver services and the first 180 days of care in a nursing facility for enrollees who enter a nursing facility after enrollment. MSC+ is similar to MSHO in the long term care services it covers but does not include Medicare services or Medicare Part D drugs.seniors enrolled in MSC+ must obtain their Medicare Part D drugs through a separate Medicare prescription drug plan. Enrollment in MSC+ is mandatory.

Kathleen Collins Pagels Arizona Health Care Association

AHCCCS- Arizona Health Care Cost Containment System Emphasis on Cost Containment approximately 71% of all AHCCCS/Medicaid members are HCBS (Includes AL) 29% reside in a skilled nursing facility

Rate increases are generally established by a contractual mandate from AHCCCS to the Medicaid plans. The increases we attained in the early years of this decade were significant and were required by the state as a "pass through from the Plans. This is a result of our focus on administrative advocacy with the state agency, rather than the legislature. These increases leveled off during the state s economic decline, culminating in being held flat for two years and then a Medicaid rate cut of 5% in 2011. Specialty rates are always negotiated, scopes of service vary widely. Managing levels of care (1,2,3 and specialty) can change the rate profile of a facility. Extensive documentation and advocacy is required. The level of care assessment tool is vastly out of date. Moving forward a provider assessment legislation currentlywhich poses unique challenges in a managed care state.

NF average statewide rates 2007 2008 2009 Rate Distribution Weighted Rate Distribution Weighted Rate Distribution Weighted Class 1 $130.97 36.58% $47.91 $141.25 35.92% $50.74 $147.96 37.85% $56.00 Class 2 $143.09 36.74% $52.57 $153.98 37.60% $57.89 $161.24 37.01% $59.68 Class 3 $183.43 26.68% $48.94 $216.97 26.48% $57.46 $231.63 25.15% $58.24 Total 100.00% $149.42 100.00% $166.09 100.00% $173.92 Change $12.59 $16.66 $7.83 % of Change 9.20% 11.15% 4.71% Note the high distribution in the Class 1, 2. The highest level of care payment (Class 3) is generally less than 25% of payment to SNF s in aggregate. These rates are based on the FFS rates (which the state pays directly to the Native American tribes only) and are considered the floor. Rates may be negotiated above this floor, if the facility has the leverage. Geographic imperative- being a key point of access to care Specialty service niche- behavioral, dialysis, ventilator, dementia, etc Quality- based on the audits of the Plans, state survey, 5 star etc Relationships

Rates low in national context Limited expertise with managed care and negotiation process (particularly large national corporations and multi s) Saturation on HCBS level Focus on the dually eligible (82%) and the impact of Medicare Advantage plans Viability of SNF Network (15% loss in beds) Program Contractor/MCO financial problems Claims and payment concerns; duplication Providers are reducing Medicaid beds; state is monitoring this closely Medicare-only facilities growing Managed care plans are concerned about single point of service entry in rural areas In 1990 there were 188 skilled nursing facilities and currently there are 150. Average age of a SNF in AZ is 50 years +

The complexity is overwhelming, little uniformity Moving all to electronic submission- problems detected earlier Definition of a clean claim- interest paid after 30 days Differences between appeals and disputes Plans systems conversion an ongoing nightmare Turnover on both sides presents problems Diplomacy required in settling claims and working with AHCCCS to address systemic problems (they audit the Plans) It is a significant and time consuming member service Administrative advocacy with Plans Legislative advocacy in regard to Medicaid budget and Plan capitation rates Member education in contracting issues Work with Plans collaboratively to enhance the network and advance mutual concerns (workforce, liability, and more) Assistance with claims issues, system concerns, Plan relationships

We have experience in the managed care model AZ providers have never known pure cost reimbursement and the rest of the country can learn from our mistakes and our successes Our competitive framework demands quality and promotes best practices There is room for innovation in managed care, with pilot programs and specialty programs and services think about the virtual RFP We are geared up for pay for performance model, and quality incentives The Associations play a powerful and critical role in support to providers- it will transform your member services Get to know the managed care companies in your state, they are likely your future partners Medicaid managed care is a preview of Medicare managed care and understand that the penetration of advantage plans will increase. Focus on learning about the impact of combining the dually eligible. Begin educating providers on managed care contracting and negotiation. Be cognizant of anti trust issues. Be part of the program design, ensure competition and build a truly market driven system. Your relationship with the state Medicaid agency will increase in importance when the program is implemented. Manage the dialogue, and set the tone. Your credibility is at stake. Make sure the discussion is not always about the financial impact of managed care. Always focus on the resident, and the adequacy of the service delivery network, and the rest will follow