Welcome and Purpose: Steve Fitton
 Planning Process Update/Timeline: Kathy Stiffler
 Policy Bulletin Overview: Kathy Stiffler
 Core Competency Process: Kathy Stiffler
 Rates and SNAF: Brian Keisling
 Outreach/Communications: Lonnie Barnett
 Enrollment Process: Julie Denny
 Primary Care Provider Selection Process and Family
Centered Medical Home: Dr. Jane Turner
 Care Coordination: Kathy Stiffler and Lonnie Barnett
 Prior Authorization Transition Procedures: Dr. Nina
Mattarella
 Contract Administration: Kim Hamilton
 Performance Monitoring: Sheila Embry
 Discussion: all

2


Update children’s hospitals and pediatric
regional centers on the State’s plans to
transition CSHCS population with Medicaid into
Medicaid Health Plans (MHPs)
Provide an opportunity for Department to
obtain input from hospitals and regional centers
on transition plans
3
Approximately 21,000 children (and some
adults) enrolled in CSHCS with full MA.
Approximately 3,500 of this group will be
voluntary for or excluded from managed
care enrollment
 DCH estimates approximately 10 – 15
thousand CSHCS eligibles (CSHCS “look
alikes”) are currently enrolled in the MHPs –
not enrolled in CSHCS
 Data indicates that look-alike population has
a lower acuity and expenses than CSHCS
enrolled population as a whole
 MHPs do serve high acuity individuals –
ABAD, CSHCS aged-outs, etc.

4
Budget for FY12 passed in May 2011
 Sec. 1204. By October, 2011, the department
shall report to the senate and house
appropriations committees on community
health and the senate and house fiscal
agencies on its plan for enrolling Medicaid
eligible children’s special health care services
recipients in the Medicaid health plans. The
report shall include information on which
Medicaid health plans are participating, the
methods used to assure continuity of care
and continuity of ongoing relationships with
providers and projected savings from the
implementation of the proposal

5
In FY12, administration concurred that the
planning process for transitioning this
population required a more extensive
planning and implementation process than
the transition of other populations
 Therefore, implementation of the transition
will take place in FY 13

6

The internal work group has identified
several benefits to enrolling CSHCS
beneficiaries into MHPs:
 Organized approach to primary care
 Addition of complex case
management
 Ability for quality monitoring
 Access to outpatient mental health
services
 Increased access to non-emergency
transportation services
7
Following similar structure used to
transition of other populations
 Department convened internal work
group comprised of 25 state staff from
CSHCS and MSA
 Meetings monthly as a group with
additional meetings for subgroups on
topics such as data, systems
 Department utilizing regularly scheduled
monthly operations workgroup meetings
with Medicaid Health Plans to discuss the
infrastructure within the MHPs to
successfully transition population
 Key staff from CSHCS, MSA and
Enrollment Broker regularly attend

8

During internal and operations
workgroups, staff and other experts are
providing educational sessions on
multiple topics relevant/unique to the
transition of CSHCS population into
managed care
 Contract requirements
 Care coordination
 Quality strategy
 CMS clinics
 CSHCS benefit package
 Family-centered medical home
 Prior/Authorization for DME,
therapies, etc.
9

Department also making contact with
key stakeholders such as hospitals, local
health departments and CSHCS Advisory
Committee to obtain input/feedback
10
11







Last two provider L-letters being finalized
 All providers, including out of state
providers
 Transplant providers
Member services training by CSHCS for
MHP under development
Coordination meetings with LHDs and CMS
Clinics
Final system changes are in testing phase
System changes will go into CHAMPS on
9/28/2012
Outreach to CSHCS families and providers
continues
Monitoring of the CSHCS family phone line
and Beneficiary HelpLine will begin in
October
12
August 1: CSHCS stopped mailing
applications to Medicaid beneficiaries also
eligible for CSHCS; CSHCS eligible =
enrolled in CSHCS for these beneficiaries
 October 1: MHP enrollees with new CSHCS
diagnoses since 8/1 will begin in the
CSHCS-MC benefit plan and the MHPs will
be required to meet the special contract
requirements
 October 1: Enrollment of UP CSHCS
enrollees
 November 1: Current CSHCS/FFS enrollees
in lower MI begin enrollment over 5 week
period – begin with Kent County and end
with Wayne County
 April 1: Conversion of MHP Enrollees
meeting CSHCS eligibility criteria to CSHCSMC
13






Policy Bulletin issues 9/1/2012; effective 10/1/2012
Requires individuals who have both CSHCS
eligibility and MA eligibility (CSHCS/MA
beneficiaries) to enroll in health plan unless
excluded for some other reason such as PPO
insurance or incarceration
MI Enrolls will conduct the choice counseling and
process the enrollment into the MHPs
Individuals have 90 days after enrollment to
transfer to another MHP
All providers MUST verify eligibility and enrollment
status prior to providing services; CSHCS/MA
beneficiaries will have CSHCS-MC listed as the
benefit plan another with the name of the MHP
in which the beneficiary is enrolled
14
MHPs must cover all Medicaid covered services
specified in contract
 MHPs may have different PA requirements,
formularies and documentation requirements
 All services currently carved out of MHP contract
remain carved out; plus the following will be
carved out effective 10/1:

 In-state approved intensive feeding clinic
 Drugs used to treat coagulopathies such as
hemophilia
 Orphan drugs used to treat rate metabolic
disorders
15

Following services continue to be covered by
CSHCS and are not the responsibility of the MHP:
 LHD care coordination and case management
 Children's Multidisciplinary Specialty Clinic facility
payment
 Orthodontia (for specific qualifying diagnoses)
 Respite
 Private insurance premium payment
16

Effective 10/1/2012 individuals authorized by FFS
to receive PDN services are excluded from
managed care enrollment
17








Access Standards
Network Adequacy
Referral Processing
Performance Monitoring
Grievance/Appeals
Prior Authorization
Family Involvement
Overall MHP Performance
18
Core Competencies issued to plans: May 7
 Decision by DCH that all plans that met core
competencies would be required to
participate: June 1
 Core Competency submissions to MSU
Institute for Health Care Studies due: July 2
 Plans must be compliant with Core
Competency requirements by: 8/31/12
 Final documentation of compliance by 12
plans issued to DCH by MSU IHCS: 7/18/12

19








CSHCS-specific care managers
Planning workgroups including community
providers/hospitals
PCP attestations built into provider contracts
Special data analysis procedures
No PA requirements for pediatric subspecialists
Weekly reporting on CSHCS-specific issues/training
needs
Policies that specify coordination of DME with
referring specialists and family
CSHCS-specific DME complaints and grievances
procedure
20





Quarterly focus groups with CSHCS
members/families, member surveys, case
management surveys, action plans to address
internal and external concerns
CSHCS/Family Ombudsman
CSHCS Member Advisory Council
Integration of behavioral health services
Special care management procedures that
include family involvement
21






Encounter and FFS claims experience from FY10 and
FY11 associated with the CSHCS population was
analyzed by consulting actuarial firm Milliman
Data were both completed and trended 30 months
from the claims/data year to mid-rate year of FY13
CSHCS population rates were developed using its
own rate structure (base rate, regional factors, etc.)
Rate structure and actuarial models for CSHCS are
consistent with existing MCO rates
CSHCS population split between Disabled and TANF
populations with further divisions in the TANF group
by age
Children less than 1 (both Disabled and TANF) also
have a unique rate cell based on their historically
high costs
22





•
•
Specific carve-outs were identified for exclusion from the
rates (dental services and certain pharmaceuticals)
Beneficiaries receiving private duty nursing were
excluded entirely from the rate analysis since they will not
be enrolled in the health plans
Adjustments made to include non-emergency
transportation, HMO administration, amounts equivalent
to FFS supplemental payments (GME, HRA, SNAF) and
claims tax
Stop/loss or risk sharing arrangements were investigated,
but the decision was made to pursue a full risk
arrangement for this population
Rates were presented to MHPs and discussed at length
Final capitation rates assumed managed care savings
fairly evenly distributed across provider categories
Rates were submitted to CMS in July for approval
23
•
While all MHPs have different approaches
for improving cost-effectiveness, some or all
of the following elements come into play
(this is a general discussion that is not
CSHCS-specific):
– Each member is assigned a primary care
physician who is responsible for
coordinating the member's care
– Improved access to primary and
specialist physician care reduces ER,
outpatient, and inpatient hospital costs
24
– Coordinated care management:
• Avoids duplicative lab, x-ray, and other
diagnostic work
• Avoids duplicative and conflicting
pharmaceuticals
• Promotes better communication between
primary care and specialist physicians
– Emphasis on preventive care and
compliance with regimens improves health
outcomes and lowers costs
– Emphasis on prenatal care results in fewer
intensive care babies and therefore lowers
costs
25
– Intensive case management of Disability
clients in particular improves health
outcomes and lowers costs
– Better access to mental health care
reduces need for more intensive care
from the mental health system down the
road
26

Medicaid Health Plans (MHPs) have
agreements with 6 Public Entities
 University of Michigan
 Wayne State University
 Michigan State University
 Hurley Hospital
 Oakland University
 Western Michigan University

Amount is built into MHP capitation by
MDCH to reflect historical usage of
physicians affiliated with these Public
Entities
27



If MHPs cannot provide the specialty
services within their networks, this
arrangement comes into play
MHPs pay the Public Entities from the SNAF
capitation component in proportion to
the Public Entities' percentage of SNAF
services provided
The SNAF component is designed to
reimburse Public Entity physicians up to
roughly commercial rate levels and, in
effect, supplements the amounts paid by
the MHPs to the Public Entity physicians
when the provider claim was paid
28
CSHCS Advisory Committee
 Correspondence to Families

 Initial letter
 Second letter
 Enrollment letter
 Welcome letter (new CSHCS enrollees)
Family FAQs
 Family Focus Groups

29
www.michigan.gov/
cshcs
 Family
correspondence,
FAQs, and other
materials
 Focus Group Report

30



Local Health Departments
 Regional Meetings
 Monthly Calls
 FAQs
 Visits to Large Health Departments
Family Phone calls
 Family phone line
 Local Health Departments
Provider L-Letters
31
Customized Letters for CSHCS Families:
 Michigan ENROLLS sends letter that has been
customized for the CSHCS families and
include a CSHCS dedicated phone line
 Dedicated Phone Line:
 Dedicated toll free phone number connects
directly to Michigan ENROLLS staff specially
trained to assist this complex population
 Specially Trained, Experienced Call Center
Counselors:
 Experienced counselors with special scripts
and desk reference materials and authorized
provider information shared from DCH
32



Initial Extended Enrollment Timeline:
 Timeline for enrollment extended from 30
to 60 days is for the initial push of CSHCS
beneficiaries into MHPs and allow for:
 CSHCS Customized Reminder Letter
 Phone Call to Families
Assignment Process: Perceptive to the family’s
needs, based on available information
 Are other family members on the case in a MHP?
 With what MHPs do the authorized providers
participate?
 In the event of a tie the MHPs have equal weight
and the assignment to the MHPs will be evenly
distributed, taking into consideration MHP
capacities
33

Capacities
 Capacity: Number of beneficiaries a
Medicaid Health Plan (MHP) can
adequately serve in a county.
 CSHCS capacity request is submitted by the
MHP and reviewed by MDCH
 Capacities are monitored constantly to
ensure adequate coverage in all service
areas
34

CSHCS-MC enrollee with a provider who
is added as an authorized provider:
 “This NPI is Listed….” message displayed.
 Access allowed to CSHCS Restrictions
page:
 Indicates auth diagnosis codes and
providers for DOS.
35
Eligibility Response Ex: Member Benefit Level page
36
Eligibility Response Ex: CSHCS Restrictions page to access authorized diagnosis
codes and providers for DOS.
37
37

CSHCS-MC enrollee but the provider is
not listed as an authorized provider:
 Beneficiary enrolled in MHP but the provider is
not listed as CSHCS authorized provider:
 No access to CSHCS Restrictions page.
 “This NPI is Not Listed….” message
38
Eligibility Response Ex: Member Benefit Level page
39
39
PCP approval process – MHP list of approved PCP
based on “attestation”
 Official PCMH certification (i.e. NCQA, PGIP)
NOT required
 Family may choose PCP not on the list – family
preference trumps all.
 Practice based care coordination
 Point person for care coordination
 Components of practice based care
coordination – checklist from workbook
 Communication/coordination with MHP case
manager, LHD coordinator, CMS clinic,
subspecialists, mental health provider, schools.

42

Enhanced payment per member per month to
compensate for extra effort for care
coordination.
 Only approved PCP will receive enhanced
payment
 $4 / $8 per member per month
43
Workgroup established including representatives
from CSHCS, MSA, LHDs, and MHPs
 Workgroup charge: to develop a model whereby
the care coordination activities delivered by the
various providers be coordinated to assure that
the family is receiving the necessary services and
supports to achieve the best outcome for the
beneficiary while avoiding duplication
 For care coordination/case management that
results in a care plan, the goal is a single clear,
comprehensive plan of care in which the families
have input and can easily understand/follow
 Seeking electronic solutions for secure portal
through which involved providers can
access/update care plan
44

Current focus is on coordination of LHD/MHP
coordination activities, but will soon include CMS
Clinics. Coordination with FCMH practices is
longer term
 Product: CSHCS Coordination Agreement
template for use between MHPs and respective
LHDs
 Base template can be modified to address the
unique strengths and needs of each MHP and
LHD as well as the communities they serve

45

For members not meeting complex case
management criteria, plans typically provide:
 Assessment, individualized care plan
development, prioritized goals and barrier
busting
 Assistance obtaining needed authorizations for
DME, therapies, or other ancillary services and
arranging for timely delivery of these services
 Facilitation of transitions between levels of care
or intensity of services
 Patient/family education, including role of family
in the treatment plan/maintenance of
member’s health status
46

For members not meeting complex case
management criteria, plans typically provide:
 Appointment scheduling assistance
 Transportation assistance
 Referral to community and other resources–
collaboration with LHDs
47

For members meeting complex case management
criteria (e.g. complex medical needs/multiple
comorbid conditions, high utilization of ED or
inpatient, need for assistance in system
navigation), plans are required by their accrediting
bodies, to provide:
 Assessment and care planning within 30 days of
identification of the member meeting complex
case management criteria
 Plan’s procedures must address all of the
following:
 Member’s right to decline complex case
management
 Comprehensive assessment, including ADL,
mental health, cognitive functions, life-planning
activities, cultural and linguistic needs, caregiver
resources, available benefits
48

Plan’s procedures must address all of the following
(Continued)
• Development of an individualized plan of care
including longer and short term goals,
resources, planning for continuity of care and
transitions, family participation
• Identification of barriers to meeting goals or
complying the with plan
• Schedule for follow-up communication with
member
49

Plan’s procedures must address all of the following
(Continued)
• Development of member self-management
plans
• Process to assess progress against case
management plans for members
• In some communities, LHDs will assist with
pieces of complex case management,
assessment and care plan development
50
Level 1 Care Coordination is the development of a
plan of care (POC) through the identification,
documentation and organization of information
regarding the health, social, familial and
environmental circumstances and needs of
the CSHCS client/family in coordination with the
MHP
 The POC is organized with and for the family and is
a resource document for families, provides and
care coordinators

51

The LHD/POC must include:
 Client summary/assessment
 Dated list of problems/concerns
 Corresponding problem-specific goal(s) unique
to each client/family, with family input
 Identification of appropriate intervention(s) and
designation of person who will provide each
intervention
52
Level 2 Standard Care Coordination consists of
interaction with the CSHCS client/family and other
involved with the care by the client by telephone,
in person or in writing.
 Level 2 Care Coordination includes but is not
limited to:
 Client advocacy
 Assisting with needed social, education or other
support services at the community level
 Processing Children with Special Needs (CSN)
Fund applications

53
LHD Case Management is designed for CSHCS
clients with complex medical care needs and/or
complex psychosocial circumstances
 LHD Case Management must be delivered in the
home or other non-institutional setting of the
family's choice and be provided face-to face in
coordination with the MHP
 The Case Management POC must be developed
by a public health nurse in collaboration with the
client/family, in coordination with the MHP

54
 DCH has developed a process to share active
PA information in the system with the MHPs for
the plan’s enrollees
 Providers must still submit a copy of the PA with
the claim for services

Three key areas:
 Transplants
 Therapies
 DME
55
Beneficiaries with a PA for a transplant will remain
excluded from MHP enrollment until 30 days prior to
the end of the PA
 MHP will work with the transplant provider to
establish a new PA
 FFS PA will remain in effect for the first 30 days in
which the beneficiary is enrolled with the MHP
 If the beneficiary is actively receiving a transplant or
immediate post-transplant care at the time of the
expiration of the PA, it may be possible to extend the
PA and continue the beneficiary’s exclusion from the
MHP. This will be decided on a case-by-case basis
by a MDCH medical consultant using medical
reports provided by the physician and hospital
involved.

56
The MHP must accept prior authorizations
(PA) in place for therapies when the CSHCS
enrollee is enrolled into the plan
 If the PA is with a non-network ancillary
provider, the provider will be reimbursed at
the FFS Medicaid rate
 After 30 days the MHP may use its own PA
procedures and network ancillary services

57
When custom-fabricated equipment
(prosthetic or orthotic) is ordered for a
beneficiary during a hospital stay but not
delivered until discharge and enrollment
changes, the payment must be made by the
party responsible for the hospital stay
 When a custom-fabricated, -fit, or -modified
service is prior authorized and ordered by the
provider before a change of enrollment, the
party that authorized the service is responsible
for payment. DME must be delivered within 30
days

58
For non-custom DMEs and medical supplies,
the MHP must accept FFS prior
authorizations (PA) in place when the
CSHCS enrollee is enrolled into the plan
 If the PA is with a non-network ancillary
provider, the provider will be reimbursed at
the FFS Medicaid rate
 After 30 days the MHP may use its own PA
procedures and network DME and medical
supplier services

59

There are various contract administration and
performance monitoring mechanisms in place that
the CSHCS population will be included in:





Monthly performance monitoring
HEDIS
CAHPS
Annual compliance reviews
MDCH conducts assessment of health plans
compliance with contract requirements and is
planning a compliance review visit to each of the
MHP’s serving CSHCS enrollees beginning in early
June 2013
60
The 2013 compliance review focus study visit will
focus solely on the MHP’s management of the
CSHCS population and its ability to provide quality
and coordinated care
 Physicians from the MDCH Office of Medical Affairs
(OMA/CSHCS) will be attending these compliance
review visits for a clinician perspective

61

DCH added contract requirements on several
topics to ensure access to care and monitoring of
the Role of MHP in providing data for CSHCS
eligibility
 Maintaining continuity of care for primary and
specialty care
 Following thru on FFS prior authorization for
providers in and out of MHP network
 Special contracted network adequacy and
availability requirements, including use of out-ofnetwork providers for providing services to
CSHCS enrollees
 Maintaining Grievance and appeal process
specific to CSHCS enrollees/ Separate reporting
62
 Monitor and report performance against
defined measures for CSHCS enrollees (e.g.,
HEDIS, EPSDT, inpatient admissions for
ambulatory care sensitive conditions, and
emergency department use).
 Special requirements for selection of primary
care physician
 Requires special payment to Family Centered
Care and Medical Homes
 Required to establish a contract between MHP
and Local Public Health Departments
 Encourage to conduct special education and
outreach to CSHCS enrollees
 Must provide Transportation, Meals and Lodging
to all covered services
63





The CSHCS population will be included in the PMR and
HEDIS data sets as they meet the specifications for
inclusion
The state currently conducts a Child CAHPS every
other year:
 Child CAHPS for the MHP child population
 Children with Chronic Conditions (CCC) CAHPs for
the CSHCS population
Both CAHPS were conducted in 2012 and will be
conducted again in 2014
We will be able to compare the results of satisfaction in
the FFS CSHCS environment and managed care
DCH will develop CSHCS-specific measures over the
next fiscal year
64