Provider Forum - 2015
Today’s Agenda
2
• Montana Health CO-OP Intro/Update – Karen
• ACA update – Open Enrollment 2014-2015 Karen
• NCQA & Inovalon – Barbara
• High Performance Network (HPN) – Barbara
• Referrals (Air Ambulance) – Katrina/Chad
• Claims & Utilization Management (UM) - Barbara
• Formulary - Isaac
• Rosters - Isaac
• Q&A
Montana Health CO-OP/Intro and Update
CO-OPs: Intent and Purpose
4
• Formed as an alternative to the “Public Option”
• Provide more competition among payors
• Strong consumer focus: member governed
• Not-for-profit: use any profits to lower premiums,
improve benefits, or improve health care
• Not sponsored by insurer or government
Who is MHC?
5
• Montana’s member-operated health insurance
CO-OP
• Home-grown (Helena-based)
• Funded via federal start-up loans
• State regulated
CO-OPs: Intent and Purpose
6
Currently approved CO-OPs:
23 currently funded and under contract, 3 expanding = 26 states

Montana  Idaho

New Mexico

Arizona

Iowa/Nebraska

Nevada

Oregon (2)

Colorado

Utah

Tennessee

South Carolina

Illinois



Massachusetts  New
Hampshire
Maine
Kentucky  West
Virginia

Connecticut

Wisconsin

New York

New Jersey

Michigan

Ohio

Louisiana

Maryland
MHC Updates
7
•
Expanded into Idaho 2015 (OE2)
• Mountain Health CO-OP
• YourHealthIdaho.org (state-run
Marketplace)
• Member services centralized in MT
• Products very competitively priced
• Link Care and Access Care products
Current MHC Member Stats
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•
•
•
•
Approaching 45,000 members (27-30K in
MT)
Approximately 110 groups
• 2650 members enrolled in group plans
90% of MHC members enrolled via
Marketplace
MHC captured approx. 45% of Marketplace
Large percentage of members in their 30s
ACA Update – Open enrollment 2014-2015
OE 1 Results:
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ACA OE1 - Montana
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In Montana – after 2013-14 Open Enrollment:
• Net increase of 30,000 people with health
insurance – approx. population of Butte
• Uninsured reduced from 20% of state
population to 16.9%
• Statewide:
• 26,429 increase in individual market
• 8,739 increase in Medicaid program
• 5,150 (insureds) decrease in small group
market
ACA OE2 - Montana
12
In Montana – after 2014-15 Open Enrollment:
• 54,266 enrolled in plans via Marketplace
• 41% new to the Marketplace
• 85% receiving tax credits to offset premium
costs.
% Increase in QHP Sign-ups from
OE1 to OE2
13
NCQA
Quality and NCQA
15
QHPs are required to achieve and maintain
NCQA accredited
NCQA (National Committee for Quality Assurance): a
private, not-for-profit organization dedicated to improving
health care quality. NCQA develops quality standards and
performance measures for a broad range of health care
entities.
• HEDIS- Medical Record Reviews- INOVALON
• Risk Adjustment Medical Records- INOVALON
• Stringent guidelines: Credentialing, Site Visits, CAQH
• Disease Management, Wellness and Health Promotions
High Performance Network (HPN)
HPN Goals
17
• To create value through quality outcomes,
efficiency and service
• Move from silo health care delivery to
integrated and coordinated care for population
members thus eliminating gaps in care,
redundancy and waste
• To “bend the cost curve” for healthcare
• To reward the value based services and align
financial incentives to achieve the measured
goals
Activities
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• Development a HPN/ACO Formalizing legal entity
• Allows for engagement of disparate physician
practices with a focus on quality improvement
• Single organization structure with Regional Service
Areas
• Health Care provider leadership of HPN
• Opportunity to participate in CMS innovation projects
like ACO/shared savings programs
• Restructure of Pay for Performance program and
reimbursement methodologies for self funded and
fully insured individuals and employers
HPN Structure RSO (Regional Service Organization)
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HPN
RSO1
RSO3
RSO2
CAH
CHC
(PCP)
CAH
Clinic
(PCP)
Clinic
(PCP)
Specialist
Clinic
RHC
(PCP)
Specialist
Clinic
Acute Care
Hospital 2
Specialist
Clinic
CAH
CAH
Acute Care
Hospital
Clinic
(PCP)
Acute Care
Hospital 1
Acute Care
Hospital
RSO (Regional Service
Organization)
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
•
•
•
Technology enables system to identify gaps in
preventative care; use of Evidenced Based
Medicine (EBM) standards
Patient proactively contacted
Better outcomes and lower future costs
Examples: Colon cancer screening,
mammography, osteoporosis screening, AAA
screening, pneumonia vaccine, prostate
screening, diabetes screening, eye exams, PCP
appointments
Gain Share
21
HPN Operational Challenges
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• Ability to share data for defined patient
population when participants have: Disparate
electronic medical records systems
• Various practice management systems
• Non standard clinical nomenclature
• Separate patient identifiers
• Differing methods for disease identification &
performance measures
Referrals (Air Ambulance)
HELP Flight is In-Network!
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 HELP Flight is our
ONLY in-network air
transport provider.
 Costs can be
excessive if out-ofnetwork air transport
is used.
HELP Flight Referrals
2015
© Sisters of Charity of Leavenworth Health System, Inc. All rights reserved.25
Highlight’s of Program
• HELP: Helicopter Emergency Lifesaving Program
• Established in 1979 Hospital based program
• CAMTS accredited (Commission on Accreditation of
Medical Transport System)
• Great Safety record more than 20 years without an
incident
• Scene calls 150 mile radius from Billings with RotoWing (RW)
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Services provided
• Adult and Pediatric services-Medical, Trauma
• Neonatal Transport Team-Neonatal Registered nurses
on the flight FW
• Maternal Flight Transport –high risk pregnancies FW
• Flight Respiratory Therapist
• Flight Registered Nurses
• Flight Paramedics
• Our team is specially trained and experienced in
critical and emergency pre-hospital care.
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Services Provided (con’t)
• Non emergent transfers to other facilities
• Communication Center
• Partner with Metro and Edwards for pilots and
mechanics
• Under Medical direction of a Board-Certified
Emergency Physician
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Aircraft
• Beechcraft Super King Air B-200-fully equipped air
ambulance that can transport patients throughout the
country.
• Roto-Wing EC-135 P2+- fully equipped air ambulance
helicopter that can transport patients within 150 mile
radius of Billings, MT.
• Thanks for allowing us to come and share what we can
provide when it comes to caring for your patients and
customers.
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HELP Flight is In-Network!
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Claims & UM
Utilization Management
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UM - a set of techniques used by or on behalf of purchasers of
health care benefits to manage health care costs by
influencing patient care decision-making through case-bycase assessments.
• Altius Utilization Management Department
• All In-Patient services need prior authorization – allow 10
Business days before services are rendered, if possible
• Listing or out-patient services on web site
• Nurses & Coordinators
• Members can access the UM dept via Customer Service by
calling the number on the back of the member ID card.
• Direct access to UM department by calling 800-879-0234
(toll-free).
Claims
33
Claim/Customer Service/Eligibility Questions:
•855-488-0622 (Toll Free)
•mhccustomerservice@cvcy.com
Paper Claims:
MHC Claim Department
P.O. Box 7147
London, KY 40742
Electronic Claim submission 25133 Emdeon
Pre-Authorization:
•800-879-0234 (Toll Free)
Montana Health CO-OP: Member Services and Claims Processing
Serving our members
35
Updated web presence with convenient access to member
services.
Serving our members
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Serving our members - Altius
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My Online Services offers
members the ability to:
• View claims, EOBs and
benefit usage details
• Access health and
wellness tools
• Research cost of care data
• Request, display, print
member ID card
• Search for doctors,
hospitals and providers
within the network.
Health Plan Networks
Connected Care & Access Care
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Connected Care
Narrow Network Exclusions are: Billings Clinic,
Community Medical Center & Monida Network
providers in the Missoula Proper
Access Care
Open Network including Billings Clinic,
Community Medical Center and any Monida
Network Providers
Engage (coming in OE3 – 2016)
HPN Providers only
Out-of-Network
Optician
44
Physical
Therapy
10%
Psy
175
Nurse
Access Care - Providers
Practitioner
365
Naturopath
7
Chiropractic
72
Dentist
23
LCPC
185
LCSW
86
Physician Asst
329
Physicians
1697
Access Care - Facilities
7 facilities
11 facilities
47 out of 48
facilities
Mental Health, Children's, etc.
Main Hospitals
Critical Access Hospitals
Connected Care - Providers
Physical Therapy
293
Psy
175
Optician
39
Naturopath
Nurse Practitioner
7
Chiropracti…
347
Dentist…
LCPC
185
LCSW
86
Physician Asst
288
Physicians
1441
Main Hospitals
9 Facilities –
Mental Health,
Excluding
Children's, etc.… Billings Clinic
and Community
Medical Center
CONNECTED CARE - FACILITIES
Critical Access
Hospitals
47 out of 48
Facilities
RX Formulary
Pharmacy
45
 Administered by Express Scripts
 Use Express Scripts for mail order!
 Pharmacy Support Email - Provider Inquiry
pharmacysupport@cvty.com
 855-488-0622 (Option 1, and then 1)
 Pharmacy information available via MHC.coop
Provider Rosters
Provider Rosters
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•
•
•
Current Provider Rosters
Web Site Current
Any Demographics Changes to Providers
Item to include:
• Tax ID
• Mailing and Business address
• Licensure
• NPI Number
• Phone Number
Please direct roster changes to Isaac Heinitz:
iheinitz@mhc.coop
Montana Health CO-OP: Online Provider Services
Serving our Providers
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Convenient link via MHC website to online provider
services.
Serving our Providers
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Directprovider.com allows secure access to critical information.
This innovative tool is available for Montana Health CO-OP
plans and provides direct connection for up-to-date information.
• View member eligibility
• Submit authorization and
referrals
• View claim status and
request adjustments
• Download and print
remittance advices
• Resource library
• Benefits
• Interqual criteria
On the horizon…
ACA on the horizon…
52
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•
•
•
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Tax implications become evident (penalties) for those who
didn’t have health insurance in 2014.
Legislature has approved Medicaid expansion in Montana.
Upcoming Supreme Court Case (King v. Burwell) to
determine whether tax credits are legal for those who buy
insurance via federally facilitated exchanges (Montana).
Oral arguments were heard March 4; ruling expected this
summer.
OE3 Dates: November 1, 2015 – Jan. 31, 2016
2016 New rules in effect for businesses. (50-99 employees
– must provide insurance).
Medicaid Expansion in MT
Senate Bill 405
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Covers adults up to age 64 earning 138% FPL ($16,200)
Effective date: Possibly January 2016, pending federal
approval.
27,000 – 45,000 Montanans could enroll over next 4 yrs. $1
billion in federal funds flow into MT; MT pays about $6
million. Feds pay 100% in 2016, down to 90% over next 4
years.
Premiums: 2% of a person’s annual income.
Coverage: Medicaid covers basic medical and dental,
includes physician & hospital visits, mental health, etc.
Personal Asset Limits: Participants can own a home, one
light vehicle and have up to $50K in cash resources.
Additional costs apply if assets exceed these limits.
Q&A
Thank you!
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Barbara Kamerzel
bkamerzel@mhc.coop
406-447-5777
Web Resources:
mhc.coop
healthcare.gov
montanahealthanswers.com