The Challenges of the Medicaid
Modernization Mandate – Part 2
Iowa Assisted Living Association
August 26, 2015
Joel L. Olah, Ph.D., LNHA
Executive Director
Aging Resources of Central Iowa
How could this initiative achieve quality
and outcomes?
• Contractors must develop
strategies to integrate care
across the system.
• This will include physical
health, behavioral health
and long-term care services.
Design includes all Medicaid
covered medical benefits
• Provides entities responsible for
oversight and coordination of all
medical services
• Provides incentives for
coordinating care and avoids
duplication
• Supports integration and
efficiency
• Prevents fragmentation of
services and misaligned financial
incentives for shifting care to
more costly setting
24
How could this initiative achieve quality
and outcomes?
Holding contractors • Increased care coordination and reduced
duplications
accountable for costs • Investment in preventative services which lead to
and outcomes creates
long-term savings
incentives for:
• Prevention of unnecessary hospitalizations
Combining
accountability for
costs and outcomes
enables:
• Savings will be achieved through appropriate
utilization management
• MCO payments tied to outcomes
• Performance outcomes can be increased each
contract year
25
How could this initiative achieve quality
and outcomes?
Member Benefits:
• All members may receive health screening and receive
services tailored to their individual needs.
• Individuals with special health care needs will have
comprehensive risk assessment.
• Care coordination must be person-centered and address
unique client needs through individualized plans.
• Contractors can provide enhanced services not available
through a fee-for-service model.
26
How does this initiative work with the
State Innovation Model (SIM)?
• The SIM grant is designed to help the state plan,
design, test, and evaluate new payment and service
delivery.
• There are two key features going forward with this
initiative:
▫ Value Index Score (VIS): MCOs will be required to use
the VIS, which will enable evaluation of outcomes.
▫ Value-Based Purchasing: MCOs will identify the % of
value-based contracts that will be in place by 2018.
27
What does this mean for providers?
• Who will pay the providers? The MCOs will pay claims
•
•
•
•
within similar timeframes as Medicaid does today.
Who will authorize services? The MCOs, based on state
policy and administrative rule.
Who will be responsible for utilization management?
The MCOs as approved by the Department.
Will there be appeal rights? Yes, providers will be able to
appeal rights like they do today.
When will providers contract with the MCOs? MCOs will
build up their provider networks in the months prior to
implementation.
28
Legislative Protections (SF505)
• Directs DHS to partner with stakeholders to convene monthly statewide public
meetings (beginning March 2016) to get input on the managed care system. These
meetings are to be held throughout the state, and would most likely be co-hosted
by interested groups. The Executive Committee of the Medical Assistance Advisory
Council will make recommendations, and compile information received from the
public.
• Establishes a Legislative Health Policy Oversight Committee (appointed by the
Legislative Council) to receive updates on managed care, review data, listen to
public concerns and recommendations, and make recommendations for improving
the system. Recommendations would be referred to the Legislature, although
changes could be addressed without legislation.
• Adds $220,000 to hire two new Long Term Care Ombudsmen in the Office of the
Long Term Care Ombudsman, and directs DHS to request Medicaid administrative
match for the work these people will do to address concerns of people receiving
Medicaid long term care services and supports.
29
Legislative Protections (SF 505)
• Directs the Office of the Long Term Care Ombudsman, Department of Public
•
•
•
•
Health, Department of Human Services, Department of Inspections and Appeals,
Disability Rights Iowa, Civil Rights Commission, Senior Health Insurance
Information Program, Iowa Insurance Advocate, Iowa Legal Aid, and other
consumer advocates and assistance programs to develop a proposal for the
establishment of a Health Consumer Ombudsman Alliance to provide a
permanent, coordinated health plan system navigation and complaint resolution
system.
If Medicaid managed care is approved and implemented, requires provider rates
to be no lower than current rates.
Requires DHS is to conduct initial functional assessments of new Medicaid
enrollees (required to be done in conflict-free manner).
Prohibits DHS from reducing Medicaid HCBS waiver slots below what is in place
January 1, 2015.
Directs DHS to contract with a private vendor to conduct electronic asset
verification as required by the Affordable Care Act.
30
Iowa’s Managed Care Organizations:
The Original 18
•
•
•
•
•
•
•
•
•
•
•
Aetna Better Health of Iowa Inc.
Amerigroup Corporation
AmeriHealth Caritas Iowa
CHA HMO, Inc. (Humana)
Cigna HealthSpring
Gateway Health Plan, LP on behalf of
it’s managed care affiliates
Goold Health Systems, an Emdeon
Company
Health Information Designs
Iowa Total Care, Inc. (Centene)
Magellan Complete Care of Iowa, Inc.
Medica Health Plan
•
•
•
•
•
•
•
Meridian Health Plan
Molina Healthcare, Inc.
MultiPlan
Shared Health
UnitedHealth Care Plan of the River
Valley, Inc.
UnityPoint Health
WellCare Health Plans, Inc.
31
Then There Were 11
•
•
•
•
•
•
•
•
•
•
•
Aetna Better Health of Iowa Inc.
Amerigroup Iowa, Inc.
AmeriHealth Caritas Iowa, Inc.
Gateway Health Plan of Iowa, Inc.
Iowa Total Care (Total Care)
Magellan Complete Care of Iowa
Medica Health Plans
Meridian Health Plan of Iowa, Inc.
Molina Healthcare of Iowa, Inc.
UnitedHealth Care Plan of the River Valley, Inc.
WellCare of Iowa, Inc.
32
Now There Are Four
• Amerigroup Iowa, Inc.
• AmeriHealth Caritas Iowa, Inc.
• UnitedHealth Care Plan of the River Valley,Inc.
• WellCare of Iowa, Inc.
33
Amerigroup Iowa, Inc.
•
•
•
•
•
•
•
•
•
State Coverage: 11 States (FL, GA, KS, LA, MD, NJ, NM, NY, TN, TX, WA)
Corporate Headquarters: Virginia Beach, VA
Parent Corporation: Anthem, Inc.
Staff: 7,000+
Members Served: 3.5 million (Nationally)
Managed Medicaid Since: 1994
Buyer or Builder: Buyer
Track Record:
Irregularities: 2006 - charges of 18,000 false claims in FL, avoiding high-risk
patients, 2008 - $225 million settlement
34
AmeriHealth Caritas Iowa, Inc.
• State Coverage: 15 States + District of Columbia (CA, FL, IN, KY, LA, MI, MN, NE,
NJ, NV, NY, PA, RI, SC, TX, DC)
•
•
•
•
•
•
•
•
Corporate Headquarters: Philadelphia, PA
Parent Corporation: AmeriHealth Caritas, Inc.
Staff: 4,000+
Members Served: 6.6 million
Managed Medicaid Since: 1997
Buyer or Builder: Buyer
Track Record:
Irregularities: False reporting of health care services, KY, paid $2 million in
damages
35
UnitedHealth Care Plan of the River Valley, Inc.
•
•
•
•
•
•
•
•
•
State Coverage: 9 States (AK, GA, IL, IA, NC, OH, SC, TN, VA)
Corporate Headquarters: Minnetonka, MN
Parent Corporation: UnitedHealth Care, Inc. (24 States)
Staff: 15,000+ (Nationally)
Members Served: 73 million
Managed Medicaid Since: 1999
Buyer or Builder: Builder
Track Record:
Irregularities: 2006 – Stock Options settlement, $468 million; 2009 – rate fixing,
$350 million settlement, NYC; 2014 – fines of $173.6 million in CA for failing to make
timely payments/respond to provider disputes (company has appealed)
36
WellCare of Iowa, Inc.
•
•
•
•
•
•
•
•
•
State Coverage: 10 States (FL, GA, HI, IA, IL, KY, MO, NJ, NY, SC)
Corporate Headquarters: Tampa, FL
Parent Corporation: WellCare, Inc.
Staff: 6,100+ (Nationally)
Members Served: 3.8 million (Nationally)
Managed Medicaid Since: 1997
Buyer or Builder: Buyer
Track Record:
Irregularities: 2009 – FL executives indicted, inflated expenses, clients
short-changed $80 million settlement, court case still pending ($193 million
37
legal fees)
Time Table For Managed Care
Activity
Estimated Date
DHS Executes Contracts with MCOs
August 2015
Orientation - Iowa AAA's and MCOs
October - December 2015
Medicaid Members Select MCO
November- December 2015
Iowa High Quality Health Care "Go Live"
January 1,2016
Transitional Period
January - June 2016
LTC/NF Portion of Managed Care Added
January 1,2017
38
Impact of Managed Medicaid
on Provider Network
• Why are MCOs interested in managing Medicaid?
$$$ - In Iowa allowable administrative expense is 11.4% of $4.2 Billion.
• How do MCOs operate?
Look for efficiencies, integrate programs, seek partners who can help
reduce costs and improve health outcomes, concentrate on the most
costly health care users.
• How should providers prepare for MCOs?
Standardize service delivery, prepare unit costs for services(fee-forservice), restructure-position services and staff to be of value to MCOs,
speak their language, engage in regular dialogue with MCOs, make sure
staff members are qualified/certified (examples to follow)
39
40
41
Provider Issues With MCOs
• Delays in payment
• Provide local services via corporate staffing
(Builders vs. Buyers)
• Learn from local providers, then buy out or fill
corporately
42
Managed Medicaid
Client Impact – Service Delivery
• Carefully study MCO program offerings and
distinguish between provider benefits.
• Special needs family members should
research each MCO and select service
options very carefully.
• Consumers should know their appeal rights.
43
Consumer Overview: Selection
• The IME will inform members of their MCO choices prior to the time
to enroll with MCOs. If members do not make a selection, they will
be assigned to an MCO. All members will have 90 days after initially
being assigned to an MCO to request a change. After that, members
may change their MCO annually, or more frequently only for good
cause (i.e. member moves, provider no longer with MCO)
• Members will receive a Medicaid card during their initial enrollment
period that should be used to access services prior to the member
being assigned to the MCO. Members will also receive a card for
their MCO.
• Family members may choose different plans and also have the
option of receiving coverage through the same plan.
44
Consumer Overview: Services
• Services provided today will continue to be offered under the
MCOs, including physical health care, behavioral care and long
term care services. All services, except for dental, will be with
the MCOs.
• The MCOs will provide prescription drug coverage and will utilize
the same Preferred Drug List (PDL) and Prior Authorization(PA)
criteria that Medicaid uses today. Members will not see a
difference in the drugs available, but depending on which MCO
members enroll, pharmacy providers may be different.
• The MCOs will be responsible for coordinating transportation
services for all Medicaid populations eligible for the services.
45
Consumer Overview: Service Providers
 Physical and Behavioral Health Care: Providers who are enrolled with
Medicaid will be part of the MCO provider network until June 30, 2016. After this
time period, provider networks will be negotiated by the MCOs and providers.
 Facility: Providers who are enrolled with Medicaid will be part of the MCO
provider network until December 31, 2017. After this time period, provider
networks will be negotiated by the MCOs and providers.
 Home and Community Based Services (HCBS) and Habilitation:
Providers who are enrolled with Medicaid will be part of the MCO provider
network until December 31, 2017. After this time period, provider networks will
be negotiated by the MCOs and providers.
 Case Management: Members will be allowed to keep their case manager until
at least June 30, 2016, if the member chooses. All case management activities
must be transitioned to the MCOs no later than December 31, 2016.
46
Consumer Overview: Appeals
• Under managed care, members will have the same
•
right to make informed choices about their health
care as they do under Medicaid.
MCOs may require members to get their health care
services from a certain network of providers, but
those providers cannot take away members right to
make their own health care decisions.
47
Managed Medicaid Client Issues
• Increased out-of-pocket costs (benefit restrictions)
• Access to care (limited referral to specialists, particularly
•
•
•
•
mental health care)
Transportation challenges (especially for disabled clients)
Communication with MCOs (timely responses)
Medications (benefit restrictions, especially over-thecounter)
Care coordination (lack of attention to non-medical
concerns)
48
Concluding Recommendations for Providers
• Maintain dialogue with MCOs
• Carefully review any contract offerings from
MCOs with legal counsel
• Continue to develop your product/service lines
• Explore evidence-based programs and innovative
practices for possible model projects funded by
MCOs
49