Medicaid Managed Care

1
Medicaid Managed Care

• National Perspective and Postcards from the
  Bleeding Edge
• Rocky Nichols
• Executive Driector, DRC Kansas

2
NCD Recommends PA Medicaid Advocacy Program

• CMS should fund a Medicaid Advocacy program
  within the federally mandated Protection and
  Advocacy agencies to ensure Medicaid managed care
  programs at the state level are adequately
  protecting the rights of consumers.

3
Kansas - The Bleeding Edge of MMC

• People lost in the cracks Not just death of
  case management
• Death by a million burecratic paper cuts
• New verification forms to stay on waiting lists
  (not getting in mail)
• People dont get the form - Even those who have
  not moved
• People send in the form lost by central office
• Not being informed of appeal rights
• NOA
• Many MMC Members were not Informed of Reductions
  in Services and Due Process Rights
• Those Informed were Misinformed and
  Systematically Discouraged from Filing Appeals
• We thought this was fixed, but seeing it occur
  again

4
Case management as we know it is gone in Kansas
under Managed Care!

• Loss of case management illustrates NCDs
  Advocacy program
• Case management as we know it is gone
• All Waivers except I/DD
• Care Coordination by MCOs replaced case
  management
• Not same thing case loads, services

5
Case management as we know it is gone

• Medicaid Managed Care (MMC) greatly weakened the
  Services and Supports System that helps Kansans
  before they qualify for Medicaid. Dont fall
  through cracks.
• Huge Case Management Gap - no one helping the
  person navigate the system before they get a
  Medicaid card.
• Prior to MMC - case managers helped Medicaid
  applicants.
• Now, little navigating application process. Fall
  through cracks
• Undermines purpose of MMC, improved health
  outcomes.
• Care Coordination doesnt help with navigation
  case loads of 150
• Crisis case management under 60 yrs old limited
  under MMC has always been (continues to be)
  limited for 60

6
Kansas - The Bleeding Edge (cont.)

• Huge Reductions in PD Waiver Enrollment Pre-and
  Post MMC --- Difference is after MMC, plummets
  further even AFTER 9 million added by
  Legislature to increase enrollment
• Dramatic Reductions in Waiver Capacity Pre Post
  MMC (since 1/1/2013)
• 23 reduction in PD Waiver slots
• 7.5 reduction in I/DD Waiver slots
• 6 reduction in TBI Waiver slots
• Cumulative Reduction of 14 across all Waivers

7
PD Waiver Enrollment Plummets
8
PD Waiver Unprecedented BOTH enrollment and
wait list DROP
9
Since MMC Waiver Capacity reduced 14 (2542
slots)MMC Started 1/1/2013
Capacity 1/01/2013 Proposed 2015-2020 Difference
PD Waiver 7,874 6,092 (1782)
DD point in time 9552 8,836 (716)
TBI Waiver 767 723 (44)
Total 18,193 16,173 (2542)
10
PD Waiver Capacity Reduced 23 after MMC
Total Change in PD Waiver Capacity 23 decrease
11
I/DD Waiver Capacity Reduced 7.5 after MMC
Total Change in DD Waiver Capacity 7.5
decrease
12
TBI Waiver Capacity Reduced 6 after MMC
Total Change in TBI Waiver Capacity 6 decrease
13
Total Waiver Capacities Reduced 14 after MMC
Total Waiver Capacity Reduction 14 reduction

14
Medicaid Managed Care National Concerns

• Inaccessible facilities and materials
• Provider incentives (withholds, bonuses) create
  disincentives to serving people with disabilities
• Limited access to specialists, DME,
  prescriptions, and non-medical services
  (transportation, respite)
• Disputes over when Due Process is triggered and
  what constitutes compliance
• Failure to provide benefits pending appeal
• Poor understanding of EPSDT requirements
• Lack of transparency (e.g. formularies, rates)

15
1115 Global Waivers allow new flexibilities
that disadvantage PWDs

• States are receiving new flexibilities from HHS
  in trade for Medicaid expansion (IA, PA, IN, OH,
  KS) (awaiting approval WY, UT, MT, FL, VA)
• Concerns
• Higher cost sharing (above nominal for
  non-emergent ER)
• Penalties for failure to pay cost-sharing
• Reliance on health savings accounts
• Waiver of non-emergent medical transportation
  requirement
• Incentives and rewards for healthy behaviors

16
Structure Already in Place for PA Medicaid
Advocacy Programs

• PAs exist in every state and territory and are
  experts in MLTSS Policy and Legal Analysis
• PAs have authority under federal law to Pursue
  legal, administrative other appropriate
  remedies on behalf of individuals with
  disabilities
• Special authority to access persons, records, and
  facilities.

17

• Principles of Protection Advocacy Systems

CLIENT-DIRECTED
LEGALLY BASED
INDEPENDENT ADVOCACY
CONSUMER-MANAGED
18

• PA Continuum of Remedies

• Information and Referrals
• Outreach to Un-served and Underserved Populations
• Training, including Self Advocacy Skills
• Legal Counsel and Advice
• Negotiation and Mediation
• Administrative Proceedings
• Individual Litigation
• Monitoring
• Public Policy and
• Legislative Advocacy
• Public Relations
• Systemic Litigation and Advocacy

19
PA Experience Providing Ombudsman Services

• PAs already run ombudsman programs, for example
  
• Wisconsin has three, including MLTSS for
  individuals under 60 yrs. the state SSI managed
  care advocacy program and the nonemergency
  medical transportation advocacy program.
• Colorado, Illinois, and Rhode Island are
  providing legal advocacy as part of Duals Demos.
• OH, WA, MM, LA. (Ombudsman programs not specific
  to dual demos)

20
Medicaid Law Includes Managed Care
Non-Discrimination Requirement

• MC contracts must prohibit discrimination on the
  basis of health status or requirements for health
  services in enrollment, disenrollment, and
  re-enrollment. 42 U.S.C. 1396b(m)(2)(A)(V)

21
ACA non-discrimination provision

• 1557 (42 U.S.C. 18116) provides Individually
  Enforceable new authority to prohibit
  discrimination against individuals with
  disabilities in applying for health insurance and
  accessing healthcare services.
• Applies Civil Rights Act, Age Discrimination Act,
  and Rehab Act to any health program or activity
  which
• receives Federal financial assistance, including
  credits, subsidies, or contracts of insurance 2)
  is administered by an Executive Agency or 3) any
  entity established under Title I of the ACA (i.e.
  The Health care Marketplace/exchanges).

22
Anti-discrimination provisions

• 1302(b)(4)(B) the Secretary shall not make
  coverage decisions, determine reimbursement
  rates, establish incentive programs, or design
  benefits in a way that discriminates against
  individuals because of age, disability, or length
  of life.
• (b)(4)(C) the Secretary shall take into account
  the health care needs of diverse segments of the
  population, including women, children, people
  with disabilities and other groups.

23
Anti-discrimination provisions, continued

• (b)(4)(D) the Secretary shall ensure that health
  benefits established as essential not be subject
  to denial to individuals against their wishes on
  the basis of the individuals age, expected
  length of life, or the individuals present or
  predicted disability, degree of medical
  dependency or quality of life.

24
PAs will Need Additional Funding to Meet
Expanding Need

• NCD Recommends
• Congress should establish a Medicaid Advocacy
  program and increase appropriations to the
  federally mandated Protection and Advocacy (PA)
  agencies by an additional 5 million to hire
  Health Advocates to assist in monitoring and
  advocacy at the state level.