The Integration of Acute and Long Term Care Services: Virginias Current Managed Care Program Note: T

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The Integration of Acute and Long Term Care
Services Virginias CurrentManaged Care
ProgramNote The Managed Care Program for the
Integrated Care Model Will LikelyBe Different
Than the Current MCO Program Design
Department of Medical Assistance
Services September 2007
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Managed Care

• DMAS mandatory managed care program with
  contracted Managed Care Organizations (MCO)
• Program began in 1996 for seven localities
• Currently operating in 110 localities serving 56
  of Medicaid individuals
• Statewide Medicaid Enrollment as of August 1,
  2007
• Fee-for-Service 255,926 MEDALLION
  51,079
• Medallion II 383,103

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Program Authority

• Medallion II operates as a result of
• CMS 1915(b) Waiver Effective 7/1/07
• Code of Federal Regulations (CFR)
• (42 CFR Part 438, aka Balanced Budget Act
  implemented June 2002)
• Virginia State Plan for Title XIX
• Virginia Administrative Code for Managed Care (12
  VAC30-120-360 through 420)
• MCO Contract

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Virginia Medicaid Managed Care Program Coverage
Map
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Our Current MCO Partners

• Anthem HealthKeepers Plus
• Optima Family Care
• Virginia Premier Health Plan
• Southern Health - CareNet
• Amerigroup Community Care

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MCO Eligibility

• Medicaid eligibility determined by Department of
  Social Services
• MCO enrollment is mandatory for managed care
  eligible clients
• Majority of Medicaid clients are managed care
  eligible, however, some are not
• Always some FFS Medicaid clients

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Currently Included in Managed Care

• Children
• Pregnant women
• Aged, Blind and Disabled
• Currently Excluded Populations
• Nursing Homes
• Other insurance (i.e., Medicare)
• Foster Care

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Enrollment Process

• Initially placed in FFS (30-45 days)
• Sent pre-assignment letter in English and
  Spanish with comparison chart and MCO brochure
• Choice of at least 2 health plans
• Assigned to MCO of choice or default health plan
• Sent MCO welcome packet, including MCO ID card,
  handbook, provider directory

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Changing MCOs

• Recipients are allowed to change from one MCO to
  another within the first 90 days without cause.
• Recipients are allowed to change from one MCO to
  another outside of the 90 day trial period for
  good cause reasons.

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Continuity of Care

• DMAS and the MCOs Value Continuity of Care
• DMAS shares claim and prior authorization data
  with MCOs
• MCOs and DMAS honor each others authorizations
• MCOs continue services without interruption as
  authorized or until completion of MCO
  reassessment
• MCOs continue the service using one of their
  network providers or may cover through
  out-of-network coverage
• (Federal regulations require that DMAS only
  reimburse DMAS participating providers)
• MCO care management is available as needed, i.e.,
  for individuals with complex health care needs,
  etc.

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Value Added Benefits of MCOs

• Patient Education Information - Member handbooks,
  provider directories, newsletters, and health
  information (available in English and Spanish)
• Enhanced Services - Most provide services above
  Medicaid covered services (i.e., vision services
  for adults)
• Case Management for special needs and identified
  population
• 24 Hour Advice and Triage Nurse Helpline - A
  toll-free number to discuss information on a
  disease or illness (e.g. asthma, pregnancy), or
  receive advice on the treatment of a minor fever,
  accident, or illness
• Outreach
• No Co-payments

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Provider Relations

• Provider Recruitment Actively recruits Medicaid
  providers into their networks. MCO recruitment
  activities have resulted in a net increase in the
  number of providers.
• Provider Credentialing All providers go through
  a rigorous process that includes, but is not
  limited to, the verification of licensure,
  malpractice verification, site visits and
  education. Re-credentialing is required every
  two years.
• Provider Education Offer education and training
  on covered services, coverage and payment
  policies and procedures, grievances and appeals
  processes, billing instructions, etc.
• Provider Payment Pay 90 of all clean claims
  within 30 days of receipt and all claims within
  12 months of receipt.
• Provider Satisfaction Survey (conducted every
  other year) - Report findings to DMAS, identify
  and report corrective measures

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Quality Assurance

• Virginia is one in a handful of states that
  requires MCOs to obtain National Committee for
  Quality Assurance (NCQA) accreditation.
• One health plan won a national award from the
  Disease Management Association of America for the
  prevention of sickle cell and reducing emergency
  department visits and hospitalizations.

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MCO Rankings

• U.S. News World Report ranked Optima, CareNet,
  and VA Premier among Americas Best Health Plans

Rankings were based on the health plans National
Committee for Quality Assurance Accreditation
Standards score and the following four measures
access to care, overall member satisfaction,
prevention, and treatment.
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Health Management
The Health Plans, with the support of their
provider networks, have been successful in the
following areas

• Immunization rate of 83 is substantially above
  the national average of 63
• Diabetes programs have demonstrated a decrease in
  hospital admission and emergency room visits
• Maternity management programs have improved
  premature births and other post-delivery problems
• The HEDIS measure for use of appropriate asthma
  medications (87 - 95) is above the national
  rate of 86

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Managed Care HelpLine

• The Enrollment Broker, Maximus, has been
  contracted since 2/1/03.
• Toll-free assistance to managed care enrollees.
• Provides telephone translation services.
• Completes health assessments with members.
• Website just for managed care eligible
  individuals Virginiamanagedcare.com

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MCO Appeals

• RECIPIENT
• Recipients can appeal adverse decisions (decision
  to deny, reduce, or delay a covered service)
  through their MCO and/or through the DMAS State
  Fair Hearing process
• Providers can appeal on behalf of the recipient
  with the recipients written authorization
• PROVIDER
• MCO reimbursement appeals process available to
  providers who disagree with adverse decisions
• DMAS - Providers can appeal to DMAS after
  exhausting the MCO appeals process.
• (DMAS Provider appeals are handled as described
  in 12VAC30-20-500)

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DMAS Oversight of MCOs
DMAS monitors the MCOs through reporting,
contract compliance, monthly meetings, network
reviews, on-site visits, complaint monitoring,
independent assessments, and focus pattern of
care studies

• MCO Licensure and Administration
• Outreach and Marketing
• Enrollment and Patient Education
• Network Analysis and Provider Relations
• Member Services and Complaint Tracking
• Encounters

• EQRO Annual Review
• Medical and Utilization Management
• Quality Assurance and Improvement
• Medical Care and Services
• Financial Management the MCOs are at full risk
  for services
• Management Information Systems and Claims
  Processing