Medicaid Managed Care Regulations

1
Medicaid Managed Care Regulations

• Silvia Rodriguez-Sánchez
• Erika Cristo

2
Discussion Overview

• Background
• MMC Regulations Technical Areas
• DMH Implementation Process
• DMH Communication with CMS
• Beneficiary Problem Resolution Processes
• Title 9, CCR, 1850.205
• Title 42, CFR, 438, Subpart F

3
Background

• Medicaid is a joint Federal and State health care
  program
• States have flexibility in administering their
  Medicaid programs
• DHS administers Californias Medicaid program
  Medi-Cal
• DMH administers Californias Medi-Cal Managed
  Mental Health Care Program

4
Background, Cont.

• The Balanced Budget Act (BBA) of 1997 allowed
  States greater flexibility in administering their
  Medicaid programs
• CMS published the MMC Final Rule on June 14, 2002
  to implement the provisions of the BBA
• The MMC regulations compliance due date was
  August 13, 2003

5
Background, Cont.

• County Mental Health Plans (MHPs) are considered
  Prepaid Inpatient Health Plans (PIHPs)
• MHPs must comply with MMC regulations that apply
  to PIHPs
• DMH must comply with MMC regulations as the
  administrator of the Medi-Cal managed mental
  health care program for California

6
MMC Technical Areas

• Information Requirements
• Beneficiary Rights and Protections
• Emergency and Post-Stabilization
• Availability of Services
• Assurances of Adequate Capacity and Services
• Authorization of Services

7
MMC Technical Areas, Cont.

• Provider Selection
• Practice Guidelines
• Quality Assessment and Performance Improvement
  Programs
• External Quality Reviews
• Health Information Systems
• Grievance and Appeals Systems
• Program Integrity

8
Regulations Text

• The full text of the MMC regulations is available
  on the CMS website
• http//www.cms.gov/medicaid/managedcare/cms2104f.a
  sp

9
DMH Implementation Process

• Detailed analysis of proposed regulations
• Participation in CMS public comment period
• Waiver Requests
• Internal Workgroup

10
DMH Implementation Process, Cont.

• California Mental Health Directors Association
  (CMHDA) Workgroup Biweekly Meetings
• Client Family Member Task Force (CFMTF) Workgroup
  Biweekly Meetings
• Joint CMHDA/CFMTF Meetings as needed

11
DMH Implementation Process, Cont.

• Proposed contract language to stakeholders for
  review and comment
• DMH/MHP contract amendments in December 2003
• Information notices and letters as needed to
  provide clarification in implementing MMC
  regulations

12
DMH Communication with CMS

• California did not meet the 8/13/03 deadline
  primarily due to resource shortages
• DMH is making a good faith effort to comply as
  quickly as possible
• DMH is in frequent contact with CMS

13
Beneficiary Problem Resolution Processes

• Grievances and Appeals

14
Title 9, CCR, Section 1850.205 (Problem
Resolution Processes)

• TIMEFRAMES
• COMPLAINTS must be resolved as quickly as
  possible.
• GRIEVANCES must be resolved within 30 calendar
  days at each level of review. A grievance
  resolution could take up to 60 calendar days if
  it went through both levels of review.

15
Title 42, CFR, Section 438, Subpart F
(Grievances)

• TIMEFRAMES
• New regulations specify that grievance
  dispositions cannot exceed 90 days from the day
  in which the MHP received the grievance.
• DMH will retain a 60 calendar day limit for
  grievances to be resolved.
• Timeframe may be extended by up to 14 days in
  certain circumstances.

16
Title 42, CFR, Section 438, Subpart F (Standard
Appeals)

• TIMEFRAMES
• APPEALS must be resolved within 45 calendar days
  of MHP receipt of appeal.
• Timeframe may be extended by up to 14 days in
  certain circumstances.

17
Title 42, CFR, Section 438, Subpart F (Expedited
Appeals)

• TIMEFRAMES
• EXPEDITED APPEALS must be resolved and the
  affected parties must be notified orally and in
  writing no later than 3 working days after the
  MHP receives the expedited appeal.
• Timeframe may be extended by up to 14 days in
  certain circumstances.
• If the MHP denies the expedited appeal process
  and reverts the appeal to the standard appeal
  process, the MHP must make reasonable efforts to
  promptly notify the beneficiary orally and must
  notify him/her in writing within 2 calendar days.