Managed Care Overview

Wisconsin Department of Health Services

Makalah WagnerManaged Care Section Chief

5/7/15

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DHS managed care overview BadgerCare Plus overview SSI Medicaid managed care overview Managed care contract requirements Monitoring member and provider relations Managed care performance Resources

Agenda

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Wisconsin has approximately 1.2 million Medicaid recipients Approximately 792,000 enrolled in BadgerCare Plus Approximately 390,000 enrolled in SSI Medicaid 69% enrolled in some type of managed care program (HMO or

medical home). All others receive covered services through Fee-for-Service (FFS).

DHCAA administers 95% of managed care enrollment through the following programs: BadgerCare Plus Supplemental Security Income (SSI) Medicaid Behavioral health managed care programs Medical home programs

DLTC administers 4% of managed care enrollment through the following programs: PACE Partnership Family Care

DHS Managed Care Programs

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Managed Care Enrollment by Program (October 2014)

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BadgerCare Plus Managed Care Overview & Enrollment

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Wisconsin has enrolled members in Medicaid HMOs since 1977.

85% of eligible BadgerCare Plus members are enrolled in an HMO in Wisconsin’s 72 counties.

Mandatory Enrollment: Refers to a service area where there are two or more HMOs and the Department may, under Medicaid MC requirements and the State Plan Amendment, require members to enroll in a HMO.

Voluntary Enrollment: Refers to any service area where the Department cannot or does not require members to enroll in a HMO because there is only one HMO available (with some exceptions).

BadgerCare Plus Managed Care Overview

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BadgerCare Plus Managed Care HMOs Anthem Blue Cross Blue

Shield Children’s Community Health

Plan (CCHP) CompCare Dean Health Plan Group Health Cooperative of

Eau Claire (GHC-EC) Group Health Cooperative of

South Central Wisconsin (GHC-SCW)

Gundersen Health Plan Health Tradition Health Plan Independent Care Health

Plans (iCare)

MHS Health Wisconsin (MHS) MercyCare Insurance

Company Molina Healthcare Network Health Plan Physicians Plus Insurance

Corporation (PPlus) Security Health Plan Trilogy Health Insurance UnitedHealthcare Community

Plan (UHC) Unity Health Insurance

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Anth

em B

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Dean

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40,000

80,000

120,000

160,000

Aug-14Sep-14Oct-14

BadgerCare Plus HMO Enrollment

The # in parenthesis reflects # of HMOs serving a county.

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SSI Medicaid Managed Care Overview and Enrollment Trends

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Introduced in 2005 to provide Medicaid-related services for elderly and people with disabilities through HMOs

Includes individuals who: Are age 19 or older Receive Medicaid and SSI or receive SSI-related

Medicaid because of a disability Are not living in an institution or a nursing

home Are not participating in a home or community-

based waiver program

SSI Medicaid Managed Care

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30% of eligible SSI members are enrolled in an HMO in 69 of Wisconsin’s 72 counties.

Voluntary Enrollment: Dually-eligible individuals (Medicaid and Medicare) Individuals in MAPP (Medicaid Purchase Plan)

“All In, Opt Out” Enrollment: Applies to SSI and SSI-related eligible members who do

not meet criteria for voluntary enrollment. Members must remain in an HMO for 2 months. Members may return to FFS or change HMOs within the

first 4 months or after 12 months of enrollment.

SSI Managed Care Enrollment

Care Wisconsin Compcare Group Health Cooperative of Eau Claire

(GHC-EC) Independent Care Health Plans (iCare) MHS Health Wisconsin (MHS) Molina Healthcare Network Health Plan UnitedHealthcare (UHC) Trilogy

SSI Managed Care HMOs

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Mol

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4,000

8,000

12,000

16,000

Aug-14Sep-14Oct-14

SSI Managed Care HMO Enrollment

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After members are determined eligible for BC+ or Medicaid, they receive a mailed packet with info about the HMO program.

Members can select a HMO on their own or receive help from the HMO enrollment specialist (Automated Health Services, Inc.).

If members do not select an HMO, they are assigned to a HMO (round-robin assignment) but can switch HMOs for a limited time.

HMO Enrollment Process

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DHS allows members with specific health needs to opt out of HMO enrollment and receive all services via FFS. These exemptions are allowed for continuity of

care reasons, such as if a provider is not in a HMO’s network or the member requires complex services.

We also allow exemptions for all tribal members, per federal requirements.

Exemption requests must come from the member, the member’s family, or a legal guardian.

Managed Care Exemptions

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Managed Care Contract Requirements

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Prior to program participation, HMOs must complete a certification application to ensure they meet DHS program requirements. Must also comply with OCI.

During certification, DHS reviews HMO policies and procedures, does any system testing, and does provider network analysis.

Once approved, HMOs sign contract. Currently DHS issues a 2-year contract covering BadgerCare Plus and SSI HMOs.

HMO Certification & Contracting

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Each HMO establishes a provider network of primary care providers, specialists, mental health professionals, hospitals, and urgent care clinics.

DHS reviews HMO provider networks prior to signing contracts with each plan.

The HMO's network must meet geographic distance standards between members and providers as well as provider-to-member ratio requirements in key areas.

HMO Provider Network Reviews

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Network adequacy requirements: In establishing the network, the HMO must consider: Anticipated BadgerCare Plus and Medicaid SSI

enrollment. Expected utilization of services, based on member

characteristics and health care needs. Number and types of providers required to furnish the

contracted services. Number of network providers not accepting new

patients. Geographic location of providers and members,

distance, travel time, normal means of transportation used by members, and whether provider locations are accessible to members with disabilities.

Provider Network Requirements

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BadgerCare Plus and Medicaid SSI HMO providers must be Medicaid-enrolled providers, except in emergency situations.

HMOs may negotiate payment rates with subcontracted providers, except they must pay 100% of the FFS rates for certain services (services by tribal providers, dental providers, or FQHCs; or out-of-network emergency services).

HMOs have flexibility in establishing timely filing periods for claims different from FFS; however, they must pay 90% of adjudicated clean claims within 30 days of receipt of the claim.

HMO Provider Networks

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HMO must notify DHS and members if any providers leave the network to smooth the transition process and provide continuity of care.

Members are assigned to a primary care provider, clinic or specialist.

The HMO’s provider directory is sent to members upon enrollment and is available on each HMO’s website.

HMO Provider Networks

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Time requirements: Less than 30 days for appointment with PCP Less than 30 days for appointment with mental

health provider for follow-up after an inpatient mental health stay.

In regions 5 and 6, less than 90 days for routine dental appointment.

HMOs must monitor compliance and take corrective action if there are longer wait times.

DHS will also investigate complaints about wait times.

Provider Network Requirements: Wait Times

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The HMO contract sets maximum distance requirements for the following provider types: Primary care: within 20 miles (or within 10

miles for the cities of Milwaukee, Kenosha, and Racine)

Mental health or substance abuse: within 35 miles for all regions of the state

Dental: within 35 miles for HMO that covers dental in regions 1–4; within 25 miles in regions 5 and 6

Provider Network Requirements: Distance

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Urgent care centers or walk-in clinics: must include after-hours care available from 5:00–7:00 p.m. and on weekends. All facilities must advertise that walk-in appointments are accepted. HMOs in regions 5 & 6, Dane County, and Brown County must have centers or clinics within 20 miles of any member in the HMO service area.

Hospitals: In regions 5 & 6, Dane County, and Brown County, a non-specialized hospital must be within 20 miles of any member in the HMO service area. In all other counties in regions 1–4, a non-specialized hospital must be within 35 miles of any member in the HMO service area.

In areas where there is no FFS provider available in the distance requirement, the HMO’s provider network must be comparable to FFS.

Provider Network Requirements: Distance

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BadgerCare Plus and Medicaid SSI in regions 5 and 6: Primary care provider: 1:100 Dentist: 1:1,600 Psychiatrist: 1:900

Provider Network Requirements: Provider-to-Member Ratios

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Members enrolled in managed care programs are entitled to the same benefits as fee-for-service members. Certain services are carved out (pharmacy, non-

emergency medical transportation, crisis and community services, prenatal care coordination, school-based services).

HMOs may offer additional benefits to their members or use different prior authorization criteria than FFS.

Coverage of dental and chiropractic services varies by region. If an HMO does not cover dental and chiropractic services, benefits are provided on a fee-for-service basis.

BadgerCare Plus members have minimal cost-sharing requirements. Twelve HMOs waive copays for enrolled members.

Managed Care Benefits

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SSI Medicaid care management penalty: assessments Timeliness: HMOs must assess new members within 60 days of

HMO enrollment. Comprehensiveness: Assessment must include member’s medical

and behavioral health needs, daily living, supports, and life goals. Coordination: Comprehensive care plan must be developed within

90 days, in collaboration with the member. Penalty: HMOs that fail to meet the 50% goal of timely and

comprehensive assessments have a penalty of $4 per member per month up to $250,000.

Health needs assessment for childless adults (CLAs) HMOs must assess new CLA members within 60 days of

enrollment. Assessment must address urgent symptoms, medical & behavioral

health needs, usual source of care, socioeconomic barriers, previous utilization of emergency rooms, & inpatient stays.

Care Coordination Requirements

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Monitoring HMO Member and Provider Relations

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The grievance process refers to the overall system that includes complaints, grievances, and appeals or expedited appeals.

Members may appeal an action to the HMO, the Department, and/or the Division of Hearings and Appeals. DHS encourages HMO members to first grieve to

their HMO, then to DHS, then to file an appeal with Division of Hearings and Appeals for a fair hearing.

However, a member may request a state-level fair hearing at any time.

Filing a complaint does not affect the member’s benefits.

Managed Care Member Complaint & Grievance Process

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Resources for members with complaints or grievances: HMOs are required to have member advocates. DHS also has managed care ombudsmen who assist

HMO members. DHS contracts with Disability Rights of Wisconsin (DRW)

as an external advocate to assist SSI HMO members. HMOs are required to report grievances quarterly. Latest data on all grievances to HMOs and DHS indicate

these areas have the most grievances filed:1. Medical surgeries2. Other services (such as, back injections or breast

reductions)3. Dental/orthodontia4. Bariatric surgery

Managed Care Member Complaint & Grievance Process

Managed Care Member Grievance Trends

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BC+ Grievances

BC+ Fair Hearings

SSI MC Grievances

SSI MC Fair Hearings

CY2008 81 25 12 3

CY2009 62 43 10 4

CY2010 81 31 13 7

CY2011 70 26 24 12

CY2012 44 58 42 9

CY2013 40 34 32 37

CY2014 45 39 13 38

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DHS provides a process for providers to appeal HMO payments. This process is described in the HMO contract, from HMOs, and in the Provider Handbook Topic 385.

HMOs must inform providers of decisions to pay or deny claims, including: Explanation of payment amount or nonpayment. Right to appeal to the HMO, including contact info and process.

Provider must appeal in writing, clearly marked as “appeal,” and include: Provider’s name, date of service, date of billing, date of

payment or denial, member’s name, and ID. Reason for appeal. Medical records (if complaint is medical).

Appeals to HMO must occur within 60 days of initial denial or payment.

Provider Appeals

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Provider can appeal to DHS if HMO fails to respond within 45 days or if provider is unsatisfied with HMO’s reply.

Providers must appeal to HMO first for resolution attempt. Submit the appeal to DHS within 60 days of HMO’s final

decision or, if no response, within 60 days of 45-day timeline allotted for HMOs to respond.

Providers must use DHS’s form (http://dhs.wisconsin.gov/forms/F1/F12022.doc), complete all fields, and send it to: ForwardHealth Managed Care Appeals P.O. Box 6470 Madison, WI 53716-0470

Provider Appeals

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Providers who are dissatisfied with the HMO’s payment can appeal to the HMO, and then to the Department for final mediation. Contract-specific timelines providers must follow to

appeal Typically low rate of DHS overturning HMO’s decision

HMO must keep records of internal appeals and perform provider outreach and education on trends to prevent future appeals to the Department.

The following areas have the most appeals filed: Medical necessity of inpatient care Level of care: inpatient vs. observation No prior authorization Coding issues

Managed Care HMO Provider Appeals

Managed Care HMO Provider Appeals

First Quarter

Second Quarter

Third Quarter

Fourth Quarter

Total

2012 113 150 502 328 1093

2013 240 214 175 299 928

2014 208 331 241 276 1056

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Managed Care Performance

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The Department requires HMO participation in our Pay-for-Performance (P4P) quality program. DHS withholds a percentage of the HMO’s capitation payment until the HMO meets annual benchmarks for clinical measures.

Managed care performance is monitored through Healthcare Effectiveness Data and Information Set (HEDIS) indicators, a tool used by 90% of health plans nationwide to measure HMO-specific care and service. The Department also uses other HEDIS-like measures where appropriate.

P4P targets are set on a statewide basis, except for dental measures, which apply to regions 5 and 6 only for 2015.

Each HMO implements a performance improvement project (PIP) each year that usually relates to the P4P quality measures.

The following slides represent the quality measures for 2015 BC+ and SSI HMOs.

Managed Care Performance

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2015 BC+ and SSI Quality Measures

Focus Area Measure BC+ (All Regions)

SSI

Preventive / Screening

Breast Cancer Screening (BCS) 0.25% 0.30%Childhood Immunization Status (CIS) 0.25% N/A

Chronic Comprehensive Diabetes Care (CDC): HbA1c Testing

0.25% 0.30%

Comprehensive Diabetes Care (CDC): HbA1c Control (Pay-for-Reporting)

0.125% 0.15%

Controlling High Blood Pressure (CBP) (Pay-for-Reporting)

0.125% 0.15%

Mental Health Antidepressant Medication Management: Continuation (AMM-2)

0.25% 0.25%

Initiation and Engagement of AOD Treatment: Engagement (IET-2)

0.25% 0.25%

Tobacco (Counseling Only) 0.25% 0.25%

Follow-Up after Mental Health Hospitalization: 30 Days After Discharge (FUH-30)

0.25% 0.25%

Pregnancy / Birth

Prenatal and Post-Partum Care (PPC): Timeliness of Prenatal Care and Postpartum Care

0.125% + 0.125%

N/A

Emergency Department

Ambulatory Care: Emergency Department Utilization (AMB) Sans Revenue Code 0456

0.25% 0.60%

MY2014 HMO P4P Withhold: 2.5 Percent of Medical Capitation

2015 BC+ and SSI Quality Measures

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Focus Area / Measure BC+ (Regions 5 and 6 Only)

SSI

Dental Care

Annual Dental Visit for Children (ADV + dental care provided by physicians)

1.25% N/A

Annual Dental Visit for Adults (similar to ADV except for age range)

1.25% N/A

MY2014 HMO P4P Withhold: 2.5 Percent of Dental Capitation

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ForwardHealth managed care website: https://www.forwardhealth.wi.gov/WIPortal/Home/Managed%20

Care%20Login/tabid/38/Default.aspx

Managed care resources including HMO contracts, enrollment data, HMO contact information for members, and HMO-specific information

ForwardHealth quality website https://quality.wisconsin.gov Includes HEDIS and other quality metrics, CAHPS member

satisfaction survey data, and the HMO Report Card to assist members with choosing a health plan

ForwardHealth Member Services (Voice/TTD): 1-800-362-3002 ForwardHealth Provider Services: 1-800-947-9627 HMO Enrollment Specialist: 1-800-291-2002 Managed Care Ombudsmen: 1-800-760-0001 SSI HMO External Advocate: 1-800-928-8778

Resources