Medicaid Update - Georgia Department of Community Health Wiant... · Medicaid Update Date: ... The...
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0 Medical Care Advisory Committee Linda Wiant, Pharm.D. Chief, Medical Assistance Plans Medicaid Update Date: November 16, 2016
Transcript of Medicaid Update - Georgia Department of Community Health Wiant... · Medicaid Update Date: ... The...
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Medical Care Advisory Committee
Linda Wiant, Pharm.D.
Chief, Medical Assistance Plans
Medicaid Update
Date: November 16, 2016
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MissionThe Georgia Department of Community Health
We will provide Georgians with access to
affordable, quality health care through
effective planning, purchasing and oversight.
We are dedicated to A Healthy Georgia.
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Agenda
• Enrollment and Expenditures
• Medicaid Procurements
• Department Initiatives
• Federal Initiatives/Regulation
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Georgia’s Children as Beneficiaries of
Medicaid and PeachCare
48% of Georgia’s children (ages 0 to 19) have access to health
insurance through Medicaid or PeachCare. (Fiscal Year 2016)
Program
GA Children
Population*
GA Beneficiaries (ages
0-19) %
Medicaid and PeachCare 2,784,116 1,319,811 48%
In addition, Medicaid pays for more than half of all Georgia births.
69,547
70,866
128,511
130,776
20,000 40,000 60,000 80,000 100,000 120,000 140,000
2013
2014
Medicaid and Total Births in Georgia
Total Births in GA GA Births Paid for by Medicaid
• - Ga. Population based on estimated 2015 population figures from census.gov. Births courtesy of the
GA Department of Public Health.
• Medicaid and PeachCare beneficiaries based on average monthly enrollment for FY2016.
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GA Medicaid and PeachCare for Kids®
Total FY2015 Expenditures (includes State, Federal and other Fund Sources):
• Low-Income Medicaid: $ 4,188,966,660
•Age, Blind and Disabled Medicaid: $ 4,903,329,343
• PeachCare for Kids® $ 327,709,847
• Average Spend per Day $36.2 million per work day
Medicaid and PeachCare
for Kids® represents 15.2%
of the state funds budget
(excluding motor fuel and
lottery) (2014)
14.3%14.5%
15.3%
18.2%
16.7%
15.6%
16.5%
15.8% 15.2%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
20.00%
2007 2008 2009 2010 2011 2012 2013 2014 2015
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Title or Chapter Slide
(use as needed; feel free to delete)
Procurement Update
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Medicaid Procurements
In Process
Drug Rebate Program
Pharmacy Dispensing Fee
Survey
CVO
Completed
MMURS (Medical Management
and Utilization Review Service)
CMO
Upcoming
Non-emergency Medical
Transportation
NEMT [email protected]
MMIS
EQRO
Nurse Aide Training and
Registry
CAHPS
Pharmacy Benefit Manager
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Managed Care Services
Georgia Families GA’s managed care program for Medicaid
PeachCare for Kids® GA’s Children’s Health Insurance Program
(CHIP)
Planning for Healthy
Babies (P4HB)
GA’s Section 1115 Family Planning Waiver
program
Georgia Families 360⁰ Children, youth and young adults in Foster
Care or receiving Adoption Assistance and
select youth involved with the Department of
Juvenile Justice
The Department of Community Health, Division of Medical Assistance
Plans, oversees selected Care Management Organizations (CMOs) for the
provision of managed care services and benefits to the following populations:
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Implementation Project Timeline
Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17
Planning and
AssessmentCMO Marketing (Subject to Deliverable Approval)
GO
LIVECMO Deliverable
Submission and DCH
Team Desk Reviews
DCH Open
Enrollment
Communications to
Members
Open
Enrollment
and Auto-
Assignment
CMS 90-Day Review
Period
Onsite
Reviews
Go,
No-Go
Decision
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Title or Chapter Slide
(use as needed; feel free to delete)
Major Initiatives
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Major Initiatives
• Centralized Credentialing Verification Organization
• Integrated Eligibility System
• Hospital Presumptive Eligibility
• CCSP
• Telemedicine
• Provider Enrollment
• Federal Regulations
– Managed Care Rule
• VBP
– Access Rule
– Outpatient Drug Rule
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Major Initiatives
Integrated Eligibility System
2011 • Project Start
2012 • JAD Sessions
2013• ACA updates to
legacy systems
2014 • Deloitte engaged
2016 • EMPI go live
2017 • System go live
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Major Initiatives
• Centralized Credentialing Verification Organization
• Integrated Eligibility System
• Hospital Presumptive Eligibility ([email protected])
• CCSP
• Telemedicine
• Centralized PA for BH
• Federal Regulations
– Provider Revalidation
– Managed Care Rule
– Outpatient Drug Rule
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Federal Regulations
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Federal Regulation/Initiatives
• Provider Revalidation
• Managed Care Rule
• Outpatient Drug Rule
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Federal Regulation/Initiatives
Provider Revalidation
– Federally Mandated
– Must be done every 5 years
– www.mmis.georgia.gov
Provider Information
Provider Notices
– Keep Your Address Updated
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Federal Regulation/Initiatives
• Managed Care Rule
– Dramatic changes to managing MCOs
• Changes actuarial review (rate cells vs rate)
• Requires quality ratings
– Changes impacting providers:
• Requires MCOs to identify 340B drugs within their claims
(both outpatient clinic and pharmacy claims)
• Providers can submit appeals on behalf of patients (with
approval from the patient)
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Questions?
