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REPORTTOGOVERNORHASSAN:

RecommendationsInMedicaidCareManagement

LessonLearnedFrom

AcuteCare

TransitionstoManagedLongTermSupportsandServices

August31,2016

TheGovernor’sCommissionToReviewandAdviseontheImplementationofNewHampshire’sMedicaidCareManagement

Program

Commentsshouldbesubmittedto:KathleenSgambati,SpecialAssistanttotheGovernor

kathleen.sgambati@nh.gov

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TableOne:

MembershipTheGovernor’sCommissiononMedicaidCareManagement:

MaryVallier-Kaplan,Chair;formerVicePresidentoftheNewHampshireEndowmentforHealthDonaldShumway,ViceChair;formerPresidentandCEOofCrotchedMountainFoundationandCommissioneroftheDepartmentofHealthandHumanServicesRobertaBerner,ExecutiveDirectorGraftonCountyCitizensCouncil,Inc.(AppointedOctober2013)ThomasBunnell,policyconsultantforNHVoicesforHealthSusanFox,AssociateDirectorUNHInstituteonDisability(ResignedMay2016)WendyGladstone,MD,pediatricianatDartmouth-HitchcockMedicalCenter’sChildAdvocacyandProtectionProgramYvonneGoldsberry,Ph.D,MPH,PresidentoftheEndowmentforHealthandformerVicePresidentofPopulationHealthandClinicalIntegrationatCheshireMedicalCenter/Dartmouth-Hitchcock-KeeneCatherineMcDowell,founderofCoosFamilyHealth(ResignedSeptember2013)DouglasMcNutt,AssociateStateDirectorforAdvocacy,AARPNHGustavoMoral,PresidentofIndependentServicesNetworkKennethNorton,ExecutiveDirectorofNAMINewHampshireJosephinePorter,MPH,DirectoroftheNHInstituteforHealthPolicyandPractice.LoriShibinetteRN,MBA,NHA,CEOMerrimackCountyNursingHome(AppointedMay2016)CommissionerNicholasToumpasoftheDepartmentofHealthandHumanServices(ex-officiomemberoftheCommission).(ResignedJanuary2016)CommissionerJeffreyMeyersoftheDepartmentofHealthandHumanServices(ex-officiomemberoftheCommission).(AppointedFebruary2016)

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Contents:

CommissionMembership 2TheWorkoftheCommission 4

IndividualsWhoHaveGivenGenerouslyOfTheirExpertise

TheCommissionHasFoundThatNewHampshire 6IsAffirmativelyInitiatingUrgentHealthCareReformUnderMedicaidCareManagementNextRecommendationsoftheCommission 11Appendix1: 25

AuthorizingStatute:Chapter125,Lawsof2011AnActRelativetoMedicaidManagedCare

Appendix2: 29

ExecutiveOrder2013–05:AnOrderEstablishingtheGovernor’sCommissiontoReviewandAdviseontheImplementationofNewHampshire’sMedicaidCareManagementProgram

Appendix3: 33

Recommendation4,2/10/15:Vision,Principle,andGuidanceAppendix4: 42

PreviousRecommendationsoftheCommissionandRecommendationCross-ReferencewithSenateBill553

Appendix5: 43

WorkGroupsoftheCommissionAppendix6: 44

References/SourcesStaffmembersoftheGovernor’sofficeprovideongoingconsultationandassistancetotheCommission.KathleenSgambati’ssupportisparticularlyappreciated.The Staff of the Department of Health and Human Services provide exemplarysupport, assuring transparent public access to information, individual quality ofcare and effective implementation of major policy change. Other State agenciesincluding the Department of Insurance and the Office of Attorney General lendvaluedsupport.All agendas, minutes, and materials of the Commission dating from 5/1/13 topresentarepostedonGovernorHassan’swebpage:http://governor.nh.gov/commissions-task-forces/medicaid-care/index.htm

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WorkoftheCommission

“Themanagedcaremodelormodels’selectedvendorsprovidingtheMedicaidservicesshallestablishmedicalhomesandallMedicaidrecipientsshallreceivetheircarethroughamedicalhome.Incontractingforamanagedcaremodelandthevariousratecells,thedepartmentshallensurenoreductioninthequalityofcareofservicesprovidedtoenrolleesinthemanagedcaremodelandshallexerciseallduediligencetomaintainorincreasethecurrentlevelofqualityofcareprovided.”Chapter125,Lawsof2011

TheCommission’sworkiscarriedoutinaccordancewiththeExecutiveOrder2013–05(seeAppendix),reflectingthefollowinggoals:

• assuringthatthepublicisengagedintheunderstandingofthebestpracticesofmanaged careand thatNewHampshireMedicaidenrollees attainhealthoutcomes needed by the citizens and communities of the State of NewHampshire;

• conducting ongoing review of the implementation of Medicaid CareManagementinaccordancewithChapter125,Lawsof2011;

• recommendingtotheGovernorchangesthatwouldassureimplementationisinthepublicinterestofassuringaccessforeligiblepopulations,qualityandappropriatenessofcare,andefficiencyofcare.

Pursuant to the Governor’s Executive Order, beginning on May 1, 2013, theCommission on Medicaid Care Management has now held its 41st Commissionmeeting. In locations around the State from Littleton and Berlin to Portsmouth,Nashua,Keene,andpointsinbetween,publicattendanceatmonthlymeetingsofanaverageof50individualshasallowedCommissionerstoreceivehundredsofhoursof testimony on individual experience in the transition to managed care in NewHampshire. Commission members received hundreds of calls, letters, and emailswith questions and comments. Every effort has been made to acknowledge eachcontact, publicly represent the issues in the formalmeetings, and follow-upwithreferral to the Department of Health and Human Services and managed careorganizations. Many outreach meetings with families, non-profit providers, keyleadersandsubjectexpertshaveoccurred.The Commission has requested and receives tremendous cooperation from NewHampshire providers of Medicaid funded and regulated care. Collaborativeengagementandsystematicproblemsolvinghasbeendemonstratedbyallparties.Commission meetings are organized around populations and problem-orientedinquiries and frequently call on local andnational experts for their review.Theseindividualsinclude:

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Table2:IndividualsWhoGiveGenerouslyOfTheirExpertise:

Date Individual(s) Organization Topics9/5/13 CarlCooley,MD

DonCaruso,MD

CrotchedMountainFoundation,CenterforMedicalHomeImprovementPresident,ChiefExecutiveOfficer,ChiefMedicalOfficer,CheshireMedicalCenter,DartmouthHitchcockKeene

MedicalHomes

10/3/13 WilliamGunn,PhD

SteveArnault,MA

Dartmouth,DepartmentofCommunityAndFamilyMedicineCenterforLifeManagement,DerryNH

BehavioralHealthIntegrationinMedical/HealthHomes

12/5/13 SandersBurstein,

MDSandraPelletier

MedicalDirector,DartmouthHitchcockNashuaPresident/CEOGatewaysCommunityServicesNashua/CareConnect

CareConnectHealthHomeforAdultswithDevelopmentalDisabilities

1/9/14 StevenRowe

GenevieveM.Kenney,PhD

President,EndowmentforHealthCo-DirectorandSeniorFellow,HealthPolicyCenter,UrbanInstitute

EvaluationofNewHampshire’sMedicaidCareManagementbytheUrbanInstitute

3/6/14 RolandLamy Helms&Company,CommunityMental

HealthCenterrepresentativeChallengesandOpportunitiesinBehavioralHealth

5/1/14 SteveNorton ExecutiveDirector,NHCenterforPublic

PolicyStudiesAging,ManagedCareandtheLongTermCareSystem

2/12/15 CindyRobertson,

Esq.BeckyWhitley,Esq.

DisabilityRightsCenter ContractConsiderationsandRecommendationsforNHMedicaid

SarahAikenCathySpinney

CommunitySupportNetwork,Inc. RecommendationsforNHMedicaid

11/12/15

DennisPowersConnieYoung

CEO,CommunityCrossroadsDirector,RockinghamCountyServiceLink

Co-locatingAreaAgencyandServiceLinkResourceCenters

1/14/16 CamilleDobson DeputyDirector,NationalAssociationof

StatesUnitedforAgingandDisabilitiesLTSSCarePlans,AuthorizationsandConsumerProtections

2/11/16 PaulSaucier,MA TruvenAnalytics CareCoordinationModelsin

ManagedLTSS 4/14/16 PeterKelleher

CarolFurlowCEO,HarborHomesVP,HarborHomes

IntegrationofBehavioralandPhysicalHealthServices

5/12/16 MichaelBailit,MBA BailitHealthPurchasingLLC EffectiveStatePurchasingin

MedicaidManagedCare 6/9/16 LisaPerales,ARNP,

MBAErinHall

CrotchedMountainFoundationBrainInjuryAssociationofNewHampshire

ChoicesforIndependenceIndependentCaseManagement

8/11/16 JohnMeerschaertFSA,MAAAPrincipal,ConsultingActuary

Milliman FinancialReportingandEvaluation

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The Commission Has Found That NewHampshire Is Affirmatively InitiatingUrgentHealthCareReformUnderMedicaidCareManagementThe“acutecare”phaseofimplementationofMedicaidCareManagement;StepOne,hasbeencomplexandfastpaced.InmanyinstancesthenationalefforttoestablishMedicaidCareManagementhaslackednationalprecedentandexperienceaswellasFederalguidanceinMedicaidpolicysoastoassureclearbestpractice.TimetablesinNH have been appropriately balanced in reflection of the need for expeditiouschange and also forprudent recognitionof vital health caredemands in this verycostly and complex transition. TheCommissionhas found thatNewHampshire isaffirmativelyinitiatingurgenthealthcarereformunderMedicaidCareManagement.1.)IndividualOutcomesandQualityofCare:EvaluationsofNH’sMedicaidCareManagement transitionarebeingconductedbybothinternalandexternalparties.Internally,astrongcommitmentbyDHHStohealthoutcometrackinghasledtothecreationofaveryvaluable,publiclyavailabledatabaseofenrolleedataandanalysis:https://medicaidquality.nh.gov/Externally there are two evaluations of note. First is the CMSmandated externalevaluationfromtheHealthServicesAdvisoryGroup.Theirreportcanbefoundat:https://medicaidquality.nh.gov/sites/default/files/2016%20Q1%20MCM%20Quality%20Update%20EQRO.pdfAlso, the New Hampshire Endowment for Health has contracted with the UrbanInstitute to conduct a series of reviews. Their work can be found at:http://www.endowmentforhealth.org/index.php?mact=Resources,cntnt01,detail,0&cntnt01articleid=76&cntnt01returnid=64These three evaluations provide significant protection to the objectiveunderstandingoftheperformanceofourMedicaidprogram.Inparticular,overthecoming years the DHHS investment in publicly available, detailed data on healthoutcomeswillprovehighlyvaluableinsteeringpublicpolicy.

DHHS’ investment in highly transparent quality of care information hasproducedtworesults.First, the outcomes from the first phases of caremanagement were publiclytrackedandultimatelyobservedtobepositive.Therewaslittleevidenceoflossin access, quality, or results in the transition toMedicaid CareManagement.This could have been a very disruptive change but the measured outcomesshowed increased access and quality. While it will take time, years in manycases, to show health status improvements, we will be able to observe the

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progressaswegoforward.ThevalueforMedicaidenrolleesandtheirfamilieswillbesignificantovertime.Second,many partners, inNHand beyond, have access to the tools of healthdata and analysis. These measurement systems have built the pathway forcontinuous learning and program improvement. In the area of the citizen’slargest tax resource commitment, this is essential. It also strengthens ourworkforce development in that quality measurement and health data areincreasingly a key ingredient of clinical and administrative education andpractice.

2.)NHHealthProtectionProgram

TheprovisionofMedicaidsupportto100,000ofourcitizens,andtheexpansionofMedicaidto50,000more,isoneofNewHampshire’smostimportantpubliccommitments to our families and communities. To accomplish so successfullythecombinationoftransformationsthatmanagedcareandcaseloadexpansionrepresenthasbeenapremieroperationalfeatoftheDepartmentofHealthandHumanServices.ThevalueinfamilyandcommunitystabilityandtheeconomicimpactofefficientaccesstocareisfundamentaltoourState’sfuture.Benefit expansion introduced by the Health Protection Program broughtsubstance use treatment to groups at high risk for severely negative healthstatus due tomisuse and addiction. The incorporation of treatment into thelarger Medicaid program is showing considerable progress and all involveddeserverecognitionforthishealthcommitment.This can also be seen as preparation to helpNHadapt quickly to aworld ofhealth care change. Getting Medicaid Care Management right will proveextremely helpful as Medicare, community health delivery systems, andpopulationhealthdrivechangeforward.Bi-partisancommitmenthasachievedthispositivepositionanditwillrequirethesamefromhere.

3.)PersonCenteredCare

TheDepartment’scommitmenttorapidresponsetoenrolleedifficultiesreflectsan ethic of caring that is critical to successful fulfillment of its legislatedmission. The State takes seriously each enrollee’s experience in its caremanagement.Asproblemshavearisen, theyhavebeenacknowledgedopenly,aggressively studied,andcreatively improved. In this, theStatehas shown itsdedication to theneededpopulationhealthpractice that the futureMedicaidprogram’ssharplyconstrainedresourceavailabilitywilldemand.TheleadershipoftheDepartmentusedthishighlyengagedproblemsolvingtoestablisha“learningorganization”cultureofhighlymotivatedstaffworkingin

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delegated, team based engagement with the public. This has served to buildpublicconfidenceandtoassurehighperformanceresults.

4.)CMSComplianceandOpportunities

FederalandStateeffortsinthispartnershiparesizablebothfinanciallyandinadministrative oversight. The public rightly demands evidence of goodgovernment in the critical arena of health care. In particular, two agendasshouldbenoted:First,CMShasupdateditsMedicaidManagedCareregulations,strengtheningrequirements in state contracting with Managed Care Organizations.Particularly important is CMS’ requirement that all states incorporate aMedical Loss Ratio (MLR) into the contract. The new rules require eachManagedCareOrganizationtodemonstrateafinancialperformanceofaMLRof85%orgreater.Thismeansthatallhealthplansmustspendatleast85%oftheir Medicaid revenue on enrollee medical care and other activities thatimprovequality.Theremaining15%canbespentonMCOadministrativetasks.Thisprotectsbothourenrolleesandourtaxpayers.Nationally,manyManagedCareOrganizationsalreadymeetthisstandard.Second,theDepartmentofHealthandHumanServicesisworkingcloselywithourcommunitiesofbehavioralhealthstakeholderstoassureaddictivedisorderprevention and treatment – one of ourmost demanding public health crises.DHHShaslaunchedafarsightedintegrationofphysicalandbehavioralhealthcarewithsocialsupports.Withthis“DeliverySystemReformIncentiveProgram”(DSRIP)DHHSandCMSaresupportinglocalpopulationhealthstrategieswitha major investment of Federal financial participation, payment reform, andcommunitypopulationhealthcommitment.

5.)EconomicandResourceSustainability

New Hampshire has shown bi-partisan commitment to a forward lookingpolicyofassuringbestmanagementofthisareaoftheState’slargesteconomicinvestment.Many states are struggling tomaintain financial stability, publicsupport,andqualityintheirMedicaidprogramandthiswillonlybecomemorechallenging over time. Our elected leadership has put aside divisiveness andmadeaverynotablecommitmenttothewellbeingofourcommunities.With Medicaid Care Management, New Hampshire is building efficientoperations thereby protecting its care giving resources. The State is alsoassuring equitable distribution of needed care thereby assuring fair,sustainablemeetingofallenrolleeshighestpriorityneedsduringtheupcomingdecadesofescalatingdemographicdemand.

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Still, it is very early in this effort. Major commitments to a constantlychallenging health care context will test New Hampshire’s politics, ouradministrative capacity, and our health care community. Thismust be facedwith a shared civic intention and a consistent strategy of highly visibleleadership,partnership,andinformationdrivendecision-making.

InSummary:AsdemonstratedbythetestimonyreceivedbytheCommission,multipleevaluatorsources, and the ongoingmaturation of theMedicaid CareManagement program,theperformanceofMedicaidCareManagement inNewHampshire isbeingshowntobepositiveandiscontinuouslyimproving.InparticulartheCommissionwishestoexpressitshighregardfortheworkoftheDepartment of Health and Human Services in this endeavor. The Departmentengagedwiththisprocessinaveryaffirmativemanner,usingpublictestimonyandin depth quality management/results analysis to track progress in each step ofimplementation, formingarapidresponse teamtodigdeeply into theconcernsofindividuals and organizations, and bringing problem solving reports back to thepubliconacontinuousbasis.Second,oftenatgreatcost,theprovidersofcaretoNH’sMedicaidenrolleesinvestedincomplexmanagementsystemsandtechnologychangesenablingtheirsuccessfultransition and uninterrupted care. Providers demonstrated great skill andcommitment to the well-being of NHMedicaid enrollees and great value to NewHampshiretaxpayors.Finally, the Managed Care Organizations, while reducing from three providers totwo,havemaintainedaveryhighcommitmenttothesuccessofthetransition.Eachhas brought value and experience to the vital, many-sided concerns of NewHampshire’s long-term stability of its population health agenda. The MCOs haveprovidedvisible leadershipandresponsivechangestrategies for thehealthofourcitizens.COMMISSIONCONSIDERATIONSTheimplementationofNH’sMedicaidCareManagementeffortwasintwoparts.InDecember of 2013, Step One put into place the Managed Care Organizations,enrolledaportionofMedicaidenrollees,andbegantheprovisionofmanaged,acutecare. One year ago, at the beginning of calendar year 2015, DHHS beganpreparations for StepTwo, the enrollment of allMedicaid eligible individuals andthe extension of care management from acute care to both acute and long-termsupportsandservices(LTSS).

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InMayof2015,inorderfortheCommissiontorevieweffortsunderStepTwoandto thereby establish its next report, the Commission organized fourwork groups.The role of the work groups was to examine the critical performance areas assuggestedbynationalCMSfindingsinordertoassureNH’sreadinessformanagedLTSS in the implementationchallengesofStepTwo.Multiplepublic conversationsensued,involvingNHMedicaidenrollees/families,providersandMCOs,thirdpartyevaluators,nationalexperts,andtheDepartmentofHealthandHumanServices.Thework group’s process of establishing questions, setting priorities, reviewing anddiscussingavailableinformation,andthenestablishingdraftrecommendations,ledtotheCommission’sNextReport.FundamentalReadiness:Many Commissioners provided comment on the importance of ongoingdevelopmentoftwoareas;dataandcommunication.

v BuildingonthesuccessofStepOnequalitymeasurementandpublicanalysis,Step Two data planning and implementation is viewed as fundamentallyimportant. The value of data development was described not only as thecreationofthedatasystemtoassurequalityoftheStepTwoimplementation,but also regarding the ongoing analysis of the impact of Step One and theMedicaid program as a whole, including access to health care for allpopulations,workforce experience, enrollee health status, and the financesandfinancialmanagementoftheMedicaidprogram.

v Communication was also seen as being critical for a successfulimplementation of Step Two, especially meaningful communication withcriticalpartners,suchastheCountygovernment,aswellasenrollees.

The important issues of Data and Communication are reflected in therecommendations, including those recommendations that call for public engagedplanning structures and processes, transparent financial and operationalmonitoring,andLTSSqualitysystems.

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TheGovernor’sCommission

ToReviewandAdviseontheImplementationofNewHampshire’sMedicaidCareManagementProgram

LessonLearnedFromMedicaidCareManagement-AcuteCare

Transitionsto

ManagedLongTermSupportsandServices

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AssuringtheIntegrityofthePlanningforEachStepinMedicaidCareManagementManagementoftheMedicaidProgramisacriticalfunctionoftheStateofNewHampshirecarriedoutonbehalfofitsmostvulnerablecitizens.Anditisanexpensiveandcomplexelementofourstate-widecommunityinfrastructure.Itisessentialthat the continuing transition toMedicaid CareManagementmaintains key values and follows established principles toguide and to assure the integrity of this fundamental fabric of New Hampshire’s family support. The Commission haspreviously recommended, and wishes to restate the following values and principles. The whole text can be seen inAppendixThree:VisionPrinciples,andGuidance:

PrinciplesforaMedicaidManagedLong-termServicesandSupportsProgram:PromotingHealth,Wellness,Independence,andSelf-Sufficiency

1. Development and implementationof a qualityMLTSSprogram requires a thoughtful anddeliberativeplanning

anddesignprocess,buildingonthestrengthsofthecurrentLTSSprogram.

2. ImplementationandoperationoftheMLTSSprogrammustbeconsistentwiththeAmericansWithDisabilitiesActand the Supreme Court Olmstead v. L.C. decision, such thatMLTSS is delivered in the community in themostintegratedfashionandsettingpossibleandinawaythatoffersthegreatestopportunitiesforactivecommunity,educational,andworkforceparticipation,alltotheextentdesiredbyandappropriatetotheindividualparticipant.

3. Paymentstructures forMLTSSsupport thegoalsandessentialelementsof theprogram, includingencouraging,

ratherthandis-incentivizing,homeandcommunity-basedcareandpromotingemploymentservices.

4. TheMLTSSparticipantmustbeassuredtheopportunityforinformedchoiceandassistancethroughconflict-freeeducation,enrollment/disenrollmentassistance,andadvocacy.

5. TheMLTSSprogrammustconsidertheuniqueneedsofthewholepersonthroughperson-centeredpoliciesand

procedures,promotionofself-determination,andopportunitiesforself-direction.

6. Ensuringoneentity isresponsible foracomprehensiveand integratedpackageofacutecareservicesandLTSS(institutional and non-institutional) increases Medicaid program efficiency, avoids cost shifting and servicedisincentives,andenhanceshealthoutcomesandqualityoflife.

7. AprovidernetworkisadequateifitisstronglyrepresentativeoftheStateLTSSinfrastructureanditensuresthe

participantachoiceofandtimelyaccesstoprovidersandnecessaryservicesaswellascontinuityofcareduringtransitionperiods.

8. ParticipanthealthandwelfareinMLTSSisbetterassuredwithstrongandclearlydefinedparticipantprotections

andsupports.

9. TheremustbenoreductioninthequalityofcareprovidedtoparticipantsintheMLTSSmodel,ascomparedtothefee-for-servicemodel and the Statemust exercise all duediligence tomaintain or increase the current level ofquality.

10. EffectiveStateoversightofMLTSSisvitaltoensuringprogramvision,goals,andmanagedcarecontractelements.

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RECOMMENDATIONS

The Governor’s Commission on Medicaid Care Management makes the followingrecommendationstotheGovernor.Therecommendationsareofferedinadditiontothe recommendations previously submitted as listed in Appendix 4: “PreviousRecommendationsoftheCommission”Theserecommendationsareofferedinconsiderationofseveralhealthsystemsgoalsdeemedessentialincluding:

• AssuringimplementationofChapter125oftheLawsof2011andthestatedrequirementsunderMedicaidManagedCareofvalue,quality,andefficiencyofcare,whichareresponsivetotheneedsandconcernsofbeneficiariesandtheircaregivers.

• Assuring accountability, transparency, and communication through datacollectionandoperations that serve tooptimizeefficient functioningof theNHMedicaidProgramforandwithallstakeholders.

• Assuringtheintegrityofacapableprovidernetwork.• Assuring that recipients of the yet to be implemented Long Term Services

andSupports(LTSS)“StepTwo”receiveappropriatecare.• Assuring Medical Homes and health outcomes reflective of best-practice

healthcareforallMedicaidenrollees.The Commission encourages a full consideration of these recommendations asDHHS works to implement Step Two of the Medicaid managed care plan. TheCommissionalsourgesconsiderationoftheserecommendationsasDHHScompletestasks associated with developing the comprehensive plan for services to beincorporated into managed care, as required by Senate Bill553(http://www.dhhs.nh.gov/sb553/documents/sb-553-final.pdf).Recommendations are cross-referencedwith the SenateBill 553plan elements inTable1below.PLANNINGNOWTOASSUREQUALITYOFCAREANDCONSUMERPROTECTIONINTHEFUTURE

ForSeniors:

Recommendation1:CreationofaSeniorSupportsCabinetTheStateshould,byexecutiveorderorlegislativeaction,conveneanongoing,multi-agency “Senior Supports Cabinet” in reflection of ourolder adult demographic growth and needed State agency efforts.Goalsshouldincludethetrackingofpredicteddemographicchangeofour aging population, State policy updating, and coordinatedcommunity awareness and strengthening of local supports. ThisCabinet should incorporate the related recommendations of the

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Governor’s Commission on Health Care and Community SupportWorkforce.

Recommendation2:CommittingtoCommunitySupportsforSeniorsDHHS should make an ongoing and long term commitment to thecommunity support needs of seniors by establishing internal andcommunity leadership roles. DHHS should develop comprehensiveand coordinated oversight and administration of all of its agingservicesregardlessoffundingsourcethroughaninternalstaffingplananassuranceofstrongleadershipforacuteandLTSSseniorcare.Thiscommitment should support access to care, services and supportscoordination, and wellness promotion opportunities by promotingandsustainingServiceLinks.

FortheMedicaidProgram:

Recommendation3:CreationofaStrategicPlan for theFutureoftheMedicaidprograminNHDHHSshouldcreateastrategicplanforthefutureofMedicaidinNH.Theplanshouldprovidestrategicpolicyandfinanceoptionstobuildvalue-based purchasing reflecting the State’s interest in NH’sMedicaid fiscal stability and quality of care. Considerations shouldreflect State assumption of current Federal, CMS authority for NHcitizenswhoare“DuallyEligible”,i.e.MedicaidandMedicareeligible.The plan should inform multi-year budget projections includingcaseload and cost trends. Approaches to workforce recruitment,retention,andtraining,reflectingtheCommissiononHealthCareandCommunity Support Workforce, should be included in the strategicplan. State, MCO, and network enrolled provider roles should berecognized.Recommendations 4: Establishment of a Consumer ProtectionCommitteeDHHS should assure the wellbeing of New Hampshire’s mostvulnerable citizens by establishing a standing “DHHS Committee onConsumerProtectionintheOversightofMLTSS”.

ForSeniorsandtheMedicaidProgram:

Recommendation 5: Planning for LTSS Financing, AddressingConcernsofSeniorsDHHS should revise the long-term supports and services financialstructure by expeditiously developing a DHHS/Stakeholder plan for

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risk based financing. The plan should specifically define nursingfacility payment systems, including County payment, Acuity Basedreimbursement, MQIP, Proshare, IMD and other State and Federalopportunities. Payment formula changes and waiver opportunitiesshould be crafted to maintain support through the change process.The plan should reflect the concerns of senior citizens in thedevelopmentofcommunitybasedcare.

ESTABLISHING DATA COLLECTION SYSTEMS AND SUFFICIENT STAFFING TOOPTIMIZEMEDICAIDFUNCTIONING: TransparentMonitoringofMedicaidFinances:

Recommendation 6: Medicaid Care Management FinancialReportingandEvaluationDHHS should assure the availability and transparency of financialanalysis and data by producing comprehensive Medicaid CareManagement financial reports. DHHS should assure fiscaltransparency, stability and accountability by monitoring MTLSSfinancing related events, results, controls and financial outcomes,including at the encounter level. Financial evaluations should useinternalandexternalaudits. ThiswillrequirethattheDHHSbudgetbeadequatetocovercontractualandactuarialservicesnecessaryforfinancial analysis and financial best practices including value-basedcontractmanagementandfraudandabusecontrols.

MedicaidEfficiencyandEffectiveness

Recommendation7:Providing SufficientDHHS Staffing to AssureMedicaidEfficiencyandEffectivenessDHHS should develop a core functions staffing model and animplementation plan that together protect the efficiency andeffectivenessof theMedicaidCareManagementProgramandassurestrong leadership capacity in contract development,monitoring andenforcement; provider network adequacy and access to services;quality and care coordination assurance and improvement;membereducation and consumer protection; and rate setting adequacy andfinancialoversight.

ASSURINGTHATLTSSRECIPIENTSRECEIVEAPPROPRIATECARE:

Byaddressingpaymentsystemsandaccessbarriers:Recommendation 8: Assurance of Rate Adequacy and NetworkAccessforLTSS

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DHHS should conduct a formal capacity assessment of the currentsystemof services for older adults specifically including a reviewofrate adequacy and network access barriers for LTSS before theconversionfromwaiveredservicestocapitated,riskbasedcontractsis implemented.Theassessmentshouldincluderecommendationstoaddress network adequacy and assurance of CMS andother Federalcompliance needs for home and community based care withimmediatepriorityonthe“ChoicesforIndependence“(CFI)waiver.DHHS should use upcoming waiver revisions to establish rateadjustmentsforseniorcare.Therateadjustmentsshouldbesufficientto reverse the multiyear financial and program losses in LTSSprograms.Thisreviewshouldberepeatedforallsubsequentwaivers.DHHSshouldclearlydefineManagedCarecontractinggoalstoreflectthe quality and financial requirements necessary to care for andsupportindividualsintheircommunities.

Byfollowingbestpracticestoprovidecare:

Recommendation9:ContractLanguagetoAssureAccesstoHealthResourcesandServicesAdministrationMedicalHomesDHHSshouldmonitorMedicaidenrollees’access topatient-centeredintegrated deliverymodels, such as patient-centeredmedical homesandhealth homes, bymeasuring and followingquality andoutcomeindicators.Thisshouldincludeindicatorsspecifically focusedontwovulnerablepopulationsof theduallyeligibleandthosewithcomplexcareneeds.Recommendation10:DHHS IdentificationofAlternativePaymentModelstoHelpPromoteMedical/HealthHomesDHHS should proactively build on the work of the Capacity forTransformation waiver by identifying alternative paymentarrangements that can support and facilitate the development ofpatient-centered integrated delivery models (Patient-CenteredMedical Homes and Health Homes) as well as supporting andenhancingtheLTSSservicesthatarenotprovidedinamedicalsetting.Payment arrangements should assure that savings accrued bymeeting population health outcomes under integrated deliverymodelsareredistributedthroughouttheLTSSdeliverysystem.DHHSshould define “value” in a clear and measurable way and establishperformanceimprovementobjectivesdirectlytiedtopaymentreformwithintheManagedCarecontracts.ThisshouldbeincludedaspartoftheDepartment’splanforimplementingmanagedLTSS.

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Recommendation 11: Assurance of Best Practice in CareCoordinationforStepTwoDHHS should sustain the commitment to quality standards byadopting and implementing best practice quality strategies for LTSSastheyaredevelopedatthenational level,suchasthroughproviderandMCO accreditation byNCQA, and by including requirements forsuch in contractual language for Managed Care Organizations andnetworkproviders.Recommendation 12:Contract Requirement for Person-CenteredCarewithEnrolleeandAdvocateInputDHHS should establish Step Two, person-centered treatment andservice planning by defining and specifying it as a requirement incontractswithManagedCareOrganizations.This should reflectCMSrequirements for person-centered care and be based on extendedreviewwithenrolleesandtheirrepresentatives.Recommendation13:ClearlyDefinetheDifferenceBetweenAcuteCareUtilizationReviewandLTSSServicePlanningDHHS should follow best practice guidelines to clearly identify anddefine a distinction between the purpose and intended outcomes ofacute care utilization review, and LTSS service /care planning,authorization, and review. DHHS should include these definitions intheMLTSSimplementationplan.

Bysupportingexistingrelationshipswithcareproviders:

Recommendation 14: Avoidance of Interruption of ExistingProviderRelationshipsforEnrolleeswithComplexNeedsDHHSshoulddevelopandenforceapolicythatcomplexcareenrolleeswhoarereceivingservices,orneedservices, fromout-of-networkorout-of-state providers are able to access these providers, or receiveadequate notice and explanation from Managed Care Organizationsforchangingproviders,duringanyappealsandgrievances.Recommendation 15: Protecting Service Continuity DuringTransitiontoIntegratedLTSSDHHSshoulddevelopserviceauthorizationrequirementsthatassurecontinuityofservicesduringthefirst12monthsofimplementationofmanaged LTSS. Due to the nature of LTSS prior authorizationcontinuationappliestoboththefunctionanditsproviderandlocation.Thisshouldrequire thatManagedCareOrganizationshonorexisting

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serviceandmedicalauthorizationsuntiltheexpirationdateorneedschange; that any reductions to services must be approved by theDepartment; and that service authorizations for specific providersmustcontinuetorecognizethatproviderwhetherornottheproviderisparticipatinginthemanagedcareprovidernetwork.

Byincludinghigh-qualitybehavioralhealthcare:

Recommendation16:MCMContracts toAssureQualityofCare inBehavioralHealthforMedicaidEnrolleesIncontractswithManagedCareOrganizations,DHHSshouldprovidesufficientdetail inprogramrequirementstoassurethattheprogramelements are implemented as identified in CMS policy or regulatoryrequirements, or State compliance requirements such as thecommunity mental health agreement. DHHS should also specifyprogramrequirementsnecessarytomeetpopulationhealthprioritiesof the State, such as the reduction of substance misuse and theprovision of treatment of substance use disorders. A formal,stakeholderinvolvedprocessshouldbeconvenedbyDHHStoaddresstheseissuespriortothenextMCOcontractcycle.

Byfollowingnationalandstatequalityandcomplianceguidelines:

Recommendation17:MCMContracts toAssureQualityofCare inLongTermSupportsandServicesforMedicaidEnrolleesDHHS should incorporate LTSS program and quality requirementsintocontractswithManagedCareOrganizationsofsufficientdetailtoassure that the program elements are implemented as identified inCMS policy or other Federal requirements, or State compliancerequirements.DHHSshouldmaintainitspolicyofnotproceedingwiththe next steps in Medicaid Managed Care until it is prepared. Suchpreparation should include the assurance of quality of caremeasurement during and after the conversion to Medicaid CareManagement.Atthistime,nonationalsystemofqualitymeasurementunderLTSSexists,unlikethewell-developednationalqualitysystemsrelatedtotheStepOnerelatedconversion.

BUILDINGANDMAINTAININGASTRONGPROVIDERNETWORK:

Recommendation 18: DHHS Engagement of MedicaidEnrollees/AdvocatesinDefiningStepTwo“NetworkAdequacy”DHHS should carefully review and consider the unique needs ofpopulationswhoareduallyeligibleand/orhavecomplexhealthcareneeds when defining network adequacy. DHHS should engageMedicaidenrollees,theirfamilies,advocatesandprovidersindefining

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“network adequacy” for services particular to Step Two and forpopulationswhoareduallyeligibleand/orhavecomplexhealthcareneeds.

Recommendation 19: Ongoing DHHS Network AdequacyEvaluationThroughSolicitationofandResponsetoProviderandEnrolleeConcernsDHHS should systematically and directly engage with MedicaidprovidersandwithMedicaidenrolleesutilizingqualityimprovementmethodologies to measure, analyze and publish concerns aboutexisting or emerging difficulties in providing or receiving care. Toassurethecontinuedavailabilityofessentialproviders,DHHSshouldmonitornetworkadequacywithmultiplemeasures,includingbutnotlimitedto:monitoringtheassociatedworkforcesupply,turnover,andvacancylevels.

ESTABLISHING STRONG RELATIONSHIPS WITH MEDICAID ENROLLEES ANDEFFECTIVELYADDRESSINGCONCERNS:

Recommendation20:AssuringEffectiveCommunicationsBetweenDHHSandLTSSRecipientsDHHS should provide clear, accessible, customer-focused educationand outreach through direct mail and other known methods ofeffective communication to all Medicaid enrollees about programchoices, benefits, and enrollee rights in advance of Step Twoimplementation. This should be vetted by consumers and includeaccessible, widely distributed, understandable information on thechanges inservicesofferedand/orserviceproviders, informationonhow to access services, program contact information,problem/complaint resolution options and enrollee’s rights tomakehealth care decisions. Explanation of their rights should includeinformationonspecificgrievanceandappealrights,theOmbudsmanProgram,departmentcontacts,andtheStatefairhearingprocess.

Recommendation 21: Requirements for Enrollee ComplaintResolutionDHHS should meet compliance standards of CMS final rules byassuring that all elements of the complaint and appeals process arecoordinatedwith,orpartof,abeneficiarysupportsystemthatservesMedicaid enrollees before and after transition into a Medicaidmanagedcareplan.

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Recommendation 22:Preventing and Addressing Abuse, Neglect,ExploitationandComplaintsDHHS should assure that systems are in place to prevent, detect,report,investigateandremediateabuse,neglectandexploitation,andthatthosesystemswilladequatelymonitorandtrackcomplaints.DHHS should provide training and education for MCO staff andproviders about abuse, neglect and exploitation and all prevention,detection, reporting, investigation and remediation procedures andrequirements.DHHS should provide initial and ongoing training and education toMedicaid enrollees about abuse, neglect, exploitation, and reportinginclusiveofcomplaints.

Recommendation23:EstablishmentofanLTSSOmbudsmanAt least four months prior to further implementation of Step Two,DHHSshouldestablishaStatewideLongTermServicesandSupportsOmbudsmanProgram.This independent Ombudsman Program should provide enrolleesdirect assistance in navigating their coverage and in understanding,andexercisingtheirrights.Itshouldprovideconsumereducationandinformation and serve as an access point for unresolved complaintsand concerns. The program should be empowered to assure timelyresolution of enrollee problems aswell as transparent reporting onissuesidentified.TheProgramshouldincludearobustdatacollectionsystem that documents the volume and type of consumercontacts/complaints toStateandhealthplanofficials alongwith theState’sMedicaidCareAdvisoryCommittee(MCAC).Reportsshouldbeprovided at least quarterly to the State, to the managed carecompanies,andtotheMCACandshouldbepostedontherespectivedistributionparty’swebpage.

Recommendation 24: Establishment of a System to Respond toComplaintsandCriticalIncidentsDHHSshouldensureefficientbeneficiaryissueresolutionandoverallsystemic improvement by implementing a transparent, coordinatedcomplaint and critical incident management system with pathwaysfor reporting, inclusive of robust data collection. DHHS shouldmonitor funding, MCO compliance, fee for service compliance andOmbudsmandata andprovide for continuousprocess improvement,maintainingoverallresponsibilityfortheidentification,reporting,andinvestigationsystems.

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CriticalIssuesNeedingAdditionalAttentionThe Commissionworkgroups identified several issues thatwill require additionalattentionbeforeimplementingMedicaidCareManagementStepTwo.WeencourageDHHS to continue working to resolve these items as they could trigger ongoingqualityconcerns.DefiningNetworkAdequacyThe Commission’s Workgroup on Assuring Access to an Adequate Network ofProviders has been particularly concerned about the availability of appropriateservices forMedicaidenrolleesand theabilityofserviceproviders toweather thevarious administrative changes as they occur. For example, it is important thatundermanagedcare,theappropriatespecializedcareforachildonMedicaidwouldcontinue to be available and not replaced by the general care available in acommunitysetting,wheretheskillsrequiredforsuccessareoftenverydifferent.Asanotherexample,aproviderofrehabilitativeservicesinasmallofficewithlimitedresources would likely find it challenging to adapt to new reporting and billingsystems under managed care and it would be essential that those necessaryadministrative adjustments not interfere with the provider’s primary role ofcontinuingtoprovideservicestoMedicaidenrollees.The network of providers under Medicaid managed care includes not onlyindividualmedicalandbehavioralhealthprofessionalsbutalsosystemsofcarethatmay be based in hospitals, outpatient facilities and/or community-based settings.The network is the source of primary and specialty care, medications, durablemedical equipment, rehabilitative services, developmental support, community-basedservices,andallothercareandsuppliesnecessaryforMedicaidenrolleestoachieve optimal physical, emotional, and social health. The network’s adequacydependsontheseprovidersbeinglocatedwithinareasonabledistanceofMedicaidrecipients and both able and willing to supply appropriate services in a timelyfashion regardless of an enrollee’s diagnosis, cultural background, access totransportation or any other characteristic that might be a potential barrier toaccessing care.When thenetwork is “adequate” for the vastmajority ofMedicaidenrollees itmay be inadequate for aminoritywith special circumstances such asthose needing care outside of the provider network. These enrollees will needindividualizedattentiontoassurethattheirhealthcareneedsaremet.Ultimately,achievingnetworkadequacymeansthatallenrollee’shealthneedsaresatisfactorily addressed and that they are able to live, learn, work, and findrecreation in the setting that they choose, working with providers acceptable tothemand/ortheirfamilies(seeWHOdefinitionofHealth).WhilenetworkadequacyiswelldefinedforMedicaidservicesthattransitiontomanagedcareunderStepOne(which includes primary care, specialty care and behavioral health), there is nosimilargenerallyaccepteddefinitionforservicestransitioningunderStepTwo(longtermcare,community-basedservices,developmentalservices,andservicesfortheelderly). Populations that are especially vulnerable to the transitions under Step

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Two include those Medicaid enrollees who are either dually eligible for bothMedicaidandMedicareand/orthosechildrenandyouthwithcomplexhealthcareneeds. Continuity of care is an essential feature of health service delivery.Movement between equally “adequate” providers may make financial sense butcouldimperilanenrollee’shealth.Assuringpatientcenteredcare(StepOne)and/orpersoncenteredcare(StepTwo)forEnrolleeswithComplexCareNeedsThe Commission’s workgroup on Assuring Access to an Adequate Network ofProviders has been concerned about developing and maintaining continuity ofservices for enrolleeswith complex careneeds, both thedually eligible and thosewithcomplexhealthissues,underapatientcenteredcare1plan(StepOne)and/oraperson centered care2plan (StepTwo).Theauthorizing statute,RSA126-A:5,XIX,requiresnodiminutioninthequalityofcareforenrollees.Aspeoplewithcomplexneeds are enrolled inMLTSS, itwill be important tomaintain contract provisionsrequiring person centered care through integrated delivery systems (medicalhomes/healthhomes)andthatthesedeliverysystemsaresupportedtomeetNCQAquality standards. The MCO contracts should specifically require the systematicavailability of person-directed supports in the settings of, and with staff supportreflecting, the person centered plan. MCO enrollee assessment, oversight, andequitable distribution of resources should reflect person centered care planning.MCO contracts should assure independent care management for enrollees withcomplexcareneeds,andongoingMCOoversightandconsumerprotectionreporting.The New Hampshire Department of Health and Human Services will need tocontinuously monitor access to services described above and specifically followindicatorsforenrolleeswithcomplexcareneedsbymeasuringoutcomesincluding:

• completionofhealthmaintenanceactivities(i.e.preventiveservices)• continuityofprescribedmedications,equipmentandtreatments• receiptofthoseservicesthatareindicatedfortheachievementandmaintenanceof

optimalphysical,emotionalandsocialhealth• enrolleesatisfactionwithservicesprovidedbytheirhome-basedcaregivers

DefiningandFullySupportingServiceAuthorizationswithinMLTSS

The Commission’s Workgroup on Assuring Effective Operations and Payment remainsconcerned about service authorizations within MLTSS. As noted in recommendationnumber13,theWorkgroupasksDHHStoclearlyidentifyanddefineadistinctionbetweenacutecareutilizationreviewprocessesandLTSSservice/careplanningprocesses,asthesetwo components of the care systemhavedifferent purposes and intendedoutcomes. TheLTSSplanshouldprovideforserviceandsupportauthorizationsforextendedtimeperiods,asappropriate,forlong-termmaintenanceorimprovementofskillsandfunctionsfordailyliving(habilitativeservicesandsupports).

1SeeNCQADefinitionsforPatientCenteredMedicalHomes.2SeeCMSDefinitionsforPersonCenteredCareinLTSS.

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TheWorkgroup suggests that DHHS follow emerging guidance (see Dobson, January 14,2016)inthisareathatincludes:

• Authorizations that are a full year in length for habilitative services, includinghabilitativephysicaltherapy,occupationaltherapy,andspeechtherapy.

• Authorizationsthatareofshorterduration(lessthanoneyear)forLTSSshort-termservices (examples may include assistive technology or environmentalmodification).

• AllLTSSinthemember'scareplanshouldbeauthorized.

ImplementingandSupportingConsumerProtections

The Commission’s workgroup on Establishing Upfront Consumer Protections has beenconcernedabouthavingmechanismsforprovidingsupport,education,andacentralcontactforcomplaintsorconcernsforenrollees,inplaceduringandafterthetransitionfromafeeforservicesystemtomanagedcare.InMay2016,theU.S.DepartmentofHealthandHumanServices (HHS) issueda final ruleonmanagedcare inMedicaidand theChildren’sHealthInsuranceProgram(CHIP)thatrequires:

• an access point for complaints and concerns about enrollment, access to coveredservicesandotherrelatedmatters;

• education on enrollee grievance and appeal rights, the State fair hearing process,andenrolleerightsandresponsibilities,andadditionalresources;

• assistance in navigating the grievance and appeal process and appealing adversebenefitdeterminationsmadebyaplantoaStatefairhearing;and

• reviewandoversightofLTSSprogramdatatoassist thestateMedicaidAgencyonidentificationandresolutionofsystemicissues.

CMS guidance also requires that states establish and maintain a structure forstakeholder engagement in program planning and oversightand that enrollees withLTSSneedsareinvolvedinpersoncenteredtreatmentandserviceplanning.TheCommissionworkgroupurges theDepartment to continue tomove forwardwithimplementing the new CMS rules and developing consumer protections processesincluding:

• Allelementsofthecomplaintandappealprocessshouldbecoordinatedwith,orbea part of a beneficiary support system that serves enrollees before and afterenrollmentintoaMedicaidmanagedcareplan.

• Membersofahealthplanshouldfirstaccesstheirplan’sCustomerServicesUnitandshouldbeprovidedwithprompt,courteousservice.Iftheproblemisnotresolvedtothe member’s satisfaction, he or she have a right to contact the Department’sAdministrative Appeals Unit for issue resolution and, if necessary, file an appealwiththeDHHS.Inurgentsituations,enrolleesmayrequestanexpeditedappealthatmustbeheardwithinthreedays.

• Inallcases,whethertheinteractionoccurswiththemanagedcareplan,DHHSRapidResponseTeam,orwiththeDHHSAdministrativeAppealsUnit, thememberhasaright to expect prompt, professional treatment thatmeets the needs of a diversepopulation.

• Qualitybenefitsmanagementdictatesthatamember’sconcernsareresolvedatthelowest level of the complaint process possible and that assistance is given in a

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timelyandcourteousmanner. Informationmustbeclear,accessible,andmeettheculturalandintellectualneedsofthemember.

• Decisionsmadeby amanaged care plan or theDepartment ofHealth andHumanServices must be made consistent with a patient centered care plan (Step One)and/or a person centered care plan (Step Two). A resolution must consider andrespondtotheuniqueneedsoftheindividual.

FullySupportingBehavioralHealthServiceNeedsThe Commission’s Workgroup on Assuring Effective Operations and Paymentremainsconcernedaboutintegratingbehavioralhealthservices(bothmentalhealthand substance use disorders) into the evolving care management system. Theseservicesincludethoseforpainmanagement,opioidcontrol,dualdiagnosissupport,and similar treatment. Of particular concern is the potential that the priorauthorizationprocessmayresult indisruptivedenials forpsychiatricmedications.DuringtheCommission’sreviewDHHSprovideddetaileddataconcerningthisissue.Whilethereiscurrentlynoevidenceofasystemicproblemwithmedicationdenials,therecontinuetobeisolatedproblemswithindividualenrolleesandproviders.TheCommission workgroup encourages DHHS to continue to actively monitor priorauthorizationdenialsinformationandtoworkcloselywithprovidersandenrolleesto resolve problems as they may occur. DHHS should also work closely withbehavioralhealthprovidersandMCOs toco-developmedicationreviewprocessesand criteria to assure that enrollees with acute or chronic behavioral healthconditionsreceivemedicationauthorizationsthatareappropriatetotheenrollee’streatmentneedsandpatientcenteredcareplans.

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AppendixOne:AuthorizingStatute

CHAPTER 125

SB 147-FN – FINAL VERSION

03/16/11 0790s

03/23/11 1019s

27Mar2011… 1564h

27Mar2011… 1610h

05/18/11 1827eba

2011 SESSION

11-0215

01/10

SENATE BILL 147-FN

AN ACT relative to Medicaid managed care.

SPONSORS: Sen. Bradley, Dist 3; Sen. De Blois, Dist 18; Sen. Forrester, Dist 2;

Sen. Forsythe, Dist 4; Sen. Gallus, Dist 1; Sen. Groen, Dist 6; Sen. Lambert, Dist

13; Sen. Luther, Dist 12; Sen. Morse, Dist 22; Sen. Odell, Dist 8; Sen. Sanborn, Dist

7; Sen. White, Dist 9; Sen. Barnes, Jr., Dist 17; Sen. Boutin, Dist 16; Sen. Carson,

Dist 14

COMMITTEE: Health and Human Services

AMENDED ANALYSIS

This bill requires the commissioner of the department of health and human services

to issue a 5-year request for proposals to enter into contracts with vendors of a

managed care model to provide for managed care services to the Medicaid

population. The commissioner, in consultation with the fiscal committee of the

general court, is granted rulemaking authority for the purposes of this bill.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - -

Explanation: Matter added to current law appears in bold italics.

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Matter removed from current law appears [in brackets and struckthrough.]

Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

03/16/11 0790s

03/23/11 1019s

27Mar2011… 1564h

27Mar2011… 1610h

05/18/11 1827eba

11-0215

01/10

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Eleven

AN ACT relative to Medicaid managed care.

Be it Enacted by the Senate and House of Representatives in General Court convened:

125:1 New Paragraph; Medicaid Managed Care. Amend RSA 126-A:5 by inserting after paragraph XVIII the following new paragraph:

XIX.(a) The commissioner shall employ a managed care model for administering the Medicaid program and its enrollees to provide for managed care services for all Medicaid populations throughout New Hampshire consistent with the provisions of 42 U.S.C. 1396u-2. Models for managed care may include, but not be limited to, a traditional capitated managed care organization contract, an administrative services organization, an accountable care organization, or a primary care case management model, or a combination thereof, offering the best value, quality assurance, and efficiency, maximizing the potential for savings, and presenting the most innovative approach compared to other externally administered models. The department shall present the opportunities of the various models or combination of models with a recommendation for the best managed care model for New Hampshire, no later than July 15, 2011, to the fiscal committee of the general court which shall consult with the oversight committee on health and human services. Services to be managed within the model shall include all mandatory Medicaid covered services and may include, but shall not be limited to, care coordination,

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utilization management, disease management, pharmacy benefit management, provider network management, quality management, and customer services. The model shall not include mandatory dental services. The commissioner shall issue a 5-year request for proposals to enter into contracts with the vendors that demonstrate the greatest ability to satisfy the state’s need for value, quality, efficiency, innovation, and savings. The request for proposals shall be released no later than October 15, 2011. The vendors of the managed care model or combination of models demonstrating the greatest ability to satisfy the state’s need for value, quality, efficiency, innovation, and savings shall be selected no later than January 15, 2012 with final contracts submitted to the governor and council no later than March 15, 2012 unless this date is extended by the fiscal committee. After the bidding process, the commissioner shall establish a capitated rate based on the bids by the appropriate model for the contract that is full risk to the vendors. The capitated rate shall be broken down into rate cells for each population including, but not limited to, the persons eligible for temporary assistance to needy families (TANF), aid for the permanently and totally disabled (APTD), breast and cervical cancer program (BCCP), home care for children with severe disabilities (HC-CSD), and those residing in nursing facilities. The capitated rate shall be approved by the fiscal committee of the general court. The managed care model or models’ selected vendors providing the Medicaid services shall establish medical homes and all Medicaid recipients shall receive their care through a medical home. In contracting for a managed care model and the various rate cells, the department shall ensure no reduction in the quality of care of services provided to enrollees in the managed care model and shall exercise all due diligence to maintain or increase the current level of quality of care provided. The target date for implementation of the contract is July 1, 2012. The commissioner may, in consultation with the fiscal committee, adopt rules, if necessary, to implement the provisions of this paragraph. The department shall seek, with the approval of the fiscal committee, all necessary and appropriate waivers to implement the provisions of this paragraph.

(b) The department shall ensure that all eligible Medicaid members are enrolled in the managed care model under contract with the department no later than 12 months after the contract is awarded to the vendor or vendors of the managed care model.

(c) For the purposes of this paragraph:

(1) An “accountable care organization” means an entity or group which accepts responsibility for the cost and quality of care delivered to Medicaid patients cared for by its clinicians.

(2) “An administrative services organization” means an entity that contracts as an insurance company with a self-funded plan but where the insurance company performs administrative services only and the self-funded entity assumes all risk.

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(3) A “managed care organization” means an entity that is authorized by law to provide covered health services on a capitated risk basis and arranges for the provision of medical assistance services and supplies and coordinates the care of Medicaid recipients residing in all areas of the state, including the elderly, those meeting federal supplemental security income and state standards for disability, and those who are also currently enrolled in Medicare.

(4) “A primary care case management” means a system under which a primary care case management contracts with the state to furnish case management services, which include the location, coordination, and monitoring of primary health care services, to Medicaid recipients.

125:2 Effective Date. This act shall take effect upon its passage.

Approved: June 2, 2011

Effective Date: June 2, 2011

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AppendixTwo:ExecutiveOrder

30

31

32

Appendix3Recommendation4:VisionPrinciples,andGuidance

33

34

35

36

37

38

39

40

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Appendix4:PreviousRecommendationsoftheCommission

andRecommendationCross-ReferencewithSenateBill553

Recommendation#1:MedicaidExpansion,May31,2013TheGovernor’sCommissiononMedicaidCareManagementherebyrecommendsthatMedicaidexpansionbeimplementedinNewHampshireduetoitsnecessityinensuringthesuccessfultransitionfromaMedicaidfeeforservicesystemtoamoreefficient,moreeffective,andmorecost-effectiveMedicaidcaremanagementsystemintheGraniteState.WerecommendtheimplementationofMedicaidexpansiontoensurethesuccessfultransitionfromaMedicaidfeeforservicesystemtoamoreeffectiveandmorecost-effectivesystemofMedicaidCareManagementinandforourstate.AfailuretoapproveandimplementMedicaidexpansionimperilsthispragmaticandcompellingopportunity”.__________________________________________________________________________________________Recommendation#2:ManagementReporting,November7,2013Governor’sCommissiononMedicaidCareManagementherebyrecommendsthattheGovernorrequestfromtheDepartmentofHealthAndHumanServices(DHHS)systematicpublicreportingofinformationthattracksimplementationconcerns,asconsistentwithDHHSdatacollectionprocessandotherreportingrequirementsassociatedwithMedicaidCareManagement.BeginningwiththeinitialimplementationofMedicaidCareManagementandthroughJune30,2014,TheCommissionrecommendsthattheGovernorrequestthatDHHSestablishPublicInformationReportingonakeysetofissueswhichhavebeenidentifiedduringCommissionmeetingsasthosethatareprioritiesforsuccessfulpublicbenefitofMedicaidCareManagement.TheCommissionrecommendsthatthereportingbecompletedonatimelybasis,publishedasfrequentlyasmonthlywhenapplicable.__________________________________________________________________________________________Recommendation#3:Patient-CenteredMedicalHome,April3,2014TheGovernor'sCommissiononMedicaidCareManagementherebyrecommendsongoingsystemtransformationthatembracesthePatient-CenteredMedicalHome(PCMH)practicemodelasaprincipalprimarycareservicedeliverymodeloftheNewHampshireMedicaidCareManagementProgram.__________________________________________________________________________________________Recommendation#4:OperatingPrinciples,April3,2014:TheGovernor’sCommissiononMedicaidCareManagementherebyrecommendsthatthefollowingprinciplesbeimplementedtoguidethetransitionfromthecurrentsystemsofprovidingMedicaidfundedLongTermServicesandSupports(LTSS)toamoreefficient,effective,andcost-effectiveManagedMedicaidLongTermServicesandSupports(MLTSS)systemtoensurethattheindividualswhorelyontheseservicesexperienceasmoothtransitionandmaintainahighqualityofservicesandsupports.TheseprinciplesincorporatetheprinciplespresentedbyGovernorHassantotheGovernor’sCommission,theguidanceonMLTSSfromtheCentersforMedicareandMedicaidServices(CMS),stakeholderforuminput,andFederalMedicaidpolicy,shouldguidethedevelopmentandimplementationofMedicaidManagedLongTermServicesandSupports(MLTSS)andbeusedasaguidepostfordevelopmentofcontractswiththeMCO’s.__________________________________________________________________________________________Recommendation#5:MedicaidExpansion,May15,2016TheGovernor’sCommissiononMedicaidCareManagementherebyrecommendsthatMedicaidexpansionbecontinuedinNewHampshireduetoitspositiveimpactonthehealthofourcitizens,ourhealthcaresystemandoureconomy.__________________________________________________________________________________________

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Table3RecommendationCross-ReferencewithSenateBill553

SB553PlanElement RecommendationNumberEligibilityandEnrollment

1,2,3,5,6,7,10,11,13,14,15,16,17,21,24

CoveredServices 5,16,21TransitionPlanning 14,15,16PriorAuthorization Transportation Pharmacy 14CaseManagement 2,7,10,11,12,13,21NetworkAdequacy 1,3,7,6,15,16,19,20,21Credentialing QualityMetricsandOutcomeMeasurements

3,6,10,11,18,20

PatientSafety UtilizationManagement 8FinanceandReimbursement

2,3,5,6,11

RatesandPayment 6,7,9GrievanceandAppeals 7,15,16,21,22,23,25OfficeofOmbudsman 21,24Providingvalue,Quality,EfficiencyInnovationandSavings

1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25

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Appendix5:

WorkGroupsoftheCommission:

1)MEETENROLLEE’SNEEDSTHROUGHPUBLICENGAGEMENTANDCOMMUNITYBASEDSUPPORTSANDSERVICES: Members PriorityInquiries:

v DougMcNuttv SueFoxv Roberta

Bernier

§ MCOstaffareknowledgeablere:purpose&structureofcommunitybasedservices&LTSSandfederalandstatemandatesandthes.

§ …….earereflectedinpolicies&procedures§ DHHSstaffareknowledgeablere:purpose&structureofcommunitybasedservices&

LTSSandfederalandstatemandatesandthesearereflectedinpolicies&procedures§ Eachindividualhasaccesstocarecoordinationwhichworkswithfamily&providers

includingthemedicalhomereflectingtheirvaluesandresultingincontinuityofcare§ Infrastructure&policiesensureindividuals&providershavepersonalchoice&

controlindeterminingtheirhealthcareneeds&LTSS§ RoleofBureauofDevelopmentalServicesisclearlydefinedduringplanning,

implementation&evaluation 2)ASSUREEFFECTIVEOPERATIONS&PAYMENTSYSTEMS Members PriorityInquiries:

v YvonneGoldsberry

v TomBunnell

v Priorauthorizationisstreamlinedv MCOproceduresaccommodatelongtermcarerealitiesv Operationalconstructsallowfortimelychangeifprocessnotworkingv Conflictofinterestisclearlyarticulatedandsystemsreflectsuchv Atonset,fullstandardizationofpaperwork,communication,billing,reportingmaterialsv Paymentsystemssupportgoals&essentialelementsofprogramv Incentivizehome&communitybasedcarev Contractsallow&supportinnovation(combinewith1stitemonPA)v Addressratesetting&managementinadditiontopriorauthorization

3)ASSUREACCESSTOANADEQUATENETWORKOFPROVIDERS Members PriorityInquiries:

v WendyGladstoneMD

v JoPorterMPH

v IncludesLTSSandhomeandcommunitybaseprovidersv IncludesStep1providerstoprovidemedicalhome&specialtycaretonewStep1

populationsincludingthe“dualeligible,Medicaid-Medicareenrollees”and“childrenwithspecialmedicalneeds”

v Arewelltrainedinpriorauthorization,coding,billingandpayment(operations?)v CoordinateswithexistingprovidernetworknotrelatedtoLTSSincludingacutecare

resultinginanintegratedsystemofcarev Includesinandoutofstateservicesv Providesmedicalhomeandspecialtyservices(mergewith2ndbullet)v Addressneedsof“all”includingthe“difficultperson”

4)ESTABLISHUPFRONTCONSUMERPROTECTIONS

Members PriorityInquiries:

v GusMoralev KenNorton

§ Accesstoclientombudsmanforassistance§ Grievance&appealprocessisefficient,timely,knowledgeable&respectivefor

individuals&providers(needstobeanupfrontproblemresolutionsystemthatclientsareawareofbeforethislevel)

§ Considermaintainingexistingservicesduringinitialimplementationforadeterminedamountoftimewhereappropriate

§ Areinplace&provideinformationthatisaccessible&understandabletoall§ Programisadjustableovertimeasfeedbackisreceived§ Today’sstrongsystemofadvocacyissustained

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AppendixSix:Acronyms/References/Sources

Table5:Acronyms:CFI DHHSMedicaidWaiver;ChoicesforIndependenceCMHC CommunityMentalHealthCenterCMS CenterforMedicareandMedicaidServicesCSNI CommunitySupportNetworkInc.DHHS NewHampshireDepartmentofHealthandHumanServicesDSRIP DeliverySystemReformIncentiveProgramFFS FeeForServiceIMD InstitutionsforMentalDiseasesLTSS LongTermSupportsandServicesMCO ManagedCareOrganizationMLR MedicalLossRatioMLTSS ManagedLong-termServicesandSupportsProgramMMIS MedicaidManagementInformationSystemMQIP MedicaidQualityIncentivePaymentsNCQA NationalCommitteeforQualityAssuranceNASUAD NationalAssociationofStatesUnitedforAgingandDisabilityNF NursingFaciltiyPA PriorAuthorization InadditiontotheextensivematerialsdistributedandpostedontheCommission’swebsite,http://governor.nh.gov/commissions-task-forces/medicaid-care/index.htmthefollowingmaterialswereuseddirectlytodeveloprecommendations.ConsumerProtectionsFederalSources:FederalRegister,Vol.81,No.88,Friday,May6,2016/RulesandRegulations,page128DepartmentofHealthandHumanServices,CentersforMedicare&MedicaidServices,42CFRParts431,433,438,etal.,MedicaidandChildren’sHealthInsuranceProgram(CHIP)Programs;MedicaidManagedCare,CHIPDeliveredinManagedCare,andRevisionsRelatedtoThirdPartyLiability;FinalRule.FederalRegister,Vol.81,No.88,Friday,May6,2016/RulesandRegulations.Linkis:https://www.gpo.gov/fdsys/pkg/FR-2016-05-06/pdf/2016-09581.pdf

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CMSGuidancetoStatesUsing1115Demonstrationsor1915(b)WaiversforManagedLongTermServicesandSupportsCMSFinalRuleOther:CamilleDobson/NASUADPresentationDHHSPresentationConsumerProtectionsandCFIWaiverAmendmentCommissiononMedicaidCareManagement,StatementofPrinciplesEffectiveOperationsReferences:AARPPublicPolicyInstituteandMathematica:KeepingWatch:BuildingStateCapacitytoOverseeMedicaidManagedLong-TermServicesandSupports,DebraJ.Lipson,etal.,July2012.CamilleDobson:LTSSCarePlans,AuthorizationsandConsumerProtections,PresentationtoNHMedicaidCareManagementCommission,January14,2016.BailitHealthandtheNationalAssociationofMedicaidDirectors:TheRoleofStateMedicaidProgramsinImprovingtheValueoftheHealthCaresystem,March22,2016.Bailit,Michael:Presentation“MedicaidManagedCare:LessonsLearnedAboutEffectiveStatePurchasing”,NewHampshireMedicaidCareManagementCommissionMeeting,May12,2016NationalGovernor’sAssociation,Bailit,et.al.,“2015MedicaidHealthCarePurchasingCompendium.”NationalGovernor’sAssociationCenterforBestPractices,November2015.Norton,Steve(2014).“Aging,ManagedCareandtheLongTermCareSystem.”PresentationtotheGovernor’sCommissiononMedicaidCareManagement.May1,2014.Norton,Steve(2012).“AgingandthePublicLong-term-careSystem.”ReportpublishedbytheNHCenterforPublicPolicyStudies.September2012.Norton,Steve(2015).“TheEconomicsofAging:ChallengesandOpportunities.”PowerpointPresentation.http://www.nhpolicy.org/topics/health-care-in-nhOlmsteadv.L.C.,527U.S.581(1999).WorldHealthOrganization(1946),WHODefinitionofHealth.