Updating the Building Code: Modernizing Medicaid Managed Care Regulations

Tricia BrooksSarah SomersKelly Whitener

CCF Conference 2015

OVERVIEW OF PROPOSED REGULATIONS –

WHY THIS? WHY NOW?

2

Kelly Whitener

Why Now?

• The NPRM is the first update to Medicaid and CHIP managed care regulations in over a decade. - Today, the predominant form of Medicaid is managed care,

relying on capitated, risk-based arrangements- More than two-thirds of children in Medicaid or CHIP rely

on managed care

3

Why This?

• The NPRM is governed by 5 key principles- Alignment with other insurers- Delivery system reform- Payment and accountability improvements- Beneficiary protections- Modernizing regulatory requirements and improving the

quality of care

4

IMPROVING THE BENEFICIARY EXPERIENCE

CONSUMER INFORMATIONENROLLMENTDISENROLLMENT BENEFICIARY SUPPORT SYSTEM

5

Tricia Brooks

Consumer Information• Modernizes communications, including use of

electronic communication methods• Requires use of common definitions of

managed care terms• Improves transparency and access to

information• Boost language and accessibility requirements• Specifies content for provider directories,

enrollee handbooks, and other materials

6

Transparency – State Website Requirements

• MC contracts and related plan data*

• MC approval status (state review or accreditation)

• Network adequacy standards

• Enrollee Handbooks• Provider Directories• Formulary Drug List

• Statewide quality strategy

• Quality metrics and performance standards

• Evaluation of quality strategy effectiveness

• EQR Technical Report

* State may post or provide upon request 7

Enrollee Information• State or contracted

representative• Provide in paper or electronic

form at time of eligibility or required enrollment within timeframe that allows plan selection– Info on right to disenroll

and process– Populations excluded,

subject to mandatory vs. voluntarily enrollment

– Basic features of managed care

– Network adequacy standards– Service area– Benefits provided by plan, by

state, referrals when services are not covered due to moral/religious objections

– Provider directories– Cost-sharing– Quality and performance

indicators

8

Enrollee Handbook• State must develop

model handbook (and notices!)

• Each plan must provide • Content must include

info that enables enrollee to understand how to use managed care

• Minimum Content

– Benefits including amount, duration, scope

– How and where to access benefits

– Cost-sharing– Transportation– Excluded services

(moral/religious objections)– Emergency care and access– Enrollee rights– Changing PCP– Grievances, appeals, fair

hearings– Advance directives– Accessing auxiliary aids

9

Provider Directory• Each plan must provide

in paper and electronic form

• Update paper monthly and electronic in 3 days

• Available on website in machine readable format

• Minimum Content

– Providers name and group affiliation

– Includes all provider types and pharmacies

– Street address(es)– Telephone number(s)– Website URL– Specialty – Accepting new patients?– Cultural and linguistic

capabilities– Accessibility for people with

physical disabilities

10

Formulary Drug List• Each plan must provide

in paper and electronic form

• On website in machine readable format

• Minimum Content– Covered drugs (both

generic and brand)– Tier

11

Likes• Transparency and

requirements for web posting

• Detailed enrollment information

• Specificity on enrollee handbooks and provider directories

• Standard managed care terms

Wants• More specificity on

“prevalent” languages• Federal standard or model

managed care definitions• Federal model handbooks• Require posting of all

enrollee information• More specificity on drug

formulary• Require “competent” oral

and written translation

12

Beneficiary Support System

• New section boosts consumer access to assistance and information

• Provides support to beneficiaries prior to and after enrollment

• Some aspects focus on LTSS only*

• Elements of the BSS:

– Choice counseling– Training for network providers and

plans on community supports– Assist enrollees in understanding

“MC”– Outreach in multiple ways– Assistance on LTSS*

• Access point for complaints• Education on and assistance with

grievances, appeals, fair hearings• Review and oversight of LTSS

program data to identify and resolve systemic issues

13

Likes• Boosts consumer assistance

similar to SHIPs and Navigators

Wants• Provide full scope of BSS to

all enrollees, not just LTSS• Most parts of BSS should be

independent from state (perhaps not choice counseling)

14

Enrollment

• New regulations relating to enrollment in voluntary managed care where none exist

• Aligns enrollment requirements for voluntary and mandatory managed care

• Requires that all beneficiaries be enrolled in FFS during 14-day enrollment period

• Adds criteria for auto-assignment

15

Likes• Standards for voluntary

enrollment period before enrolling with only opt-out opportunity

• Alignment standards for voluntary and mandatory

• Provides enrollment period and use FFS in interim

• Enrollment clock doesn’t start until 3 days after info mailed

• Additional criteria for auto-assignment

Wants• Boost enrollment period to

45 days for exempt groups, and 30 days for all others

• Tweaks to auto-assignment based on existing provider relationships

• Delay enrollment clock by 5 days

16

Disenrollment

• Carries forward annual opportunity to switch plans

• Clarifies that ability to switch plans in first 90 days is limited to the initial enrollment

• Clarifies timeframes for processing disenrollment requests

• Adds cause for LTSS disenrollment if care would be disrupted due to provider leaving the network

17

Likes• Continues ability to

disenroll at any time for cause

• Continues protection from plans “dumping” high needs enrollees

• Protects LTSS enrollees from disruptions in care

Wants• Add cause reasons – PCP or

other provider giving treatment leaves network

• Suggest reframing annual disenrollment opportunity to annual open enrollment or opportunity to switch plans

• Recommend aligning annual open enrollment with renewal

18

Marketing Restrictions

• Carries forward restrictions on managed care plan marketing to enrollees

• Adds text messaging and email to definition of cold-calling

• Marketplace QHPs are expressly excluded

19

IMPROVING THE BENEFICIARY EXPERIENCE

NETWORK ADEQUACY

20

Sarah Somers

Network Adequacy – New Requirement

• Primary care – Pediatric and adult

• OB/GYN• Behavioral health• Specialist

– Pediatric and adult• Hospital

• Pharmacy• Pediatric dental and • Additional provider

types (det. by CMS)– Requests comment on

whether there should be standard for family planning

21

Would require states to develop time and distance standards in 7 specific areas, and to develop specific standards for MLTSS:

Network Adequacy

• Would require states to establish network adequacy standards for specified provider types- Does not specify what those standards must be- Did not impose national standard for provider

ratios- Did not follow Medicare model - seeks comment

on this

22

Network Adequacy

• Would require plans to ensure access by enrollees with disabilities and LEP enrollees, and requires plans to participate in state efforts to deliver culturally competent care

• Would require plans to document and states to assess network adequacy and certify to CMS at least annually that the network is sufficient

• Includes explicit requirement to develop time and distance standards for LTSS- Both for travel to providers and provider travel to

beneficiaries

23

Likes• Requires states to have

time/distance standards• Imposes specific

requirements for COC

Wants• Require additional

standards (provider ratio)• Break out pediatric

behavioral health• Specify time/distance for at

least some services• Provide for COC in other

circumstances (moving from MCO to FFS, moving from plan to plan)

24

Continuity of Care (COC)

• Requires states to adopt a COC policy for enrollees who move from fee-for-service (FFS) to managed care or who switch plans- Maintenance of comparable level of services

during transition, continuation of care with out-of-network provider when risk of serious detriment to enrollees' health or risk of hospitalization or institutionalization

25

Continuity of Care • When an enrollee moves from FFS to MCO, would

require state to:- Provide historical utilization data in a timely fashion- Would allow discretion as to – • which providers are covered• how long COC will last• what process plans must follow in terms of sharing

medical records during the transition process• State would be allowed to give each MCO

discretion to tailor its own COC policy

26

Grievance and Appeal

• Extend requirements to PAHPs• Adds definition of “adverse benefit determinations”

- Medical necessity- Appropriateness or effectiveness- Setting where care is provided

• Imposes uniform 60 day deadline for filing appeals• Requires plans to decide appeal in 30 days (change

from 45)• Requires exhaustion of internal plan appeals

27

Grievance and Appeal

• Constitutional requirement to provide services if an enrollee has a pending appeal

• Current regs – allow MCOs to end services at the end of the authorization period even if enrollee appeals

• New regs – would require plan to continue services until final appeal decision- “we believe that this is acritical enrollee protection, given

the nature and frequency of many ongoing services, particularly for enrollees receiving” MLTSS.

28

Exhaustion of MCO Appeal

• Current: may be required by state Medicaid agency

• Proposed: states must require it- Change in policy for many states (California,

District of Columbia, Florida, Idaho, Maryland, Michigan, Missouri, New Jersey, New York, Pennsylvania, Tennessee, Texas, Virginia, Wisconsin)

29

Likes• Services continuing until

appeal (not just authorization period expiration)

• Clear requirements for time frames

Wants• No exhaustion requirement

30

STRENGTHENING PROGRAM INTEGRITY AND SYSTEM REFORM EFFORTS

31

Sarah Somers

Actuarial Soundness

• Rates projected to provide for all reasonable, appropriate, and attainable costs for population covered

• Proposing definition, standards for rate setting- Based on generally accepted actuarial principles and

practices- Based upon encounter data, audited financial reports, FFS

data

32

Transparency in Rate Setting

• Would require more consistent and transparent documentation of rate setting process

• Would prescribe specific steps to be taken during rate setting process

33

Contracting requirements• Would require contract to include:

- Capitation rate- Prohibition on enrollment discrimination- Services covered- Requirement to comply with applicable laws/conflict of

interest safeguards- Inspection of records/recordkeeping- Physician incentive plans- LTSS/duals- Outpatient drugs- Payments for institutions for mental diseases

34

QUALITY IMPROVEMENT

35

Tricia Brooks

Substantial Changes to Quality Regulations

• Expands scope of Statewide Quality Strategy• Extends External Quality Review (EQR) to all

types of capitated managed care plans• Boosts public input to quality strategy• Provides transparency in quality requirements

and plan performance• Provides opportunity for CMS to align with

Child Core Set and National Quality Strategy

36

State Comprehensive Quality Strategy

• Written plan for assessing and improving quality of health care and services for all beneficiaries

• No longer limited to MCOs and PIHPs

• Includes FFS, PAHPs, PCCM Entities, CHIP

• Must include:– Goals for continuous

improvement that are measurable and relate to all populations served

– Identify specific quality metrics and performance targets

– Post quality metrics and performance outcomes at least annually

37

Public Input and Transparency

• Must obtain input of Medical Advisory Committee and other stakeholders, including tribes in development

• Make strategy available for public comment• Submit initial strategy for CMS comment and

feedback, and at time of major revisions • Post final strategy on state website• Review and update at least every 3 years

38

Review Effectiveness of Strategy

• Must evaluate the effectiveness of strategy at least once every three years

• Post results and findings of the effectiveness evaluation on the state website

39

Quality Measurement and Improvement

• Specifications on quality assessment and performance improvement program

• Requirements for state review and approval of all contracting MCOs or formal accreditation

• Specifications for Medicaid managed care plan rating system

• Specifications for managed care elements of comprehensive quality strategy

• Updated requirements for EQR

40

Updates Definitions

• Adds definition for access, referencing new network adequacy standards and availability of services

• Updates quality relating to EQR and degree to which desired health outcomes are achieved- Adds evidence-based knowledge to provision of

services- Incorporates positive trends and performance

measures and clinically significant results from performance improvement activities

41

Quality Assessment and Performance Improvement

• Adds stakeholder input to process if CMS specifies performance measures that states and plans must use- Allows for state exemption (e.g. insufficient

enrollment, population not served)• States may add PIP topics and performance

measures• Adds requirement for specific LTSS quality

evaluation

42

Performance Improvement Projects

• Added regulatory language: “These projects must be designed to achieve, through ongoing measurements and intervention, significant improvement, sustained over time, in clinical care and nonclinical care areas that are expected to have a favorable effect on health outcomes and enrollee satisfaction.”

43

Sates Must Review and Approve Plans

• Applies to MCOs, PIHPs, and PAHPs• Must be accredited by CMS recognized entity

or state must review based on “as stringent” standards

• Must reapprove at least every 3 years• Plans must maintain consistent performance

44

Medicaid Managed Care Rating System• 5 star similar to Medicare Advantage Plans or

Marketplace QHPs• CMS will establish methodology using 3 criteria:

- Clinical quality management- Member experience- Plan efficiency, affordability, and management

• State collects data, applies the measures to a quality rating, posts quality ratings

• State may request CMS approval for alternative

45

External Quality Review

• Adds mandatory activity – validate network adequacy

• States may require that a qualified EQRO performs EQR for each PCCM entity

• May not use an EQRO that conducted an accreditation review of that plan

• EQR results recommendations: how state can target goals and objectives in the comprehensive quality strategy

46

Likes• Comprehensive strategy

expanded to all delivery systems

• Requirement for validation of network adequacy as an EQR activity

• Transparency and public process

• Opportunity for CMS to require reporting on Child Core Set

Wants• Add focus on health

disparities• More distinction on needs of

pediatric population• Need specificity on how

measures and improvement projects apply to FFS

• Add structure to public processes (similar to §1115)

• Require direct testing in validating network adequacy

• Limit exemptions and do not accept accreditation for quality reporting

47

CHIP

48

Kelly Whitener

CHIP Alignment with Medicaid

• Medical loss ratio• Information requirements• Disenrollment• Conflict of interest• Continued services to

enrollees• Network adequacy• Enrollee rights and

protections

• MCO, PIHP and PAHP standards

• Quality measurement and improvement

• External quality review• Grievance system• Program integrity• Sanctions

49

CHIP substantially adopts Medicaid provisions related to:

How is CHIP different?

• Contracting- CHIP managed care contracts are not submitted to nor

reviewed by CMS regularly at this time- Existing regulations for CHIP managed care are very light

and do not include standard contracting provisions- The NPRM proposes that states submit CHIP contracts to

CMS for review, but does not condition FFP on prior approval

50

How is CHIP different?

• Enrollment- The NPRM does not adopt the Medicaid enrollment

standards- The NPRM does adopt the Medicaid standards for a

default enrollment process, but only when states have one- These distinctions are related to differences in the CHIP

statute and overall program structure• CHIP does not require a choice of plans at enrollment, and many

separate CHIP states do not have a FFS delivery system at all• CHIP may require a premium payment prior to enrollment

51

How is CHIP different?

• Beneficiary support system- The NPRM does not propose to adopt a beneficiary

support system requirement in CHIP- One function of the beneficiary support system – choice

counseling – may be inapplicable to CHIP in some states, but other aspects are still relevant, like assistance with appeals & grievances processes

• External quality review- The NPRM proposes to match CHIP EQR expenditures at

the CHIP enhanced FMAP rate that applies generally to CHIP, but subject to the 10% limit on administrative expenses

52

Likes• Alignment with Medicaid will

help promote efficiency and uniformity

• Additional guidance on CHIP contracting requirements, along with requirements to make the contracts public, will allow for greater transparency

• Integrating CHIP into the state comprehensive quality strategy will promote better quality care for kids across the board

Wants• Require submission of CHIP

contracts as a condition of FFP

• Collect information on CHIP enrollment processes for future rulemaking

• Collect information on CHIP capitation rates

• Add the beneficiary support system requirement to CHIP

• Allow EQR expenditures to be accounted for outside of the 10% administrative cap

53