Medicaid Managed Care Regulations

1. Medicaid Managed Care Regulations Silvia Rodriguez-Sánchez Erika Cristo

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

3. Background • Medicaid is a joint Federal and State health care program • States have flexibility in administering their Medicaid programs • DHS administers California’s Medicaid program: Medi-Cal • DMH administers California’s Medi-Cal Managed Mental Health Care Program

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

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

6. MMC Technical Areas • Information Requirements • Beneficiary Rights and Protections • Emergency and Post-Stabilization • Availability of Services • Assurances of Adequate Capacity and Services • Authorization of Services

7. MMC Technical Areas, Cont. • Provider Selection • Practice Guidelines • Quality Assessment and Performance Improvement Programs • External Quality Reviews • Health Information Systems • Grievance and Appeals Systems • Program Integrity

8. Regulations Text The full text of the MMC regulations is available on the CMS website: http://www.cms.gov/medicaid/managedcare/cms2104f.asp

9. DMH Implementation Process • Detailed analysis of proposed regulations • Participation in CMS’ public comment period • Waiver Requests • Internal Workgroup

10. DMH Implementation Process, Cont. • California Mental Health Directors Association (CMHDA) Workgroup – Biweekly Meetings • Client Family Member Task Force (CFMTF) Workgroup – Biweekly Meetings • Joint CMHDA/CFMTF – Meetings as needed

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

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

13. Beneficiary Problem Resolution Processes Grievances and Appeals

14. Title 9, CCR, Section 1850.205 (Problem Resolution Processes) • TIMEFRAMES • COMPLAINTS must be resolved as quickly as possible. • GRIEVANCES must be resolved within 30 calendar days at each level of review. A grievance resolution could take up to 60 calendar days if it went through both levels of review.

15. Title 42, CFR, Section 438, Subpart F (Grievances) • TIMEFRAMES • New regulations specify that grievance dispositions cannot exceed 90 days from the day in which the MHP received the grievance. • DMH will retain a 60 calendar day limit for grievances to be resolved. • Timeframe may be extended by up to 14 days in certain circumstances.

16. Title 42, CFR, Section 438, Subpart F (Standard Appeals) • TIMEFRAMES • APPEALS must be resolved within 45 calendar days of MHP receipt of appeal. • Timeframe may be extended by up to 14 days in certain circumstances.

17. Title 42, CFR, Section 438, Subpart F (Expedited Appeals) • TIMEFRAMES • EXPEDITED APPEALS must be resolved and the affected parties must be notified orally and in writing no later than 3 working days after the MHP receives the expedited appeal. • Timeframe may be extended by up to 14 days in certain circumstances. • If the MHP denies the expedited appeal process and reverts the appeal to the standard appeal process, the MHP must make reasonable efforts to promptly notify the beneficiary orally and must notify him/her in writing within 2 calendar days.