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Apple Health (Medicaid) Managed Care Program Overview

Apple Health (Medicaid) Managed Care Program Overview. Preston W. Cody , Division Director Health Care Services November 16, 2015. Introduction. Preston Cody, Division Director Health Care Services Division Washington State Health Care Authority. Overview. Introduction Overview

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Apple Health (Medicaid) Managed Care Program Overview

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  1. Apple Health (Medicaid) Managed Care Program Overview Preston W. Cody, Division Director Health Care Services November 16, 2015

  2. Introduction Preston Cody, Division Director Health Care Services Division Washington State Health Care Authority

  3. Overview • Introduction • Overview • Objectives • What is Managed Care? • Managed Care History • Managed Care in Washington • Demographics • Managed Care Churn • Managed Care Quality and Contract Monitoring • Rate Setting • Potential Challenges • Network Adequacy • Current WA Initiatives • State Innovation Grant • Healthier Washington • Fully Integrated Care • Behavioral Health Organizations • Regional Service Areas • Earlier Enrollment • Foster Care Managed Care

  4. Objectives • Provide an introduction to managed care in Washington • Provide overview of Managed Care program operations • Discuss initiatives to improve the health care system in the State of Washington • General conversation about Washington States Medicaid Managed Care experience

  5. What is Medicaid Managed Care? Managed Care is a health care delivery system organized to manage cost, utilization, and clinical and service quality Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services By contracting with MCOs, states can reduce Medicaid costs and better manage utilization of health services MCO contracts with the State Medicaid Agency are profit-limited contracts MCOs strive to reinvest cost savings through shared savings programs and provider partnerships Improvement in health plan performance, health care quality, and outcomes are key objectives of Medicaid managed care

  6. Some Facts about the History of Managed Care • One of the earliest references to managed health care in the country dates back to 1910 in Tacoma, Washington • In 1947, 400 families organized to form Group Health Cooperative of Puget Sound • California was the first state to move its Medicaid population into a managed care model in the early 1970s • In the US approximately 80% of Medicaid enrollees are served through managed care • Medicaid Managed Care delivery systems and program implementation are regulated by 42 CFR 438 and various federal authorities

  7. Medicaid Managed Care in Washington Health Care Authority (HCA) is the single state Medicaid agency in Washington, which means it holds the authority and receives payment from the federal government for Medicaid HCA and Department of Social and Health Services (DSHS) have agreements in place that places management and oversight of most behavioral health programs within DSHS Since 1987, Washington has utilized managed care for physical health coverage (through 1932a) – originally “Healthy Options” and now “Apple Health” Since 1993, the state has operated its mental health Medicaid benefit via a 1915b waiver - through the RSNs Both authorities require enrollment in managed care

  8. Medicaid Managed Care in Washington Today • 1.8 million Washingtonians enrolled in Apple Health (Medicaid) and approximately 85% are enrolled in managed care • Others to transition into managed care overtime • 6 Medicaid Managed Care Plans are contracted with the state to deliver physical health and mild to moderate mental health services on a county by county basis • Molina Healthcare of Washington, Community Health Plan of Washington, UnitedHealthcare, Coordinated Care, Amerigroup, Columbia United Providers (CUP)

  9. Role of MCOs in Washington • MCOs provide coordinated care through a defined network of health care systems and providers • MCO role goes far beyond paying claims and approving or denying authorization for services...MCOs invest significant time and resources to: • Facilitate Care Management • Assure Clinical and Service Quality • Build Provider Networks • Engage & Partner with Communities • Leverage Data and Technology • Monitor & Maintain Compliance (TeaMonitor)

  10. Building Provider Networks • Contract with providers to ensure the availability of a sufficient number and type of providers within a required distance to meet the diverse needs of the members • To engage providers, most MCOs offer a continuum of payment approaches including value based models for provider partners to provide opportunities to share savings and be rewarded for high quality care • Networks are routinely monitored to ensure Access & Availability standards are maintained

  11. Community Engagement • MCOs partner with community-based organizations and agencies at the local level to increase health care coverage, improve health literacy, drive health education campaigns and build better connections across the service delivery continuum • MCOs hire local and regionally based staff and resources

  12. MCOs’ Role and Contributions to ACHs • MCOs are a local resource and thought partner • MCOs have dedicated staff and subject matter experts serving on ACH boards, councils and workgroups across the state • MCOs participate with HCA and Healthier WA on ACH discussions • MCOs partner with other health care stakeholders to plan and prepare for ACH work • MCOs work collaboratively with each other as a sector

  13. Care Management • Utilization Management: • Right Care: Medically Necessary • Right Time: Pursue Appropriate lower level interventions first • Right Provider/Right Care: Pay for quality/performance and Evidence Based Practices • Case Management for High Needs Members • Complex case management, care coordination, disease management, and health education • Health Homes as example of strong community based care management

  14. Leveraging Data and Technology • Advanced healthcare analytics and data. • Information Exchange and Interoperability • Examples: • Claims-based data • Link4Health (Clinical Data Repository) • Real-time ED/admission based data (Pre-Manage/EDIE) • Patient registry • Shared cost savings analysis

  15. DemographicsManaged Care Eligibles and Managed Care Enrollees by County – October 2015Reflects Enrollees Only 2936 2,981 98% 38,922 40,887 95% 10,934 11,476 95% Ferry Stevens Whatcom Okanogan Pend Oreille 11,324 11,983 95% San Juan 1,258 1,392 90% 26,981 28,217 96% 3,003 3,297 91% Skagit 9,657 10,397 93% Clallam Island 3,746 4,058 92% 122,276 127,198 96% Snohomish Chelan 10,180 10,467 97% 19,564 20,278 96% Spokane 5,669 6,036 94% Jefferson Lincoln 115,799 123,263 94% Kitsap King 38,811 41,549 93% 2,342 2,504 94% 309,239 324,931 95% Mason Douglas Grant Grays Harbor 12,578 13,372 94% Kittitas 17,524 19,104 92% 27,723 28,896 96% 7,616 7,908 96% Whitman Adams 163,425 173,665 94% 5,898 6,077 97% 7,580 7708 98% 46,787 49,622 94% Thurston Pierce Yakima Pacific 19,066 20,717 92% 27,247 28,251 96% Franklin 4,713 5,033 94% Lewis Garfield 85,156 88,718 96% Benton 12,641 13,303 95% Columbia 42,803 44,831 95% Asotin 824 904 91% Wahkiakum Cowlitz 26,531 28,852 92% Skamania 4,714 5046 93% 179 156 115% Walla Walla 775 826 94% 2,265 2,403 94% Klickitat 471 499 94% Clark 91,487 95,346 96% County enrollment in managed care is voluntary. Source: ODS Data Warehouse, CLNT-802.2, Run Date: 11/03/2015 ODS Data Warehouse, MC-849.1, Run Date: 11/02/2015 Currently eligible managed care clients are in black font. Currently enrolled managed care clients are in red font. The ratio of enrolled to eligible is expressed as a percentage. 15

  16. January-September 2015 Enrollment Trends • The charts display enrollment over a 9 month period. Enrollment continues to increase for most • programs through the end of September 2015: • AHAC (Adult expansion population) shows significant increase of 18%. This program was initiated January 1, 2014 • AHF (Family program) or the ‘welcome mat’ group has increased by 5% in large part due to outreach efforts in 2014 to ensure those eligible for Medicaid made application for services • AHBD had a slight decrease of 1% while CHIP has a slight increase of 2% Apple Health Demographic Analysis, October, 2015

  17. AHAC Enrollment (as of November 1, 2015) *Transactions may contain client duplicates and decrease per month due to loss of eligibility, causing retro changes. AHAC Enrollment November 1, 2015

  18. Apple Health Program Enrollment By Health Plan *Enrollment as September 1, 2015 Apple Health Demographic Analysis, October 2015

  19. Enrollment By Age Bracket The percent of enrollment by age is similar across health plans, except for the birth to 19 year old category. Both Molina Healthcare (MHC) and Community Health Plan (CHPW) have a much larger market share in this category. This is the result of two factors. First, managed care enrolled mostly women and children from its inception until July 2012 when the SSI Blind/Disabled (a mostly adult population) was added to managed care. Both MHC and CHPW, longstanding plans in the marketplace served a higher percentage of the women/child population. Second, in July 2012 three new MCOs entered the marketplace and received a higher share of the adult blind/disabled population. HCA methods for assigning new enrollees during this period of transition rewarded new plans, resulting in higher enrollment of this population to new managed care entrants. Apple Health Demographic Analysis, October, 2015

  20. Enrollment By Gender • Gender is an important determinant of services that will need to be provided, as well as programs that need developed • Female enrollment in Apple Health is 10% greater than male enrollment • The distribution of gender patterns across health plans are similar; however, AMG has more male enrollees than female enrollees Apple Health Demographic Analysis, October, 2015

  21. Gender by Age Group and Program • Using gender and age grouping data to inform policymakers of the Apple Health population is crucial for future budgeting and planning at multiple levels Apple Health Demographic Analysis, October, 2015

  22. Enrollment By Race • Providing client race is voluntary on Apple Health program applications • Collecting this information is crucial to ensure appropriate programs and services are available for clients • The population of Medicaid individuals is generally homogeneous and is reflective of the race distribution in the statewide population • 25% of the client population’s race is unknown either because it was “Not Reported” or the client indicated “Other Race” Apple Health Demographic Analysis, October, 2015

  23. Enrollment Breakdown by Race and Ethnicity • 1% of clients indicate they are of mixed race • A client who self-identifies as a member of one or more minority groups is counted in each of those minority categories, and is counted once in the Any Minority column. Clients who identify as White with no minority group membership are tallied under White Non-Hispanic Only column. Some Medicaid clients will not show up in the percentages because they have an unknown race Apple Health Demographic Analysis, October, 2015

  24. Managed Care Enrollment By County • Managed care population by county aligns with population centers in the State of Washington with King and Pierce counties having higher enrollment followed by Snohomish and Spokane counties • The analysis of county population provides important information that can be used to determine provider network adequacy and client needs in different areas Apple Health Demographic Analysis, October, 2015

  25. Enrollment By Preferred Spoken Language (Other Than English or Spanish) • English and Spanish language numbers were 1,192,644 and 128,163 respectively • For 5% (64,750) of Apple Health enrollment, the primary language is not known to HCA • Receiving information in an individual’s primary language enhances one’s ability to understand and act on information provided to the individual • HCA requires MCOs to translate materials if 5% or more enrollees speak a specific language other than English Apple Health Demographic Analysis, October, 2015

  26. Health Plan and County Preferred Spoken Language • Health Plans have the same top two languages English and Spanish • County analysis shows the top two measureable languages as English and Spanish except in Spokane and Stevens counties, where it is English and Russian Apple Health Demographic Analysis, October, 2015

  27. Enrollment by Federal Poverty Level (FPL)and Income Bracket • Clients whose application indicates they have no income is represented on the chart as $0 (zero) • Income is another important determinant in a client’s ability to access healthcare • Both gross income and the FPL provide an important picture of the Apple Health population Apple Health Demographic Analysis, October, 2015

  28. FPL Groupings By Race • The largest portion of the population is below 25% of the FPL and make up 45% of the overall population • The second largest portion of the population is between 101-133% of the FPL and make up 14% of the population • With poverty identified as a barrier to health care access, this information is crucial to ensure health care services and transportation programs are in place Apple Health Demographic Analysis, October, 2015

  29. Average Medicaid Managed Care Client FPL and County Unemployment Rate • The county unemployment rates (Medicaid and non-Medicaid) were obtained from the Employment Security Department (ESD) as of August 2015 • The highest unemployment exists in Ferry (10%), Pend Oreille (9%), Grays Harbor (8%), Lewis (8%) and Mason (8%) Apple Health Demographic Analysis, October 2015

  30. Churn • Without MCO plan lock-in churn can be expected

  31. Health Plan Outgoing Churn(September 2015) 71 Managed Care Health Plan Churn October, 2015

  32. Health Plan Incoming Churn(September 2015) 33 Managed Care Health Plan Churn October, 2015

  33. Health Plan Churn Percentage Per County Based on County Enrollment(September 2015) Average Churn .70% Managed Care Health Plan Churn October 2015

  34. MCO Monitoring • CFR/EQR Requirements for states • Structured monitoring of MCOs • Performance Improvement Projects • 2015 Monitoring results of calendar year 2014 • Select Performance Measure and Survey data

  35. CFR/EQR Requirements for States-Mandatory Activities • Review of MCOs conducted by an external quality review organization (annual EQR report) • Structured monitoring of MCOs (HCA) • Annual validation of MCO clinical and non-clinical performance improvement projects (PIP) (HCA) • Annual validation of MCO performance measures (aka HEDIS audit by EQRO)

  36. CFR Requirements for States - Optional Activities • Validate MCO encounter data • Surveys (Consumer Assessment of Healthcare Providers and Systems) • Additional performance measures • Additional PIPs and Focused quality studies

  37. Structured Monitoring of MCOs • Areas reviewed based on federal requirements and monitoring protocols: • Availability of services • Coordination and continuity of care • Program Integrity • Quality assessment and performance improvement • Coverage and authorization of services (utilization management) • Enrollee Rights • Grievance System • Practice Guidelines • Credentialing • Timely Claims Payment • Subcontracts • Enrollment and Disenrollment • Health Information Systems

  38. 2015 Monitoring Results

  39. 2015 Monitoring Report

  40. Well-Child Visits – 3-6 Years of Age

  41. Adolescent Immunizations

  42. CAHPS – Child and Child with Chronic Conditions Survey

  43. Finance Capacity • MCOs are risk-bearing entities • MCOs have risk-adjusted rates • MCOs are profit-limited. The State Medicaid agency sets a maximum profit. Profits greater than the limit must be returned to the Medicaid Agency • MCOs maintain sufficient reserves as required by the Office of the Insurance Commissioner • MCOs have payment model expertise • MCOs have actuarial resources in order to validate that rates are actuarially sound

  44. Rate Setting Process • The U.S. Centers for Medicare and Medicaid Services (CMS) mandates that rates paid to Medicaid-funded MC plans must be based on actual cost experience and be certified as actuarially sound. An independent actuary firm, Milliman, analyzes and certifies the AH rates • Rate changes are implemented at the start of, and effective for the remainder of each Calendar Year (CY). The total impact of the CY 2016 rate change across SFY 2016 and SFY 2017 is estimated at $470.2 million ($302.0 million GF-F and $168.2 million GF-S)

  45. Managed Care Rate Setting • Apple Health (AH) premium payments (rates) will account for nearly half of the Washington Health Care Authority’s (HCA) total budget in State Fiscal Year (SFY) 2016. • Total AH per member per month (PMPM) premiums - including all services, funds and rate groups - are projected to increase by about 7 percent from SFY 2015 to 2016 • AH rates are increasing because projected costs are increasing, overall about five percent from 2014 to 2015 • About $11 of the total $14 increase - nearly 80 percent - is due to pharmacy cost increases

  46. AH Adult Cost Trend

  47. Blind / Disabled Cost Trend

  48. Historical Rates in the Blind / Disabled and COPES Rate Groups • The following graph shows that the annual projected rate trend from July 2012 to December of 2016 is +2.9% • The initial MCO contract to serve blind and disabled clients saved over $100 million in 2012 over fee-for-service

  49. Components of 2014 to 2015 AH Cost Increases

  50. Potential Challenges • Integration of services (behavior and physical health) • Network adequacy • Distance, time and count • Provider contracting and payment expectations • Non-participating providers • Encounter data quality • Transition from fee-for-service to managed care • Contractual arrangements • Voluntary service areas

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