Medicaid Updates • Planning Administration • Office of Health Services • Finance Administration • Office of Eligibility Services • Office of Systems, Operations, and Pharmacy
Health Care Reform Implementation:Updates from the Planning AdministrationTricia Roddy, Director
Planning AdministrationReform Updates: Overview • HealthChoice 1115 Waiver Renewal • Eligibility Renewals • Alternative Benefit Package • Presumptive Eligibility • Pregnant Women
1115 HealthChoice Renewal • The Department began the public process for renewing its HealthChoice Program last Spring. • Officially submitted the Waiver Application to CMS on June 28, 2013. We will be negotiating the terms with CMS over the next 5 months. • The new parent and childless adult populations eligible for full Medicaid benefits starting January 2014 will receive benefits through the HealthChoice Program.
Eligibility Renewals • Maryland sought approval to delay eligibility renewals scheduled to occur between January and March 2014 by 90 days. • The Department pulled out this request from the 1115 Waiver application and submitted a separate request to be considered earlier. CMS approved this request on July 19, 2013.
Alternative Benefit Package • Maryland requested the authority to offer its State Plan benefit package to the newly eligible expansion population under its Waiver Application. • The Final Rules published by CMS on July 15, 2013 state that Medicaid must cover Essential Health Benefits in its Alternative Benefit Package. The newly eligible expansion population is required to be enrolled in benchmark equivalent coverage and the Affordable Care Act amended the benchmark coverage to include Essential Health Benefits.
Alternative Benefit Package • States must supplement that package with the EHP categories. States, however, can substitute any benefit if it is actuarially equivalent and in the same EHB category. • CMS also indicated in the Final Rule that it did not intend to pursue compliance actions on this issue to the extent states are working toward, but have not completed a transition.
Pregnant Women • In Maryland, pregnant women up to 250% FPL are eligible for full Medicaid benefits. • Beginning in 2014, women between 138-250% FPL will be eligible for: • Advanced Premium Tax Credit to purchase Qualified Health Plans; or • Full Medicaid benefits during their pregnancy and 60 days postpartum care • Maryland explored two options • Option 1: Require pregnant women to enroll in Medicaid • Option 2: Require pregnant women to remain in QHPs and provide premium assistance and wraparound benefits • For at least the first year, Maryland is pursuing Option 1.
Pregnant Women • We recognize that education and outreach to pregnant women will be critical to ensure a smooth transition between Medicaid and QHPs. • The Department will work with local health departments and will explore opportunities to educate women during the enrollment process. • Additionally, the Department will continue to discuss how to better deliver care to these higher income women.
Presumptive Eligibility • The Final Rules published by CMS on July 15, 2013 allows any participating Medicaid hospital to make a presumptive eligibility determination for an individual. • States are required to allow hospitals to conduct presumptive eligibility determinations on all MAGI-eligible populations. • The rules allow states to establish standards and corrective action procedures for hospitals.
Health Care Reform Implementation:Updates from the Office of Health ServicesSusan Tucker, Executive Director
OHS Health Reform Updates: Overview • Provider Directory Cleanup Project • MCO Shopping Experience • SPA and Regulations Updates
Provider Directory Cleanup Project • The Maryland Health Connection will contain provider directories for all QHPs and MCOs • The Chesapeake Regional Information System for Our Patients (CRISP) will standardize and de-duplicate data from QHPs and MCOs before loading the data into the Maryland Health Connection provider directory • Medicaid will collect data from all MCOs and pass the data to CRISP, including NPIs, PCP Indicators, quantity restrictions, etc.
Provider Directory Cleanup Project • Recognizing both need and opportunity, OHS informed MCOs in March that a massive network cleanup project would take place • From March until the end of June, MCOs submitted test files to the Department; testing yielded numerous layout and input issues for MCOs. • OHS and Systems facilitated bi-weekly TA workgroup calls to troubleshoot all issues throughout “practice” submission
Provider Directory Cleanup Project • On July 1, Medicaid “termed” PCP indicators and end-dated all MCO network files to add and change all information • Systems is currently running some of its own testing on those files and addressing any issues before sending the final file to CRISP
Provider Directory Cleanup Project • The file submitted to CRISP will mark each MCO with an individual 9-digit indicator (cross-walked to the HIX 5-digit identifier) and will contain all valid provider network information • The file submitted to CRISP will then facilitate the MCO Shopping Experience
MCO Shopping Experience • Network data workflow leading into the shopping experience: • MCOs to DHMH • DHMH to CRISP (cleans using P360) • CRISP to Connecture • Connecture to Consumer (displayed as the MCO Shopping Experience)
MCO Shopping Experience • Those eligible for Medicaid will be directed to the shopping experience after completing an eligibility assessment on the Maryland Health Connection • Participants will be able to shop by MCO or by doctor • The Department, Connecture, and CRISP are working to produce content that is in compliance with current eligibility and MCO selection policies
MCO Shopping Experience • OHS has acted as the liaison between HIX developers and the MCOs, offering demos and addressing enrollment concerns • The Department has also been instrumental in developing the text and presentation of the shopping experience as it relates the consumer: • Policy and benefits clarification • Appropriate reading levels • Information display
MCO Shopping Experience • OHS, Planning, and Eligibility have collaborated to revamp distribution materials related to the enrollment process; materials will be available in both paper and e-format: • Health Services Needs Information Form (formerly the Health Risk Assessment) • The MCO Comparison Chart OHS is also working with colleagues in the Department to address enrollment and eligibility logistics, as well as general outreach and communication issues
CMS has developed 21 different eligibility SPA templates for State Medicaid Programs to complete • OHS is convening internal workgroups to complete these templates • Goal will be to submit most by October 1st • Remainder to be submitted before January 1st
Regulations • State has to update regulations to come into compliance with provisions of Health Care Reform. Examples include changes to: • General, MCHP, and MCHP Premium eligibility regulations to reflect streamlining of eligibility coverage groups under MAGI • Elimination of PAC program • Fair hearing regulations • Presumptive eligibility rules for hospitals
Health Care Reform Implementation:Updates from the Financing AdministrationAudrey Parham-StewartDirector, Financing Administration
Cost Allocation and Federal Claiming • Cost allocation plan approved by CMS effective 4/2011 for a 58/42 percent federal reporting split of MHBE costs • Key Milestones • First claim submitted on CMS 64 in FY 13 for prior periods • Includes claims for administrative expenses
New Adults Enhanced Federal Matching Funds • Eligible for 100 percent federal matching • Budget includes funding for 110,000 new Medicaid recipients • Medical homes will be provided by MCOs who will be paid capitation based on estimated HealthChoice costs that are higher than TANF and lower than the Disabled population with consideration for pent up demand, demographics and contingency. • Project Status – Budget approved by legislature
Rate Setting • Established new rate category for managed care capitation payments • New rates are being calculated by actuaries to be presented in August • New Federal reporting must be programmed to capture the costs and bill for the enhanced rates
Enhanced Matching Opportunity for Eligibility • May be eligible to receive 75/25 percent enhanced matching rate for Medicaid Eligibility • Ongoing funding available once a plan is approved by CMS • Request to CMS (APD) must be submitted • Project Status • Waiting for guidance from CMS
Health Care Reform Implementation:Updates from the Office of Eligibility ServicesDebbie RuppertExecutive Director, Office of Eligibility Services
How to Apply • Applicants whose eligibility is based on MAGI (Modified Adjusted Gross Income) will be able to apply through several channels: • Phone • Mail • In-person at a local Health Department, local Department of Social Services, or Connector Entity • Online through the Maryland Health Connection • Enrollees will be able to select an MCO online through Maryland Health Connection. • If an MCO is not selected online, the Enrollment Broker will send a packet and selection will made just as it is today.
Call Center • Consolidated Service Center (CSC) Contract • MHBE awarded the CSC contract to Maximus Health Services on June 13th • Maximus will provide customer support to HealthChoice applicants and recipients through a variety of ways including: • Assisting recipients with new applications, redeterminations, and the collection of additional information • Answering a variety of customer questions about eligibility for insurance affordability programs • Anticipated start date 8/1/13
Call Center • Staffed by at least 100 employees and supported by a fulfillment center • DHMH is working closely with MHBE to ensure a smooth handoff from both a recipient and operations perspective
Training • MHBE awarded the Training Curriculum and Delivery Contract on June 17th to GP Strategies • All users will be trained on using the Maryland Health Connection and on Medicaid rules and regulations. Groups to be trained include: • LHD and LDSS Caseworkers; • Certified Individual Navigators; • Assisters; • Certified Application Counselors; and • Consolidated Service Center (CSC) Individual Permitted Employees. • DHMH is working with MHBE to ensure that training materials effectively communicate the rules and regulations associated with the Medicaid expansion.
Training • GP Strategies will provide assistance in several areas: • Instructional design • Curriculum development • Test design and implementation • Logistics planning • Registration • Training rollout
Appeals and Grievances • DHMH and MHBE will have a coordinated process for MAGI-related Medicaid appeals and grievances • Appeals will be heard by the Office of Administrative Hearings (OAH) and the entity who initiated the Medicaid application will represent the agency • Connector Entities, LHDs, DSS, and MHBE
Connector Entities and LHDs • DHR/DHMH/MHBE meet with CEs on a monthly basis to ensure coordination • DHMH is working with LHDs to develop standard operating procedures with Connector Entities to ensure a smooth handoff for individuals who may be eligible for Qualified Health Plans (QHPs) • 6 geographic areas
Health Care Reform Implementation:Updates from the Office of Systems, Operations and Pharmacy Keith Sewell, Executive Director
Data Conversion • Working closely with MHBE, Noridian, and DHR to make sure that over 840,000 Medicaid enrollees are converted into Maryland Health Connection prior to 1/1/14. • Includes CARES, PAC and MCHP Premium data.
State Electronic Interfaces • Collaborating to ensure that the Maryland Health Connection will interface with other systems • Eligibility will be able to be verified in real time by searching federal and state income databases, as well as databases to verify citizenship status • MMIS will be updated nightly with new eligibility information
End-to-End Testing • MMIS and Maryland Health Connection will go through extensive end-to-end testing to ensure that eligibility files are successfully transferred • All other interfaces will also be tested prior to go-live
User Acceptance Testing (UAT) • DHMH, DHR, LHD, DSS, and MHBE staff involved in testing • Over 150 testers completed UAT orientation (July 15 – 19) • UAT Phase I – 8 weeks of testing - July 22, 2013 – Sept 13, 2013
October 1, 2013 Release • OSOP staff are making MMIS systems changes to prepare for new coverage groups and new transactions from Maryland Health Connection • Medicaid Eligibility Transactions will be stored in Maryland Health Connection and transmitted to MMIS in December