Agenda Step 2 Planning, DSRIP/1115 Waiver, and DHHS Personnel, - - PDF document

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MCM Commission

July 14, 2016 Legislative Office Building Room 206, Concord, NH NH Department of Health and Human Services

Agenda

• Step 2 Planning, DSRIP/1115 Waiver, and

DHHS Personnel, Enrollment Data – Commissioner Meyers

• Prior Authorization Data Update, Quality

Summary, and Final Rule – Deb Fournier

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Source: NH MMIS as of 7/5/16 for most current period; Data subject to revision.

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NH Medicaid Enrollment by Program, 7/1/16

Notes: Members are open for services as of the point in time as of the source date. Data excludes members without full Medicaid benefits (Family Planning Only & Medicare Savings Plans). Non-MCM/PAP includes members transitioning into MCM or PAP, members exempt from both programs, including members with employer-based insurance purchased by Medicaid through the Health Insurance Premium Program.

NH Healthy Families, 62,600 Well Sense, 74,362 PAP, 40,381 Non-MCM/PAP, 8,069 MCM, 136,962

MCM Pharmacy Claims, Authorizations & Appeals

(Note: logarithmic scale y axis)

892,249 974,270 994,598 968,484 810,536 7,549 10,496 9,543 6,852 5,151 3,065 4,025 4,030 3,641 2,679 200 293 229 279 258 53 120 92 123 116 1 10 100 1,000 10,000 100,000 1,000,000 CY2015-Q1 CY2015-Q2 CY2015-Q3 CY2015-Q4 CY2016-Q1

Counts Total Claims Total Requests Subject to Service Authorization Denied Authorizations Appeals of Denied Authorizations Upheld Appeals of Denied Authorizations

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Source: NH MCM Quality Data as of 5/25/16; Data subject to revision.

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MCM Claims, Authorizations & Appeals Mental Health Drugs

(Note: logarithmic scale y axis)

115,287 123,419 121,089 123,499 102,976 2,754 2,846 2,015 1,238 1,102 335 350 267 639 577 16 12 9 30 61 6 7 5 10 17 1 10 100 1,000 10,000 100,000 1,000,000 CY2015-Q1 CY2015-Q2 CY2015-Q3 CY2015-Q4 CY2016-Q1

Counts Total Claims Total Requests Subject to Service Authorization Denied Authorizations Appeals of Denied Authorizations Upheld Appeals of Denied Authorizations

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Source: NH MCM Quality Data as of 5/25/16; Data subject to revision.

MCM Claims, Authorizations & Appeals PT/OT/ST

(Note: logarithmic scale y axis)

6 Source: MCM Quality Data as of 7/6/16; data subject to revision.

16,290 19,725 18,258 16,339 9,732 3,152 3,522 3,186 3,476 4,081 153 179 139 226 203 21 3 27 14 33 13 3 7 6 20 1 10 100 1,000 10,000 100,000 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1

Counts

Total Services Paid Total Requests Subject to Service Authorization Denied Authorizations Appeals of Denied Authorizations Upheld Appeals of Denied Authorizations

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Grievances and Appeals for PT/OT/ST Services Newly Mandatory vs. Total MCM Population

7 Source: MCM Quality Data as of 6/21/16; data subject to revision.

Total Appeal of Denial Filed Appeal of Denial Filed (1915b only) Total Grievances Total Grievances (1915b only) May-15

• Jun-15

2

• 1
• Jul-15

10

• Aug-15

11

• Sept-15

6

• Oct-15

8

• Nov-15

3

• Dec-15

3

• Jan-16

13

• Feb-16

8 1 Mar-16 12 3 Apr-16 18 3

MCM Non-Emergent Medical Transportation Requests, Authorizations, Appeals, & Grievances

(Note: logarithmic scale y axis)

Source: NH MCM Quality Data as of 7/31/16; Data subject to revision.

8 86,154 93,694 95,440 137,282 160,427 85,953 93,304 95,079 136,919 160,169 76,631 85,614 91,896 112,818 130,790 1 3 3 6 7 1 1 4 3 12 6 5 14 18 1 10 100 1,000 10,000 100,000 1,000,000 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1 Total Requests Total Approved Requests Rides Delivered Appeals of Denied Authorizations Upheld Appeals of Denied Authorizations Grievances Filed

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MCM Non-Emergent Medical Transportation Rides Delivered by Service Type

Source: NH MCM Quality Data as of 7/31/16; Data subject to revision.

9 8,512 8,394 7,725 7,410 9,999 19,410 24,501 19,586 22,557 28,506 43,720 48,800 60,515 78,619 87,119 4,989 4,805 4,070 4,232 5,166 20,000 40,000 60,000 80,000 100,000 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1 Mental Health Provider Medical Provider Methadone Treatment Other (eg. Hospital and Pharmacy)

Questions?

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