Select Topics in Implementing an Integrated Medicaid Managed - - PowerPoint PPT Presentation

Select Topics in Implementing an Integrated Medicaid Managed Long-Term Care Program

TennCare Overview

Tennessee’s Medicaid Agency Tennessee’s Medicaid Program

• Managed care demonstration implemented in 1994
• Operates under the authority of an 1115 waiver
• Uses managed care to cover persons otherwise not eligible for Medicaid
• Entire Medicaid population (1.2 million) is in managed care
• Medical, behavioral and now long-term care services are administered by two (2)

“At-Risk” Managed Care Organizations (MCOs) located in each region of the state (mandatory enrollment in managed care)

• TennCare Select manages care statewide for certain special populations (e.g.,

children receiving SSI, children in State custody, persons enrolled in MR waiver programs) via an ASO (i.e., modified risk) arrangement

• Prescription drugs administered by a statewide Pharmacy Benefits Manager
• Dental Services for children under 21 administered by a statewide Dental Benefits

Manager

Key Design Elements

• Began as a legislative initiative:

Long-Term Care Community Choices Act of 2008

• Integrates TennCare nursing facility (NF) services

and HCBS for the elderly and adults with physical disabilities into the existing managed care delivery system (roughly $1 billion); MR services remain carved out

• Amended 1115 demonstration waiver authority—1-year approval process; existing 1915(c)

waiver folded into 1115, including same benefit package (with minor modifications) and individual cost neutrality cap based on cost of NF care

• Enrollment target for HCBS supports controlled growth while developing sufficient

community infrastructure to provide care (persons transitioning from a NF and certain persons at risk of NF placement are exempt)

• Cost and utilization managed via individual benefit limits and individual cost neutrality cap
• Specific requirements regarding NF diversion and NF-to-community transition
• Consumer directed options for core HCBS using a prior authorization model
• Electronic Visit Verification system assures quality of care and program integrity
• State leadership, collaboration, and strong contract requirements are key; CRA available at:

http://www.tn.gov/tenncare/forms/middletnmco.pdf

Contracting Considerations

• Amended contracts with existing MCOs selected via

competitive bid process

• Existing TennCare recipients remained with their currently selected MCO which

became responsible for LTC services upon CHOICES implementation

• TennCare members do not change MCOs when LTC services are needed
• Blended capitation payment for all physical, behavioral and LTC services (NF and HCBS)

with separate rate cells for duals/non-duals aligns incentives to rebalance

• MCOs at full risk for all services, including NF (not time-limited)
• Risk-adjustment for non-LTC component of the rate based on health plan risk assessment

scores – John Hopkins ACG Case-Mix System – using MCO encounter data at start date of

• perations and annually thereafter (or upon significant circumstances) with adjustment for a

+/- change greater than 3%, 2%, or 1% during each of the first 3 years, respectively

• Risk-adjustment for LTC component of the rate based on mix by setting at implementation

and open enrollment periods with adjustment for a +/- change greater than 1/2 of 1%

Contracting Considerations for Members

• Freedom of choice of NF/HCBS
• Continuity of care provisions to ensure as seamless a transition as possible
• Receive same services specified in NF/HCBS Plan of Care for at least 30 days
• Utilize existing NF/HCBS Waiver providers (in or out-of-network)
• Continue pending comprehensive assessment and development/implementation of

new comprehensive person-centered plan of care

• Care coordination – processes, timeframes, tools, and staffing
• Comprehensive Care Coordination provided by MCOs
• Each member has an assigned Care Coordinator—nurses/social workers
• Comprehensive ongoing needs assessment /person-centered care planning
• Coordination of physical, behavioral, functional and social support needs
• Management of chronic conditions and care transitions
• On the ground and face-to-face with minimum contact requirements

Contracting Considerations for Members

• Care coordination
• Prescriptive processes (in contract requirements and protocols)
• Member referrals, new members, NF-to-community transitions
• Standardized forms and informational materials
• Specific time frames, e.g.,
• 6 days to process referrals (screening, intake, needs assessment, POC)
• 10 days to process new members (intake, needs assessment, POC, initiate svcs)
• 14 days ea. to conduct transition screening, assessment, develop transition plan
• Greater flexibility in tools and staffing
• May use proprietary instruments; must include minimum State-specified elements
• No minimum staffing ratios
• Prescriptive processes and timelines with minimum contacts, depending on

setting

Contracting Considerations for Members

Consumer Direction

• State contracts with a single statewide fiscal employer agent to perform fiscal intermediary and

supports brokerage functions for all CHOICES members

• Consumer direction provides members (or qualified representative) with employer authority
• MCO authorizes a fixed amount of services based on need
• Members assessed to need a service available through consumer direction must be given
• pportunity to receive services thru consumer direction or traditional provider agency
• Member/rep, using fiscal/employer agent, is the employer of record and must be able to

perform CD responsibilities

• Member/rep sets the reimbursement rates for the worker from list of available rates set by

the State and signs a Service Agreement with each qualified worker

• Members may also “self-direct” certain health care tasks as part of consumer directed

services

Contracting Considerations for Members

Electronic Visit Verification System

• State pass-through for individual MCO contracts with EVV vendor
• Services scheduled and authorized in accordance with member needs
• Providers for most HCBS (including Consumer Directed workers) log in and out at each visit
• Tracks the provision of services, including start time, duration, worker, and basic functions

performed

• Immediate notification to provider, MCO Care Coordinator and for Consumer Direction, Supports

Broker, if worker does not arrive as scheduled

• Ability to resolve service gaps immediately
• Completed visits used to generate a file that can be used for claims submission
• Increased financial accountability and program integrity

Contracting Considerations for Providers

• State sets rates of reimbursement (LTC services only)
• Non-par reimbursement set at 80% of the lowest rate paid by the MCO to

participating network providers for the same service

• Stringent prompt pay requirements
• 90% of clean electronic claims within 14 day
• 99.5% of clean electronic claims within 21 days
• Enhanced training and technical assistance for LTC providers
• Nursing Facility-specific
• MCOs required to contract with all current Medicaid certified Nursing

Facilities for first three years

• State continues to make level of care determinations
• MCOs must authorize LTC services based on State’s LOC determination

(level of reimbursement and duration)

Readiness Review

• Desk review of key deliverables
• Policies, procedures, processes and plans
• Onsite review of critical processes and operating functions
• Comprehensive test case scenarios re: needs assessment and care planning
• Videotaped intake/assessment
• Outputs, including required documentation and forms, signed plan of

care, and service authorizations

• State participation in training activities for care coordinators, providers, EVV

training for staff, providers and FEA, and FEA training

• Care coordinator ride-alongs
• Demonstration of critical MCO systems including LTC service authorizations

to contract providers and the FEA, member referrals to the FEA, EVV system functionality and claims processing systems using actual test cases

• Validation of provider networks

Readiness Review

• Milestone deliverables for service authorizations
• 50% of service authorizations loaded 6 weeks prior to go-live
• 75% of service authorizations loaded 4 weeks prior to go-live
• 90% of service authorizations loaded 2 weeks prior to go-live
• 100% of service authorizations loaded prior to go-live
• Milestone deliverables for provider network files
• 50% of current NFs and 50% of current HCBS providers (or equivalent) contracted,

credentialed and loaded and 50% of access standards met 7 weeks prior to go-live

• 75% of current NFs and 50% of current HCBS providers (or equivalent) contracted,

credentialed and loaded and 75% of access standards met 4 weeks prior to go-live

• 90% of current NFs and 50% of current HCBS providers (or equivalent) contracted,

credentialed and loaded and 90% of access standards met 2 weeks prior to go-live

Monitoring Compliance

• Reporting (Section 2.30) on a daily, weekly,

monthly, quarterly, semi-annual, annual, on request and ad hoc basis

• Eligibility, enrollment and

disenrollment

• Specialized services
• Disease management
• Service coordination
• Provider networks/

agreements/payment

• Utilization management
• QM/QI
• Customer service/provider service
• Member complaints
• Fraud and abuse
• Financial management
• Claims management
• Information systems
• Administrative requirements
• Subcontract
• HIPAA
• Non-discrimination
• Terms and conditions

Monitoring Compliance

• Site inspections
• Inspections of work performed/audits
• Independent review - EQRO

Assuring Compliance

• Corrective Action Plans
• Liquidated Damages
• Level A – pose a significant threat to patient care or the

continued viability of the TennCare program

• Level B – pose a threat to the integrity of the TennCare program,

but do not imperil patient care

• Level C – pose threats to the smooth and efficient operation of

the program, but do not imperil patient care or the integrity of the program

Assuring Compliance

• Capitation payment withhold
• Monthly withhold distributed in the next

monthly payment, unless retained for non-compliance

• 10% for first 6 months of operation and any 6 months following notice
• f deficiency
• 5% for 2nd 6 months of operation (if no notices of deficiency)
• 2.5% thereafter (if no notices of deficiency)
• Months withheld for non-compliance are not payable pending

correction of identified deficiencies

• Payments retained for 6 consecutive months without correction of

identified deficiencies are no longer payable to the MCO and MCO may be declared ineligible for future distribution of 10% withhold

• Contract termination