Managed Care Learning Collaborative Texas Council Managed Care Steering Committee

Continuing Legal Education (CLE) This session qualifies for 1.5 hours of CLE credit. Course Title: 32nd Annual Conference Course Number: 928006023 Date: June 28-30, 2017 Visit the CEU Desk across from the Registration Desk in Expo Hall to pick up a CLE packet with instructions on how to report credit.

Forming a Managed Care Steering Committee (MCSC) Shelley Smith, CEO, West Texas Centers Jessee Campbell, CFO, West Texas Centers

Importance of Forming an Internal Managed Care Steering Committee (MCSC) Brings focus to managed care Provides direction of healthcare industry of the future Illustrates the effects of managed care on all aspects of business Builds understanding of how the actions of departments all affect one another

Who should lead the MCSC? Senior level manager who: Has broad understanding of different areas of the organization Introduces and implements principals from the business world Challenges all levels of leadership to self-examine Confronts “NO” on a routine basis. Challenges current thinking Understands this is a cultural shift for the entire Center Selected by, and has 100% support of ED/CEO ED/CEO ensures that Executive Teams view MCSC committee chairperson as a person of influence

Who should be on the MCSC? Keep the size manageable, but include key decision makers Include cross-sectional representation from all areas impacted by managed care Executive Leadership Contracting Credentialing Programs (MH, IDD, ECI, LTSS, etc.) Utilization Management Revenue Cycle Management

Examples: Chief Executive Officer (CEO) Chief Financial Officer (CFO) Chief Operating Officer (COO) Chief Information Officer (CIO) Chief Strategy Officer (CSO) Managed Care Director BH Director Chief of IDD Services 1115 Director ECI Director HR Director MIS Director Credentialing Specialist Reimbursement Representative

Starting a MCSC Review the Texas Council’s Reference Materials Pick a few chapters of the Quick Reference Guide to discuss at each meeting Review the quarterly “Things Every Consortium Should be Talking About: Managed Care” Review “Managing and Negotiating MCO Contracts” Establish policies and goals for MCO contracting and revenue cycle management Share knowledge and feedback with the Texas Council MCSC!

MCSC as it Relates to Revenue Cycle Management All areas of business are affected – challenge department managers to understand their connection to the process Not limited to Reimbursement, Accounting or Financial Services Contracting, Credentialing, Systems Configuration, Hiring, Accountability, and Training are the foundation of Revenue Cycle Cultural impacts: Tone from Executive Teams Integration with all other planning and meetings Performance reviews Corporate communications

Breakout Session 1

Medicaid 101 Elizabeth LaMair, Healthcare Policy Director, Texas Council of Community Centers

Medicaid State Plan Contract between the CMS and State Includes mandatory and optional benefits State Plan benefits must be covered under both FFS and managed care Available to eligible children and adults as an entitlement when medically necessary Mandatory benefits – “basic” benefits like primary care, hospital services, labs and x-rays, family planning, home health services. Everything covered under SSA 1905(a). Optional benefits – extras that that state has agreed to cover – Rx drugs, therapies, TCM, dental services, etc. If the State Plan covers both children & adults, why do kids get more benefits? Early Periodic Screening Diagnostic and Treatment – EPSDT requires states to provide all services included in 1905(a) to “correct or ameliorate” physical or mental health conditions found by screening, regardless of whether treatment is part of the state’s traditional Medicaid package. Examples of benefits for kids under EPSDT – hearing aids, preventative dental care, personal care services, private duty nursing, rehabilitative services, DME and supplies.

Why do kids get more benefits under Medicaid? Children (≤20) get EPSDT services Adults (≥21) no not get EPSDT State Plan EPSDT Services State Plan Adult Services Early Periodic Screening Diagnostic and Treatment – EPSDT requires states to provide all services included in 1905(a) to “correct or ameliorate” physical or mental health conditions found by screening, regardless of whether treatment is part of the state’s traditional Medicaid package. Examples of benefits for kids under EPSDT – hearing aids, preventative dental care, personal care services, private duty nursing, rehabilitative services, DME and supplies.

Medicaid HCBS Waiver Services Additional services designed to keep people in the home and community For people who would otherwise need institutional care Generally provided through waiver agreements with the CMS (e.g., 1915(c) or 1115) Waiver agreements establish eligibility requirements and benefits Also called “long-term services and supports” or “waiver services” Examples: personal assistance services, respite, financial management support, dental, minor home modifications, therapies, adaptive aids and supplies

Waivers as Managed Care Delivery Models 1915(b) 1915(c) 1115 1915(b)= to provide State Plan services through an MCO 1915(c) = to provide HCBS Services through and MCO 1115 = demonstration waiver, can include both State Plan and HCBS

HHSC Managed Care Programs Primary Population Services STAR Children and pregnant women State Plan (basic health care) STAR+Plus Elderly and disabled adults State Plan, HCBS waiver services STAR Health Children in Foster Care State Plan, with enhanced features (e.g., Health Passport) STAR Kids Children with disabilities, children in HCBS waivers CHIP Low income children who don’t qualify for Medicaid Limited set of benefits (basic health care)

Where to Find Managed Care Requirements Quick Reference Guide for Medicaid and CHIP Managed Care Includes MCO contract requirements, links to contracts and other helpful information HHSC Uniform Managed Care Manual Provider Contract Checklist includes all the required clauses for MCO/provider contracts HHSC Medicaid and CHIP in Perspective (“The Pink Book”) General information on all Medicaid and CHIP programs, services, and eligibility requirements Texas Medicaid Provider Procedures Manual Best resource for covered services and benefits (but remember MCO UM policies can differ) Tell where to find all of these resources MCO Provider Contract Checklist – professional liability not required for governmental entities, claims adjudication standards – MCOs must pay within 30 days for most clean claims or pay 18% interest

Breakout Session 2

Measures that Matter to MCOs Mary Duffy, Director of Utilization Management, Bluebonnet Trails Community Services

Quality Programs and Value-Based Contracting MCO Pay for Quality (P4Q) Program: Suspended for 2017 Will be revamped for 2018 3% of the MCO capitation payments at risk for meeting quality outcome measures Allows incremental improvement toward meeting the measures NEW: maintaining high performance Managed Care Plans are evaluated on their performance against benchmarks and against self Texas Council Managed Care Quick Reference Guide, p. 87

2018 P4Q Program Focus (pending approval) Recent Quality Measure redesign for managed care companies to make it easier to understand and track Rewards both improvement and high performance Focus on: Prevention Chronic disease management including behavioral health Maternal and infant health Measures selected to align with federal regulations and priorities, standardized and align with other current initiatives (DSRIP, CCBHC, etc.)

Measure Selection Considerations State and federal regulations and priorities Ensuring measures are standardized and nationally recognized (HEDIS) Alignment with other initiatives (DSRIP, CCBHC, MACRA, etc.) Number of members impacted Measures where state needs improvement Severity of problem in the state Can it currently be measured?

2018 P4Q Selected Measures Potentially Preventable ED Visits PPVs   STAR STAR+PLUS CHIP DSRIP CCBHC MACRA Potentially Preventable ED Visits PPVs X HEDIS Well Child Visits (W15) HEDIS Weight Assessment and Counseling for nutrition and physical activity for Children and Adolescents (WCC) HEDIS Treatment for Children with Upper Respiratory (URI) HEDIS Prenatal/Postpartum Care HEDIS High Blood Pressure (CBP) HEDIS Diabetes Screening for people with Schizophrenia or Bipolar Disorder using antipsychotics (SSD) HEDIS Diabetes Control (CDC) HEDIS Cervical Cancer Screening HEDIS Adolescent Well care (AWC Bonus Pool: Quality Indicator Composite (PQI) Bonus Pool: Potentially Preventable Readmissions (PPRs) Bonus Pool: Potentially Preventable Complications Bonus Pool: Potentially Preventable Admissions (PPAs) Bonus Pool: Percentage of PCP network recognized as a NCQA patient Centered medical Home Bonus Pool: Low Birth Weight Bonus Pool: Childhood immunization status Bonus Pool: CAHPS of children with good access to urgent care Bonus Pool: CAHPS Adult rating health plan 9 or 10 2018 P4Q Selected Measures

Performance Improvement Projects (PIPS) HHSC picks two PIP topics per Program Medicaid and CHIP MCOs must develop one PIP per topic MCOs also pick PIP measures (HEDIS, AHRQ, or others developed by MCO) MCOs are not placed at-risk, but results are published Examples of PIP topics: Adherence to Antipsychotic Medications Antidepressant Medication Management Behavioral Health (BH) Follow-up after BH Hospitalization Improve Care Transitions and Coordination to Reduce BH-related Admissions and Readmissions BH Family Support Services to Caregivers Texas Council Managed Care Quick Reference Guide, p. 90

Strategies Use the measures to negotiate better rates or value-based contracts Not all Measures cross all programs Best place to look for current measures is the HHSC website Make sure you read and understand the specifications of each measure before approaching the MCO (e.g., HEDIS specifications) Understand how you fit into their population Research why the measure was selected for P4Q or PIP program Research current MCO performance on measure (if available)

Negotiating a Contract – Focus on Common Goals Do’s Communicate your value and options for mutual gain Prioritize issues Educate about your concerns Understand what’s in the contract Don’ts Come in unprepared Take extreme positions Saturate the document with red ink Experience with measures gives you better standing in contracting

Breakout Session 3

Opening the Door to Commercial Insurance Opportunities Ayanna Castro-Clark, Director of Contract Management, Western Behavioral Health Network

Who are the players and what are they looking for? The primary type of commercial insurance plans include PPOs, HMOs and EPOs Players: MCOs you’re already contracted with for Medicaid/CHIP or other programs MCOs you’ve had no previous relationship with Looking to: Tap into unserved or underserved market opportunities Expand their service array HMOs rely heavily on prior authorization for most services and will only pay for in-network providers EPOs typically also only pay for in-network providers PPOs pay providers who are out-of-network

Avoid the “Cookie Cutter” Approach to Service Delivery Commercial insurers do not have to follow the HHSC MCO Contract or the Performance Contract Do not have to use the CANS/ANSA Client deductibles/co-pays are outlined in the contract (not an entitlement population) Sliding fee scales do not apply Commercial insurance clients don’t have to be included in performance contract metrics Commercial insurance products do have to adhere to the TDI regulations

Succeeding in a Commercial Insurance World Remember: RATES ARE NEGOTIABLE! Rate setting is typically based on the Medicare fee schedule When negotiating rates, consider that the total payment amount is the agreed-upon contract rate minus any client co-pay or deductible Credentialing and complaint processes differ from Medicaid and are guided by TDI regulations Review the provider contract or manual for claims filing deadlines (typically 95 days) and other operational details

Succeeding in a Commercial Insurance World Ensure your front desk processes are updated and stay up to speed on the commercial insurance world by: Verifying client’s coverage prior to their appointment Verifying your center’s/provider’s network status (par or non-par?) Obtaining prior authorization if necessary. Commercial plans only pay for covered services, which vary by plan Approaching each client individually because plans can vary by employer (for example, UHC HealthSelect Plan Coverage vs. other UHC plans) Collecting client co-pays or deductibles before providing services Being aware of any modifier or other billing requirements. They vary by plan and are not standard No continuous coverage/eligibility like in CHIP (12 months) or Medicaid (6 months)

Breakout Session 4