1. Interest Circle Call June 3, 2010 1

2. Overview What is a Managed Care Entity (MCE)? How is behavioral health structured in an MCE? What do MCE’s do? What is the difference in roles between the MCE and the state purchaser of MCE services? What does all this mean for Parity and HCR? 2

3. Definition of a Managed Care Entity An organization responsible for a system of health care delivery that influences utilization, cost, quality of services, and measures performance. The goal is a system that delivers value by giving people access to quality, cost-effective health care. 3

4. Structure Managed care takes various forms/names: Managed Care Entity (MCE) Managed Care Organization (MCO) Primary Care Clinician Model (PCCM)- primary care as gatekeeper) Pre-Paid Inpatient Health Plan (PIHP) Health Management Organization (HMO) Administrative Service Organization* Integrated plan Carve-out plan 4* ASO may retain responsibility for only partial list of described activities

5. Structure (cont) Need to know how the MCE manages the behavioral health benefit Is it: Integrated within one plan Subcontracted to another organization Carved-out from any physical health management 5

6. Structure (cont) MCE approaches to BH Integrated BH & PH One integrated plan responsible for physical and behavioral Integrated but with a BH sub One integrated plan responsible for physical and behavioral but subcontract with a BH specialty MCE Separate BH and PH MCE’s Different entities responsible for physical health and behavioral health 6

7. Implications Substance use disorders/addiction impacts and requires strategies that address both physical health and behavioral health It sits at the intersection of the MCE and its’ operations Substance use disorders predispose people to PH problems, complicate existing PH conditions, co-exist with other BH issues, and impact self-care MCE structures that are not geared to look “across” the health of individuals, may under-recognize, under-report and under-prepare to support this population 7

8. Implications MCE structure will inform how behavioral health – specific information is used by the MCE Physical “side” is larger than BH “side” – inadvertent competition for resources Depth of knowledge about substance use/addiction How incentives are aligned (or not) to address SA Ability to access/use data to guide action 8

9. MCE Key Responsibilities 4 Major Activities: Utilization Management (UM) Quality Management (QM) Network Management (NM) Rates & Claims Payment These activities are inter-dependent and are not separate activities 9

10. Managed Care Activities 10

11. Utilization Management (UM) Processes that address under and over utilization Covered services Criteria for access to a covered service Medical necessity criteria Initial, concurrent, and discharge criteria Care Management ( and/or disease management) Authorization--amount, duration, scope & processes used Clinical reviews Appeals 11

12. Network Management (NM) Types of activities include: Provider credentials for each covered service Ensuring that providers can meet access standards set by federal or state requirements: Ex: language, geography/travel time, choice Ensuring that providers deliver services according to service definitions and clinical/practice standards (also tied to QM) 12

13. Quality Management (QM) Types of activities include: Evidenced-based practices (also tied to UM and covered services) Outcome measures Performance or service delivery process measures Pay-for-performance 13

14. Rates & Claims Payment Types of activities include: Establishing rates for services Paying “clean” claims Pursuing any other insurance available for an MCE covered member Fraud and abuse monitoring 14

15. Implications MCE processes may or may not be geared to address unique aspects of substance abuse/addiction Approaches to QM, UM or NM may pose barriers MCE ‘s use of provider and consumer input 15

16. Differences between MCE and State Purchaser roles Important to know when a state purchaser has authority over an issue, when it is the purview of an MCE, and when it is shared by both 16

17. Differences between MCE and State Purchaser roles * State Purchaser MCE Defining covered services Use of evidenced-based practices Defining access standards (Ex: geography, language, choice) Ensuring standards are met by providers Strategies used to manage utilization Establishing provider credentialing Establishing performance measures Setting rates and paying claims Use of data to improve quality and control costs 17* Numerous federal requirements guide both state purchaser and MCE activities

18. Implications State purchaser of MCE services may /may not be substance abuse authority for the state/level of knowledge of SA MCE may/may not be knowledgeable about SA Gathering information and advocating for changes may require discussions with the MCE, the state purchaser or both Timing of changes in contract between state and MCE 18

19. Current Political Context Wellstone-Domenici Mental Health Parity and Addictions Equity Act effective 1/1/10 Health Care Reform Payment reform HIT Private insurers and coverage Controlling costs Integrating care Improving quality 19

20. Political Context (cont) Medicaid Cost Containment Medicaid Enrollment Services Rates Utilization 20

21. Implications of Parity and HCR State purchasers and MCE’s scrambling to assess impact and implement changes Party Act is in effect but time lag on full implementation of contracts, procedures, etc Parity and HCR have changed how state level Medicaid programs can control their costs No longer can use the same “levers” of enrollment, services and rates Reliance on managed care to keep utilization in check will increase 21

22. Summary The community expertise on SA is essential Opportunities to partner with MCE Opportunities to partner with state purchaser Use of data 22