2. TA Partnership for Child and Family Mental Health FINANCING SYSTEMS OF CARE Medicaid Managed Care Mary B. Tierney, MD April 15, 2004

3. TA Partnership for Child and Family Mental Health MEDICAID Federal/State PartnershipsFederal/State Partnerships State Agency RequirementsState Agency Requirements EligibilityEligibility ServicesServices Payment for ServicesPayment for Services

4. TA Partnership for Child and Family Mental Health MANAGED CARE GENERAL CONCEPTS

5. TA Partnership for Child and Family Mental Health HISTORY OF HEALTH INSURANCE Originally based upon fire and flood insurance models – insure against catastrophic lossOriginally based upon fire and flood insurance models – insure against catastrophic loss Growth in all health insurance through the workplace after World War IIGrowth in all health insurance through the workplace after World War II Managed Care was a small component of health insurance movement until 1970’sManaged Care was a small component of health insurance movement until 1970’s

6. TA Partnership for Child and Family Mental Health HISTORY OF HEALTH INSURANCE AND MANAGED CARE Enactment of the Health Maintenance Organization Act of 1973Enactment of the Health Maintenance Organization Act of 1973 In the 1980’s and 1990’s there was continued growth of the private sector and subsequently, public sector use of Managed CareIn the 1980’s and 1990’s there was continued growth of the private sector and subsequently, public sector use of Managed Care

7. TA Partnership for Child and Family Mental Health DEFINITIONS Fee for ServiceFee for Service Managed CareManaged Care Capitation/Per Member Per MonthCapitation/Per Member Per Month Risk ContractRisk Contract

8. TA Partnership for Child and Family Mental Health GROWTH OF MEDICAID MANAGED CARE

9. TA Partnership for Child and Family Mental Health MANAGED CARE LEGISLATIVE AND REGULATORY REQUIREMENTS

10. TA Partnership for Child and Family Mental Health LEGISLATIVE AND REGULATORY HISTORY From 1965 To 1997 States must obtain waivers for managed careFrom 1965 To 1997 States must obtain waivers for managed care The Balanced Budget Act (BBA) of 1997 allows states to mandate enrollment in managed care without waiversThe Balanced Budget Act (BBA) of 1997 allows states to mandate enrollment in managed care without waivers The BBA mandates certain protections such as quality improvement and grievance rightsThe BBA mandates certain protections such as quality improvement and grievance rights

11. TA Partnership for Child and Family Mental Health LEGISLATIVE AND REGULATORY HISTORY June 14, 2002, managed care regulations (except external quality improvement) finalized, became effective, June 14, 2003June 14, 2002, managed care regulations (except external quality improvement) finalized, became effective, June 14, 2003 January 24, 2003, external quality improvement regulations finalized, become effective January 24, 2004January 24, 2003, external quality improvement regulations finalized, become effective January 24, 2004

12. TA Partnership for Child and Family Mental Health ORGANIZATIONS COVERED BY THE REGULATONS Managed Care Organizations (MCO)Managed Care Organizations (MCO) Primary Care Case Management (PCCM)Primary Care Case Management (PCCM) All 1915 (b) waiversAll 1915 (b) waivers Most 1115 waiversMost 1115 waivers ContractorsContractors State Plan amendmentsState Plan amendments

13. TA Partnership for Child and Family Mental Health Regulatory Requirements Limits on EnrollmentLimits on Enrollment Guaranteed EligibilityGuaranteed Eligibility Protection of MCO membersProtection of MCO members Restrictions and Regulations on MarketingRestrictions and Regulations on Marketing Solvency RequirementsSolvency Requirements Fraud and Abuse SanctionsFraud and Abuse Sanctions Quality ImprovementQuality Improvement

14. TA Partnership for Child and Family Mental Health LIMITS ON ENROLLMENT Individuals also Eligible for MedicareIndividuals also Eligible for Medicare Native AmericansNative Americans Categories (Katie Beckett)Categories (Katie Beckett) Foster Care or Out-of Home PlacementFoster Care or Out-of Home Placement Children under age 19 years who are:Children under age 19 years who are: - On SSI - Other Special Needs

15. TA Partnership for Child and Family Mental Health GUARANTEED ELIGIBILITY States have the option to guarantee 6 months eligibility for Medicaid if enrolled in an MCOStates have the option to guarantee 6 months eligibility for Medicaid if enrolled in an MCO This guarantee applies even if one loses Medicaid through TANF, SSI or other eligible groupsThis guarantee applies even if one loses Medicaid through TANF, SSI or other eligible groups

16. TA Partnership for Child and Family Mental Health PROTECTION OF MEMBERS Complaints and Grievance ProceduresComplaints and Grievance Procedures Protection against liability for payments to providers in case of insolvency of the MCOProtection against liability for payments to providers in case of insolvency of the MCO ConfidentialityConfidentiality Communication requirements including use of clear concise languageCommunication requirements including use of clear concise language Translation into other prevalent languagesTranslation into other prevalent languages Distribution of “Rights and Responsibilities”Distribution of “Rights and Responsibilities”

17. TA Partnership for Child and Family Mental Health MARKETING RESTRICTIONS Marketing Materials Receive State ApprovalMarketing Materials Receive State Approval Distribution to Entire Service AreaDistribution to Entire Service Area No Door to Door, Telephone, Cold-CallsNo Door to Door, Telephone, Cold-Calls Accurate Information ProvidedAccurate Information Provided

18. TA Partnership for Child and Family Mental Health SOLVENCY REQUIREMENTS Must Comply with State-wide Solvency Requirements Used by the State Insurance CommissionerMust Comply with State-wide Solvency Requirements Used by the State Insurance Commissioner Members May Not be Held Liable for Debts Incurred by MCO in the Case of InsolvencyMembers May Not be Held Liable for Debts Incurred by MCO in the Case of Insolvency

19. TA Partnership for Child and Family Mental Health FRAUD AND ABUSE Range of Sanctions Must be AvailableRange of Sanctions Must be Available Monetary SanctionsMonetary Sanctions Cancellation of the ContractCancellation of the Contract

20. TA Partnership for Child and Family Mental Health QUALITY IMPROVEMENT Internal Quality ImprovementInternal Quality Improvement External Quality ReviewExternal Quality Review

21. TA Partnership for Child and Family Mental Health INTERNAL QUALITY IMPROVEMENT Use of Clinical Practice GuidelinesUse of Clinical Practice Guidelines Measure Performance using Objective IndicatorsMeasure Performance using Objective Indicators Systems Intervention to Improve QualitySystems Intervention to Improve Quality Evaluation of Effectiveness of InterventionsEvaluation of Effectiveness of Interventions Planning and Initiation of Activities for Increasing or Sustaining ImprovementPlanning and Initiation of Activities for Increasing or Sustaining Improvement

22. TA Partnership for Child and Family Mental Health EXTERNAL QUALITY REVIEW/MANDATORY Independent External Organization with Expertise in QI ReviewIndependent External Organization with Expertise in QI Review Validation of MCO Internal QI ActivitiesValidation of MCO Internal QI Activities Validation of Performance Measures and Compliance with MeasuresValidation of Performance Measures and Compliance with Measures Review of Previous Activities to Determine Compliance with QI PlanReview of Previous Activities to Determine Compliance with QI Plan

23. TA Partnership for Child and Family Mental Health EXTERNAL QUALITY REVIEW/OPTIONAL Validation of Encounter DataValidation of Encounter Data Administration or Review of Member Satisfaction Surveys and Other ActivitiesAdministration or Review of Member Satisfaction Surveys and Other Activities Conduction of Quality Improvement Activities in Addition to Those of the MCOConduction of Quality Improvement Activities in Addition to Those of the MCO

24. TA Partnership for Child and Family Mental Health OPPORTUNITIES FOR SYSTEM OF CARE COMMUNITIES

25. TA Partnership for Child and Family Mental Health OPPORTUNITIES Contracting with MCO’s for:Contracting with MCO’s for: - “Case-Management” - Wrap-Around - Provision of Mental Health Services Contract Requiremements including the Regulations, LicensureContract Requiremements including the Regulations, Licensure

26. TA Partnership for Child and Family Mental Health OPPORTUNITIES Participation in Quality Improvement ActivitiesParticipation in Quality Improvement Activities - Clinical Practice Guidelines - Assist in Development of Quality Indicators - Measuring Effectiveness of Wrap-Around and Other Activities

27. TA Partnership for Child and Family Mental Health TAKE HOME MESSAGE WHAT GETS MEASURED GETS MANAGED

28. TA Partnership for Child and Family Mental Health CAN WE TALK?