Medicaid Managed Care Transformation - NCACDSS...SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019 10 Medicaid Transformation Timeline July Aug. Sept. Oct. Dec. Jan. Feb.

Medicaid Managed Care Transformation

NC Medicaid

July 31, 2019

1. Why Managed Care?

2. Benefits of Managed Care?

3. Managed Care in Context

4. What Has Happened So Far

5. Managed Care Timeline

6. Managed Care Updates

7. DSS Supports

8. Issues and Concerns

9. Transition of Care

10.Next Steps

SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019 2

Agenda

In 2015, the NC General

Assembly enacted Session

Law 2015-245, which

directed the Department of

Health and Human Services

(DHHS) to transition

Medicaid and NC Health

Choice from fee-for-service

to managed care.

SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019

Medicaid Transformation

3

“North Carolina has

continued to perform

below average in a

national ranking of state

health systems, moving

from 35th in 2018 to

34th this year.”

https://www.northcarolinahealthnews.org/2019/0

6/13/health-report-cards-north-carolina-below-average-performance-access/

Opportunities for Health

4SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019

• Integration of care

• Implement whole-

person centered, and

well-coordinated

system of care

• Address medical and

non-medical drivers

of health.

Opportunities to Improve Health

5SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019

6

Managed Care In Context

• Transitioning to managed care is most significant change

that NC Medicaid has ever undertaken.

• With any rollout of this magnitude, there will be have been

issues and questions that arise.

• We are committed to doing everything possible to resolve

problems quickly


What has happened so far?

• Phase 1 Enrollment Packets started to be distributed on 7/8 (205,000+)

• Phase 1 Open Enrollment began 7/15

NC Medicaid Website is live

− Ncmedicaidplans.gov

Enrollment Broker Call Center is open and accepting calls

− Toll Free Phone Number: 1-833-870-5500

− TTY: 1-833-870-5588

Health Plan Member Service Lines are open and accepting calls

− WellCare: 1-866-799-5318 |

− UnitedHealthcare: 1-800-349-1855 |

− HealthyBlue: 1-844-594-5070 |

− AmeriHealth Caritas: 1-855-375-8811 |

− Carolina Complete Health: 1-833-552-3876 |


8

Medicaid managed care rumor #1

Medicaid Managed

Care has been delayed

You may have heard…


9


Medicaid Managed

Care has been

delayed

FALSE TRUE

• Managed Care is still slated to go

live Nov. 1st 2019

• An approved budget is necessary to

support managed care



Medicaid Transformation Timeline

Jan. Feb.Sept. Oct. Dec.July Aug.

Health Plans Provide Beneficiary Support

7/15/2019 – 9/13/2019

Open Enrollment

10/14/2019 -12/13/2019

Open Enrollment

02/01/2020

Managed Care Day 1

11/01/2019

Managed Care Day 1

Nov.

PHASE 1: Regions 2 & 4

PHASE 2: Regions 1, 3, 5 & 6

June

2019

2020

Enrollment Broker Provides Beneficiary Support – Choice Counseling

10/1/2019

Enrollment Packets Begin

Local DSS will continues to determine Medicaid Eligibility and Help direct beneficiary to proper Support System

Auto-Assignment

• NEMT Services for Managed

Care Members will begin

11/1/2019

• NEMT vendors will begin

accepting appointments on

10/1/2019 for appoints

scheduled on or after

11/1/2019

11

How will we measure success?

• Member Health Measures

− Quality Indicators

• Member satisfaction

− DHHS, PHPs, EB measures

− Complaints and Grievances

• Call center data

− Reported average speed to answer , abandonment rates, hold times

• Notices and correspondence

− Outbound mail communications to consumers

• Voluntary plan selection rates

− Represents the percent of population who actively select their health plan vs.

being auto-assigned into a plan

• Provider Enrollment

− Number of providers enrolled with Medicaid

− Number of providers contracted with PHPs


Inquiry Type (Call Reason)

# o

f Tic

ke

ts

Medicaid Contact Center Inquiries (Call Reasons) – Week of July 22 (to date)

So what do we know so far?

13

Open Enrollment Metrics

Enrollment Broker

Call Center

8,817 Calls

Handled

NCmedicaidplans.gov

5,010 Website Visits

NC Medicaid Managed

Care Mobile App

3780 Sessions

All information for the period of July 25, 2019


14

Open Enrollment Metrics

NCmedicaidplans.gov

1384 web chats

NC Medicaid Managed

Enrollments

3477 Enrollments

All information for the period of July 25, 2019


15


Providers are

not enrolling

in managed

care

You may have heard…



Network Adequacy & Member Enrollment• DHHS’ priorities

− Medicaid and NC Health Choice beneficiaries have broad access

to providers

− NC providers continue to participate in the Medicaid program.

• Foundation

− Large Provider Network - 90,412 Medicaid Direct (FFS) providers

enrolled 11/2018*

− Provider Choice

− Rate Floors

− Centralized credentialing

− No deadline established for provider contracting

− PHP Network adequacy requirements

− Ongoing oversight and monitoring of Network Adequacy standards

− Clear contract terms to hold PHP’s accountable with wide range of

remedies (CAPs, liquidated damages, termination of contract)

*Consideration- when comparing provider numbers consider that not all enrolled providers are currently billing Medicaid.

Providers Enrolled

− All current providers are not yet enrolled

− As of 7/24/2019 there were over 23,000 providers enrolled in Managed Care Medicaid

Issues with Provider Enrollment

- Some providers are not in the directory

- Beneficiaries cannot locate their PCP

- Provider Information is displayed differently than in NC FAST

Solutions

Networks will grow, most providers will contract

− DHHS will monitor networks between now and go-live and ongoing

− Beneficiaries can wait (the EB will remind them later)

− Beneficiaries will be auto Assigned

− Beneficiaries can change plans until January 31, 2020

− DHHS is focused on correcting information


Where are we now?

18


FALSE

Providers are

not enrolling

in managed

care

TRUE

• Providers are contracting

• Provider numbers will increase daily

until we go live

• DHHS will hold PHPs accountable to

meeting network adequacy

standards and ensuring that we

have sufficient providers to meet

member needs


DSS Support?

19

• Managed Care on-boarding sessions (Feb-Mar 2019)

• Health Plan cross functional training (April 2019)

• Monthly webinars (ongoing)

• Virtual office hours (ongoing)

• Enrollment Broker onsite for in-person support

(begins July 2019)

• DHHS staff onsite for in-person support (begins July 2019)

• County Playbook

• DSS staff in ALL 27 Phase 1 counties trained as of June 14


What has happened so far?

• Heads of Household for some minors unable to make selections.

• Authorized Representative not displaying for Enrollment Broker

• Beneficiaries may not be able to find their Primary Care Provider of choice in the provider directory.

• The Enrollment Broker call center agents can now verify that the person is the head of household associated with the minor.

• The Enrollment Broker call center agents can now verify that the person is the authorized representative.

• Beneficiaries do not have to choose now. A reminder call will be mailed in August. May be auto assigned and can change later.

Issue Solution


What issues have we encountered?

• A few individuals have received letters who should not have

• Provider Directory information

• Corrections have been mailed. New letters will go out (in case of Dual Eligibles)

• EB revisions to directory

• Provider Corrections in NCTRACKS

Issue Solution


What issues have we encountered?

QUESTION: What should I do if contacted by

PHP for a meeting?

QUESTION: What if a PHP wants to set up a

booth in my lobby?

QUESTION: What if a PHP wants to contract

with DSS?

QUESTION: What if I have not heard from the

PHP?


Other Areas of Concern?

• PHPs can engage in permitted marketing

activities in certain locations:

• Community centers or health fairs

• Markets/Malls /Retail establishments

• Hospitals, Pharmacies and Other Provider

Sites• Only in common areas, not treatment areas; all PHPs contracted

must have equal opportunity to be represented

• Schools• Only at university campuses or at community-based events/health

fairs

• Other state-approved community-based

events or locations


DSS, PHP, EB Interactions

• PHP marketing

−What’s not permitted• Direct or indirect cold-call marketing+

• Practices that seek to influence enrolment in conjunction with sale of any

other insurance product +

• Activities that could mislead, confuse or defraud members or potential

members +

• Offer of material or financial gain to members or inducement to enroll +

• Practices that are discriminatory or that target prospective members based

on health status+

• Direct mailings

• Offering of coupons for produce of value

• Outreach activities related to enrollment (must refer to Enrollment Broker)

• Outreach activities/materials in treatment areas

• Activities that seek to target individuals currently enrolled in another

Contractors’ plan


DSS, PHP, EB Interactions

25

Tailored Plan Implementation Update

• Eligibility Update/Revisions

−Data criteria

−Services available only in Tailored Plan

−Meeting eligibility criteria when enrolled in a Standard

Plan

−Urgent Need for Services in a Tailored Plan

• Eligibility Reconciliation

• Exemption Form

−Beneficiary Form

−Provider Form

• Crisis Services Memo

• Policy Papers – next Care Management Data Strategy

PaperSOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019

Benefit Packages/Services

BH, TBI and I/DD Services Covered by Both SPs and BH I/DD Tailored Plans

BH, I/DD and TBI Services Covered Exclusively by BH I/DD Tailored Plans(or LME-MCOs Prior To Launch)

Enhanced behavioral health services are italicizedState Plan BH and I/DD Services• Inpatient behavioral health services• Outpatient behavioral health emergency room services• Outpatient behavioral health services provided by direct-

enrolled providers• Partial hospitalization• Mobile crisis management• Facility-based crisis services for children and adolescents• Professional treatment services in facility-based crisis program• Peer supports (move from( b)(3) to state plan)* • Outpatient opioid treatment• Ambulatory detoxification • Clinically managed residential withdrawal (aka social setting

detox)* • Research-based intensive behavioral health treatment• Diagnostic assessment • EPSDT• Non-hospital medical detoxification• Medically supervised or ADATC detoxification crisis stabilization

State Plan BH and I/DD Services• Residential treatment facility services for children and adolescents• Child and adolescent day treatment services• Intensive in-home services• Multi-systemic therapy services• Psychiatric residential treatment facilities• Assertive community treatment• Community support team • Psychosocial rehabilitation• Substance abuse non-medical community residential treatment• Substance abuse medically monitored residential treatment• Clinically managed low-intensity residential treatment services* • Clinically managed population-specific high-intensity residential programs*• Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)• Substance abuse comprehensive outpatient treatment program (SACOT)**• Substance abuse intensive outpatient program (SAIOP)**

Waiver Services• Innovations waiver services• TBI waiver services • 1915(b)(3) services (excluding peer supports if moved to state plan)

State-Funded BH and I/DD ServicesState-Funded TBI Services

Only BH I/DD TPs will cover a subset of high-intensity State Plan BH services; TBI, Innovations and 1915(b)(3) waiver services; and State-funded BH, I/DD, and TBI services

*DHHS will submit a State Plan Amendment to add this service to the State Plan** updated 7/31/19


Current Behavioral Health and Non Behavioral Health

LME / MCO

NC Innovations

I/DD

Substance Use

Mental HeathState Funded

Doctors

Hospital

Physical

Therapy


Future and Tailored Plans

LME / MCO

NC Innovations

I/DD

Substance Use

Mental HeathState Funded

Doctors

Hospital

Physical

Therapy


Future and Tailored Plans

Tailored Plan

• NC Innovations

• Respite

• Supported Employment

• ICF-IID• Enhanced Services

• State Funded Services

Doctors

Hospital

Physical

Therapy

Care

Management

Care

Management

Who are the LME /MCOs?

Alliance Health

Cardinal Health Innovations

Eastpointe

Partners

Sandhills Center

Trillium

Vaya


Similar• Both require physical health and behavioral health.

• Both offer comprehensive array behavioral health services

Different

• TPs target individuals with significant BH, TBI & I/DD

needs, thus services in the plan match individuals needs.

• 1915(b)(3), Innovations, TBI wavier services and state-

funded behavioral health and I/DD services will only be

available in TPs or LME-MCOs (prior to TP launch).

• Care management will be available to all TP enrollees.

• TPs can have closed provider network for BH.

Plans are tailored to meet the needs of members


How are SPs and BH I/DD TPs different?

32

Foster Care Update

• Design in Progress

• Approach will address

−Unique needs of children in foster care, adoptive

placements and those formerly in foster care up to age

26

−Statewide

−Specific PHP staffing

− Transition of Care

• DSS Feedback will be sought

• Timeline – 2021

• Until then- Foster Children remain in current system


• Procurement Continues

• Silent Period in force

• https://www.ncdhhs.gov/request-information

• Numerous updates to RFP

• Most recent

− https://files.nc.gov/ncdhhs/20190724-Omb-RFP-30-

190485-DHB-Addendum-5-Revisions-to-the-

RFP.pdf

−Revisions to RFP

−Extend opening

33

Ombudsman


https://www.ncdhhs.gov/request-information

https://files.nc.gov/ncdhhs/20190724-Omb-RFP-30-190485-DHB-Addendum-5-Revisions-to-the-RFP.pdf

• DHHS transfer of claims data

• PHP Expectations

−Honor Prior Authorizations

−Offer Appeal Rights

−Non Participating providers

• Pay claims and authorize service

−Non Emergency Medical Transportation (NEMT)

• Accept NEMT appointments for post-MCL services one

month prior

• Identify NEMT utilizers through claims detail.

• Substance Use Disorder (SUD)-related

Requirements


Transition of Care

Number to call if I have issues getting care after my start date.

My Health Plan Is

Number to call if I have questions about my supplies.

Number to call if I need to schedule a ride to an appointment after I start getting

care through my health plan.

My primary care provider is:

Preparing for Managed Care: Helping Members through Crossover Process

When I will start getting care through my health plan

We want to

ensure

Members

have simple,

clear, “pocket

reference”

answers to

these

questions.


Supporting Members through the Crossover Experience

• DHHS will be creating member-facing tools

to assist members “know where to go.”

• Will focus on supporting members to

organize information and to be aware of

“who to call” with questions or issues.

• We want members to “be prepared, not

scared.”

SOURCE:


Upcoming DHHS-Sponsored Webinars on Crossover

• For August 15, 2019: MCT 112

− Supporting the LTSS Community through the Transition to Managed Care

− As NC transitions to managed care, North Carolina is establishing processes for

ensuring providers and members have a smooth transition. This webinar will discuss

activities related to Prior Authorization submissions and provider payment

considerations at the time of transition.

• For September 5, 2019: MCT 113

− NC’s Transition to Managed Care: The Crossover Series

− This session provides general crossover guidance, with a focus on identifying

beneficiary managed care detail and guidance on submitting prior authorization

requests during the crossover period.

• For September 19, 2019: MCT 114

− NC’s Transition to Managed Care: The Crossover Series (Continued)

− This session is a continuation of the session on Sept. 5, 2019, providing a brief

review of topics previously covered and additional guidance for supporting

beneficiaries through the transition to Medicaid Managed Care.


Questions to SSI Attendees

• What other information do you anticipate

beneficiaries will need/want to prepare for

Crossover?

• How can DSSs best support members to

understand these elements?

• What are your insights on effective

distribution mechanisms?


• Summer

−Phase 1 Open Enrollment (July 15-September 13)

−Standard Plan/Tailored Plan Split

−Health Plan/Provider contracting to build adequate

networks

− Foster Care Policy Recommendation

• Fall

−Phase 1 Auto-Assignment (September 16)

−Readiness Reviews – network, operations, IT

−Phase 2 Open Enrollment (October 15-December 13)

−Phase 1 Health Plan Effective (November 1)

39

Upcoming Major Activities


ABOUTELIGIBILITY

Continue to come to local DSS

Find contact information at

ncdhhs.gov/localdss

ABOUTCHOOSING

A PLAN OR PCPAND ENROLLING

Go to ncmedicaidplans.gov

(chat available)

Use theNC Medicaid

Managed Caremobile app

Call 1-833-870-5500(the call is free)

TTY: 1-833-870-5588

ABOUTNC MEDICAID

MANAGED CARE PLAN OR BENEFITS

Call theirHealth Plan

ABOUTNC MEDICAID

DIRECT BENEFITS

AND CLAIMS

Call the Medicaid Contact Center

toll free:

1-888-245-0179

40

Contacts for Beneficiaries


Questions

41

MEDICAID MANAGED CARE WEBCAST | JULY 15, 2019

Medicaid Managed Care Transformation - NCACDSS...SOCIAL SERVICES INSTITUTE MANAGED CARE UPDATE JULY 31, 2019 10 Medicaid Transformation Timeline July Aug. Sept. Oct. Dec. Jan. Feb.

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