September 13, 2012

1. Enrollment of Children’s Special Health Care Services (CSHCS) Beneficiaries with Medicaid into Medicaid Health Plans (MHPs) September 13, 2012

2. Agenda • Welcome and Purpose:  Steve Fitton • Planning Process Update/Timeline:  Kathy Stiffler • Policy Bulletin Overview:  Kathy Stiffler • Core Competency Process:  Kathy Stiffler • Rates and SNAF:  Brian Keisling • Outreach/Communications:  Lonnie Barnett • Enrollment Process:  Julie Denny • Primary Care Provider Selection Process and Family Centered Medical Home:  Dr. Jane Turner • Care Coordination:  Kathy Stiffler and Lonnie Barnett • Prior Authorization Transition Procedures:  Dr. Nina Mattarella • Contract Administration:  Kim Hamilton • Performance Monitoring:  Sheila Embry • Discussion:  all

3. Purpose of Today’s Meeting • Update children’s hospitals and pediatric regional centers on the State’s plans to transition CSHCS population with Medicaid into Medicaid Health Plans (MHPs) • Provide an opportunity for Department to obtain input from hospitals and regional centers on transition plans

4. Background • Approximately 21,000 children (and some adults) enrolled in CSHCS with full MA. Approximately 3,500 of this group will be voluntary for or excluded from managed care enrollment • DCH estimates approximately 10 – 15 thousand CSHCS eligibles (CSHCS “look alikes”) are currently enrolled in the MHPs – not enrolled in CSHCS • Data indicates that look-alike population has a lower acuity and expenses than CSHCS enrolled population as a whole • MHPs do serve high acuity individuals – ABAD, CSHCS aged-outs, etc.

5. Legislative Background • Budget for FY12 passed in May 2011 • Sec. 1204. By October, 2011, the department shall report to the senate and house appropriations committees on community health and the senate and house fiscal agencies on its plan for enrolling Medicaid eligible children’s special health care services recipients in the Medicaid health plans. The report shall include information on which Medicaid health plans are participating, the methods used to assure continuity of care and continuity of ongoing relationships with providers and projected savings from the implementation of the proposal

6. Legislative Background • In FY12, administration concurred that the planning process for transitioning this population required a more extensive planning and implementation process than the transition of other populations • Therefore, implementation of the transition will take place in FY 13

7. Benefits for Enrolling CSHCS Population into Managed Care • The internal work group has identified several benefits to enrolling CSHCS beneficiaries into MHPs: • Organized approach to primary care • Addition of complex case management • Ability for quality monitoring • Access to outpatient mental health services • Increased access to non-emergency transportation services

8. Planning Structure • Following similar structure used to transition of other populations • Department convened internal work group comprised of 25 state staff from CSHCS and MSA • Meetings monthly as a group with additional meetings for subgroups on topics such as data, systems • Department utilizing regularly scheduled monthly operations workgroup meetings with Medicaid Health Plans to discuss the infrastructure within the MHPs to successfully transition population • Key staff from CSHCS, MSA and Enrollment Broker regularly attend

9. Planning Structure • During internal and operations workgroups, staff and other experts are providing educational sessions on multiple topics relevant/unique to the transition of CSHCS population into managed care • Contract requirements • Care coordination • Quality strategy • CMS clinics • CSHCS benefit package • Family-centered medical home • Prior/Authorization for DME, therapies, etc.

10. Planning Structure • Department also making contact with key stakeholders such as hospitals, local health departments and CSHCS Advisory Committee to obtain input/feedback

11. Timeline

12. Planning Process/Timeline Update • Last two provider L-letters being finalized • All providers, including out of state providers • Transplant providers • Member services training by CSHCS for MHP under development • Coordination meetings with LHDs and CMS Clinics • Final system changes are in testing phase • System changes will go into CHAMPS on 9/28/2012 • Outreach to CSHCS families and providers continues • Monitoring of the CSHCS family phone line and Beneficiary HelpLine will begin in October

13. Key Dates • August 1: CSHCS stopped mailing applications to Medicaid beneficiaries also eligible for CSHCS; CSHCS eligible = enrolled in CSHCS for these beneficiaries • October 1: MHP enrollees with new CSHCS diagnoses since 8/1 will begin in the CSHCS-MC benefit plan and the MHPs will be required to meet the special contract requirements • October 1: Enrollment of UP CSHCS enrollees • November 1: Current CSHCS/FFS enrollees in lower MI begin enrollment over 5 week period – begin with Kent County and end with Wayne County • April 1: Conversion of MHP Enrollees meeting CSHCS eligibility criteria to CSHCS-MC

14. MSA 12-46 • Policy Bulletin issues 9/1/2012; effective 10/1/2012 • Requires individuals who have both CSHCS eligibility and MA eligibility (CSHCS/MA beneficiaries) to enroll in health plan unless excluded for some other reason such as PPO insurance or incarceration • MI Enrolls will conduct the choice counseling and process the enrollment into the MHPs • Individuals have 90 days after enrollment to transfer to another MHP • All providers MUST verify eligibility and enrollment status prior to providing services; CSHCS/MA beneficiaries will have CSHCS-MC listed as the benefit plan another with the name of the MHP in which the beneficiary is enrolled

15. MSA 12-46 • MHPs must cover all Medicaid covered services specified in contract • MHPs may have different PA requirements, formularies and documentation requirements • All services currently carved out of MHP contract remain carved out; plus the following will be carved out effective 10/1: • In-state approved intensive feeding clinic • Drugs used to treat coagulopathies such as hemophilia • Orphan drugs used to treat rate metabolic disorders

16. MSA 12-46 • Following services continue to be covered by CSHCS and are not the responsibility of the MHP: • LHD care coordination and case management • Children's Multidisciplinary Specialty Clinic facility payment • Orthodontia (for specific qualifying diagnoses) • Respite • Private insurance premium payment

17. MSA 12-46 • Effective 10/1/2012 individuals authorized by FFS to receive PDN services are excluded from managed care enrollment

18. Core Competencies • Access Standards • Network Adequacy • Referral Processing • Performance Monitoring • Grievance/Appeals • Prior Authorization • Family Involvement • Overall MHP Performance

19. Core Competency • Core Competencies issued to plans:  May 7 • Decision by DCH that all plans that met core competencies would be required to participate:  June 1 • Core Competency submissions to MSU Institute for Health Care Studies due: July 2 • Plans must be compliant with Core Competency requirements by: 8/31/12 • Final documentation of compliance by 12 plans issued to DCH by MSU IHCS: 7/18/12

20. Core Competency Best Practices by MHPs • CSHCS-specific care managers • Planning workgroups including community providers/hospitals • PCP attestations built into provider contracts • Special data analysis procedures • No PA requirements for pediatric subspecialists • Weekly reporting on CSHCS-specific issues/training needs • Policies that specify coordination of DME with referring specialists and family • CSHCS-specific DME complaints and grievances procedure

21. Core Competency Best Practices by MHPs • Quarterly focus groups with CSHCS members/families, member surveys, case management surveys, action plans to address internal and external concerns • CSHCS/Family Ombudsman • CSHCS Member Advisory Council • Integration of behavioral health services • Special care management procedures that include family involvement

22. Rate Development • Encounter and FFS claims experience from FY10 and FY11 associated with the CSHCS population was analyzed by consulting actuarial firm Milliman • Data were both completed and trended 30 months from the claims/data year to mid-rate year of FY13 • CSHCS population rates were developed using its own rate structure (base rate, regional factors, etc.) • Rate structure and actuarial models for CSHCS are consistent with existing MCO rates • CSHCS population split between Disabled and TANF populations with further divisions in the TANF group by age • Children less than 1 (both Disabled and TANF) also have a unique rate cell based on their historically high costs

23. Rate Development • Specific carve-outs were identified for exclusion from the rates (dental services and certain pharmaceuticals) • Beneficiaries receiving private duty nursing were excluded entirely from the rate analysis since they will not be enrolled in the health plans • Adjustments made to include non-emergency transportation, HMO administration, amounts equivalent to FFS supplemental payments (GME, HRA, SNAF) and claims tax • Stop/loss or risk sharing arrangements were investigated, but the decision was made to pursue a full risk arrangement for this population • Rates were presented to MHPs and discussed at length • Final capitation rates assumed managed care savings fairly evenly distributed across provider categories • Rates were submitted to CMS in July for approval

24. Sources of Managed Care Savings • While all MHPs have different approaches for improving cost-effectiveness, some or all of the following elements come into play (this is a general discussion that is not CSHCS-specific): • Each member is assigned a primary care physician who is responsible for coordinating the member's care • Improved access to primary and specialist physician care reduces ER, outpatient, and inpatient hospital costs

25. Sources of Managed Care Savings • Coordinated care management: • Avoids duplicative lab, x-ray, and other diagnostic work • Avoids duplicative and conflicting pharmaceuticals • Promotes better communication between primary care and specialist physicians • Emphasis on preventive care and compliance with regimens improves health outcomes and lowers costs • Emphasis on prenatal care results in fewer intensive care babies and therefore lowers costs

26. Sources of Managed Care Savings • Intensive case management of Disability clients in particular improves health outcomes and lowers costs • Better access to mental health care reduces need for more intensive care from the mental health system down the road

27. SNAF (Specialty Network Access Fee) • Medicaid Health Plans (MHPs) have agreements with 6 Public Entities • University of Michigan • Wayne State University • Michigan State University • Hurley Hospital • Oakland University • Western Michigan University • Amount is built into MHP capitation by MDCH to reflect historical usage of physicians affiliated with these Public Entities

28. SNAF (Specialty Network Access Fee) • If MHPs cannot provide the specialty services within their networks, this arrangement comes into play • MHPs pay the Public Entities from the SNAF capitation component in proportion to the Public Entities' percentage of SNAF services provided • The SNAF component is designed to reimburse Public Entity physicians up to roughly commercial rate levels and, in effect, supplements the amounts paid by the MHPs to the Public Entity physicians when the provider claim was paid

29. Outreach/Communications • CSHCS Advisory Committee • Correspondence to Families • Initial letter • Second letter • Enrollment letter • Welcome letter (new CSHCS enrollees) • Family FAQs • Family Focus Groups

30. Outreach/Communications • www.michigan.gov/cshcs • Family correspondence, FAQs, and other materials • Focus Group Report

31. Outreach/Communications • Local Health Departments • Regional Meetings • Monthly Calls • FAQs • Visits to Large Health Departments • Family Phone calls • Family phone line • Local Health Departments • Provider L-Letters

32. Enrollment Process • Customized Letters for CSHCS Families: • Michigan ENROLLS sends letter that has been customized for the CSHCS families and include a CSHCS dedicated phone line • Dedicated Phone Line: • Dedicated toll free phone number connects directly to Michigan ENROLLS staff specially trained to assist this complex population • Specially Trained, Experienced Call Center Counselors: • Experienced counselors with special scripts and desk reference materials and authorized provider information shared from DCH

33. Enrollment Process • Initial Extended Enrollment Timeline: • Timeline for enrollment extended from 30 to 60 days is for the initial push of CSHCS beneficiaries into MHPs and allow for: • CSHCS Customized Reminder Letter • Phone Call to Families • Assignment Process: Perceptive to the family’s needs, based on available information • Are other family members on the case in a MHP? • With what MHPs do the authorized providers participate? • In the event of a tie the MHPs have equal weight and the assignment to the MHPs will be evenly distributed, taking into consideration MHP capacities

34. Enrollment Process • Capacities • Capacity: Number of beneficiaries a Medicaid Health Plan (MHP) can adequately serve in a county. • CSHCS capacity request is submitted by the MHP and reviewed by MDCH • Capacities are monitored constantly to ensure adequate coverage in all service areas

35. Eligibility: CHAMPS – Online Response Example • CSHCS-MC enrollee with a provider who is added as an authorized provider: • “This NPI is Listed….” message displayed. • Access allowed to CSHCS Restrictions page: • Indicates auth diagnosis codes and providers for DOS.

36. Eligibility Response Ex: Member Benefit Level page 2

37. Eligibility Response Ex: CSHCS Restrictions page to access authorized diagnosis codes and providers for DOS.

38. Eligibility: CHAMPS – Online Response Example • CSHCS-MC enrollee but the provider is not listed as an authorized provider: • Beneficiary enrolled in MHP but the provider is not listed as CSHCS authorized provider: • No access to CSHCS Restrictions page. • “This NPI is Not Listed….” message

39. Eligibility Response Ex: Member Benefit Level page

42. Primary Care Provider Selection Process and Family Centered Medical Home •  PCP approval process – MHP list of approved PCP based on “attestation” • Official PCMH certification (i.e. NCQA, PGIP) NOT required • Family may choose PCP not on the list – family preference trumps all. • Practice based care coordination • Point person for care coordination • Components of practice based care coordination – checklist from workbook • Communication/coordination with MHP case manager, LHD coordinator, CMS clinic, subspecialists, mental health provider, schools.

43. Primary Care Provider Selection Process and Family Centered Medical Home • Enhanced payment per member per month to compensate for extra effort for care coordination.   • Only approved PCP will receive enhanced payment • $4 / $8 per member per month

44. Care Coordination • Workgroup established including representatives from CSHCS, MSA, LHDs, and MHPs • Workgroup charge:  to develop a model whereby the care coordination activities delivered by the various providers be coordinated to assure that the family is receiving the necessary services and supports to achieve the best outcome for the beneficiary while avoiding duplication • For care coordination/case management that results in a care plan, the goal is a single clear, comprehensive plan of care in which the families have input and can easily understand/follow • Seeking electronic solutions for secure portal through which involved providers can access/update care plan

45. Care Coordination • Current focus is on coordination of LHD/MHP coordination activities, but will soon include CMS Clinics.  Coordination with FCMH practices is longer term • Product:  CSHCS Coordination Agreement template for use between MHPs and respective LHDs • Base template can be modified to address the unique strengths and needs of each MHP and LHD as well as the communities they serve

46. MHP Care Management and Complex Case Management • For members not meeting complex case management criteria, plans typically provide: • Assessment, individualized care plan development, prioritized goals and barrier busting • Assistance obtaining needed authorizations for DME, therapies, or other ancillary services and arranging for timely delivery of these services • Facilitation of transitions between levels of care or intensity of services • Patient/family education, including role of family in the treatment plan/maintenance of member’s health status

47. MHP Care Management and Complex Case Management • For members not meeting complex case management criteria, plans typically provide: • Appointment scheduling assistance • Transportation assistance • Referral to community and other resources– collaboration with LHDs

48. MHP Care Management and Complex Case Management • For members meeting complex case management criteria (e.g. complex medical needs/multiple comorbid conditions, high utilization of ED or inpatient, need for assistance in system navigation), plans are required by their accrediting bodies, to provide: • Assessment and care planning  within 30 days of identification of the member meeting complex case management criteria • Plan’s procedures must address all of the following: • Member’s right to decline complex case management • Comprehensive assessment, including ADL, mental health, cognitive functions, life-planning activities, cultural and linguistic needs, caregiver resources, available benefits

49. MHP Care Management and Complex Case Management • Plan’s procedures must address all of the following (Continued) • Development of an individualized plan of care including longer and short term goals, resources, planning for continuity of care and transitions, family participation • Identification of barriers to meeting goals or complying the with plan • Schedule for follow-up communication with member

50. MHP Care Management and Complex Case Management • Plan’s procedures must address all of the following (Continued) • Development of member self-management plans • Process to assess progress against case management plans for members • In some communities, LHDs will assist with pieces of complex case management, assessment and care plan development