Managed Care Supplemental Payment Program – 2008 Update

1. Managed Care Supplemental Payment Program – 2008 Update May 28, 2008 Moderator: Kate Breslin, CHCANYS Presenters: Peter R. Epp, RSM McGladrey Helen Pfister, Manatt Phelps & Phillips, LLP Scott Morgan, RSM McGladrey Lynn Sherman, Charles B. Wang CHC

2. Technical Tips to this Webinar’s Technology • Polling questions: We will be asking several questions during the course of today’s webinar. Your responses are confidential and will help us to identify key issues. Please respond! • If you would like to post a question to presenters: Use the button in the top, left side of your screen that says “Q&A.” Click on it, type in your question, then click on “Ask.” We’ll take a couple of breaks during the webinar to go over questions asked by participants. • We encourage all participants to register, even if it is after the event. We will use the registration list for future email correspondence about this and related issues.

3. Poll Questions 1-A and 1-B How many MCOs does your center have Medicaid/Family Health Plus contracts with? None – One – Two to three – Four or more – Don’t know How many Independent Practice Associations (IPAs) does your center contract with for Medicaid/FHP? None – One – Two to three – Four or more – Don’t know

4. Agenda • Overview of the Managed Care Shortfall Payment program • Managed Care Contracting • Shortfall Payment Rate Calculation • Billing Requirements • MCVR Reporting

5. Overview of the Program • Federal law requires states to make supplemental payments to an FQHC for services furnished pursuant to a contract between the FQHC and a Managed Care Organization (MCO) for the amount, if any, that the FQHC’s PPS rate exceeds the amount of payments provided under the managed care contract for the services rendered by the FQHC. • On February 25, 2008, the New York State Department of Health (DOH) distributed to all FQHCs the “NYS Managed Care Supplemental Payment Program Policy Documents” which consolidate policies related to this program, previously conveyed via letters, into a single source.

6. Overview of the Program (cont’d) • All FQHCs participating in the Program are required to submit electronic copies of their duly executed managed care contracts between the FQHC and the MCOs/IPAs on CD to DOH by June 1, 2008 (per Section III.B. of the Policy Document) to remain in the program. • The 2007 Managed Care Visit and Revenue (MCVR) report and corresponding Certification Form must be submitted to DOH by July 1, 2008, to apply for participation in the Program for October 2008 – September 2009. • Instructions are included in Attachment A of the Policy Document.

7. Overview of the Program (cont’d) • In order to qualify to receive supplemental payments, each FQHC must: • Have a PPS rate in effect for the time period and site where services were provided to an MCO enrollee; • Have an executed contract for Medicaid and/or Family Health Plus (FHP) with the MCO or an Independent Practice Association (IPA) that contracts with an MCO, for the time period; and • Must have received an MCO payment for services rendered that is less than the FQHC would have received for those same services under the PPS rate.

8. Submission of Qualifying MCO/FQHC Contracts • Contracts must be between the FQHC and the MCO. Contracts between the MCO and individual physicians, even if employed by or working at FQHC sites, do not qualify for FQHC supplemental payments. • Contracts between the FQHC and an Independent Practice Association (IPA) are acceptable if the IPA has a corresponding contract with an MCO, the contract explicitly covers Medicaid and/or Family Health Plus, and the FQHC can separately identify visits associated with each MCO that contracts with the IPA. The IPA and its associated MCO must be reported on the MCVR report. Contracts between the IPA and individual physicians do not qualify the FQHC to receive supplemental payments. • All contracts must clearly indicate which specific primary and specialty care services are covered.

9. Submission of Qualifying MCO/FQHC Contracts (cont’d) • The contract period must be in effect during the supplemental payment period. • Contracts with effective dates prior to the supplemental period are acceptable if they contain renewal language or signed dated amendments that clearly indicate the contract is in effect during the supplemental payment period. • Contracts with automatic renewal clauses with effective dates prior to the supplemental rate period in question that do not specifically indicate they are effective during the supplemental period must include a signed attestation from the FQHC and the MCO that the contract is in effect during the supplemental period, if the effective date of the contract is more than two years old. • For example, contracts for the October 1, 2008 through September 30, 2009 supplemental payment period must be effective no earlier than October 1, 2006, or they must be accompanied by the attestation. The attestation must be a letter signed by the Chief Executive Officer of both the MCO/IPA and the FQHC attesting that the contract and payment terms were in effect during the supplemental payment period.

10. Submission of Qualifying MCO/FQHC Contracts (cont’d) • The specific payment terms of the contract must be submitted with the contract for the applicable period, including all relevant payment schedules. • All complete contracts must be dated and duly executed. • An electronic copy of each completed contract for each MCO and/or IPA listed on the MCVR report must be submitted to DOH, in a standard searchable PDF format on a closed session CD-R (not CD-RW), with copy/read permissions. The CDs must be clearly labeled identifying the FQHC and the contracts included.

11. Submission of Qualifying MCO/FQHC Contracts (cont’d) • Additional submission guidance for 2008 was sent by DOH on April 30, 2008. • A Managed Care Contract Attestation form must be included as part of the June 1, 2008 contract submission. • If more than fourteen (14) contracts are submitted, multiple forms must be used. • A completed copy of the Attestation form must be electronically included as an Excel document on the CD along with a signed hard copy. • The contracts included on the CD must correspond with the contracts listed on the Attestation form.

12. Submission of Qualifying MCO/FQHC Contracts (cont’d) Real Life Applications – • How do you negotiate with MCOs to revise the contracts to be in the name of the FQHC facility and not the individual physician? • What is “searchable PDF format on a closed session CD-R (not CD-RW), with copy/read permissions” and how do you copy contracts onto the CD?

13. Poll Question 2 How many of your Medicaid managed care contracts are with individual providers and NOT in the name of the Center?

14. Calculation of Shortfall Payment Rate • Each qualifying FQHC's "supplemental payment" is the average difference between what that FQHC is paid by contracted MCOs and its specific PPS rate for each year. FQHCs bill eMedNY directly for the supplemental payment, for services provided to contracted MCO enrollees that would otherwise qualify under Medicaid fee-for-service rules for payment at the FQHC's PPS rate. • In 2007, DOH revised the rate-setting methodology retroactive to October 1, 2005 • Converted to a “prospective” payment system • Changed the rate calculation from using a weighted-average Medicaid fee-for-service rate base to the PPS rate

15. Calculation of the Shortfall Payment Rate (cont’d) • The 2007 MCVR will be used to determine the average managed care revenue per visit in the Shortfall payment rate calculation for the period 10/1/08 – 9/30/09. • The following table illustrates the change in the Shortfall payment rate calculation.

16. Calculation of the Shortfall Payment Rate (cont’d) • The supplemental payment amount will vary by FQHC depending on its Medicaid PPS rate and its contract terms with MCOs. The FQHC specific average managed care payment per visit will be determined based on data provided on the MCVR Report. FQHCs must list – • Each contracted MCO (whether contracted directly or indirectly through an IPA contracted with an MCO), • The number of threshold visits each MCO/IPA paid the FQHC, and • The average MCO/IPA payment per threshold visit. • The CEO/CFO must sign an attestation to the accuracy of the submitted report.

17. Calculation of the Shortfall Payment Rate (cont’d) • While the MCVR report is submitted on a calendar year basis, the supplemental payment rates are effective for the same time period as the PPS rate, which is October through September. • Once determined, averagemanaged care payment rates for each year will not be further adjusted. • If the FQHC's Medicaid PPS rate changes, the FQHC should notify DOH and the supplemental payment rate will be updated based upon the revised PPS rate for that period.

18. Criteria for Submitting Supplemental Payment Claims • FQHCs may submit supplemental claims to eMedNY for Medicaid and/or Family Health Plus enrollee visits (Child Health Plus visits are not eligible) provided per a contract with an MCO, for services that would otherwise qualify under Medicaid Fee-for-service (FFS) for payment at the FQHC's Prospective Payment System (PPS) rate code. • The FQHC must either contract directly with the MCO or indirectly through an IPA that contracts with an MCO.

19. Criteria for Submitting Supplemental Payment Claims (cont’d) Managed care supplemental claims may be submitted by the FQHC only if the following criteria are met: • The FQHC must have an FQHC PPS Medicaid rate in effect for the date of service and site of service. • The FQHC must be contracted with the enrollee's MCO either directly or through an IPA that contracts with the MCO for the service provided. • Only one supplemental claim can be submitted for an enrollee for a given day. One supplemental claim is allowed per threshold visit. • The FQHC must have evidence of a paid claim from the MCO or IPA, if the contract is on a fee-for-service basis. Supplemental claims cannot be billed for visits for which the MCO denies payment. • Under Medicaid FFS, the visit would have been billed under the PPS rate. For example, group counseling and offsite visits are not eligible for supplemental payments, as they are not paid at the PPS rate.

20. Criteria for Submitting Supplemental Payment Claims (cont’d) • Only visits for mainstream Medicaid and Family Health Plus are eligible for supplemental payments. For example, Medicare/Medicaid Advantage and Child Health Plus enrollee visits are not eligible for supplemental payments. • The Policy Document indicates that Medicare/Medicaid Advantage enrollee visits are not eligible for supplemental payments. CHCANYS is actively engaged in reversing this decision as it is inconsistent with the FQHC PPS requirements. • Visits NOT eligible for supplemental payment include the following: • Visits for which there is no managed care contract between the FQHC and the MCO. • Visits for contracts between MCOs and individual provider. • Visits that under Medicaid PPS rules would not be eligible to be billed at the FQHC PPS rate code, i.e.: a Medicaid enrollee receives treatment during a threshold FQHC visit, which cannot be completed due to administrative or scheduling problems (e.g., follow-up laboratory testing or radiology procedures).

21. Polling Question Number 3 How many of your MCOs send you remittance advices for visits covered under capitation arrangements?

22. Poll Question 4 How many of your MCOs submit “electronic” remittance advices for payments made?

23. Poll Question 5 For visits covered under capitation arrangements, as indicated on the remittance advices, do you post the MCO’s approval in your Practice Management System?

24. Poll Question 6 Is your Practice Management System able to generate a report of PAID visits by MCO and government program?

25. MCVR Form and Instructions • The Managed Care Visit and Revenue Report must be completed by each FQHC in order to receive Supplemental Payments under this program. • The report identifies each MCO that the FQHC directly contract with, as well as any indirect contracts through an IPA, along with the number of visits and amount of MCO payments, for Medicaid and Family Health Plus (FHP) enrollees. • Specific instructions for completion of the report are included as Attachment A to the Policy Document, along with the report format (Attachment B) and the Certification Form (Attachment C).

26. MCVR Form and Instructions (cont’d) MCVR Reporting Form: Note: Columns A through E are replicated for FHP as columns F through J.

27. MCVR Form and Instructions (cont’d) • MCO Name: • Enter the MCO name with which your FQHC has a direct managed care contract. MCOs include Prepaid Health Service Providers (PHSPs), Health Maintenance Organizations (HMOs). Do not report any contractual arrangements other than those with an. MCO or with and IPA that contracts with an MCO. • IPA Name: • If the information being reported is through a contract directly with an MCO, leave this field blank. • If the information being reported is through an IPA contracted with the MCO, enter the IPA's name. Continue to report the visits and revenue associated with payments from the IPA for enrollees in the MCO reported under MCO Name. • Note, visits and revenues through an IPA must be reported by the MCO. If an IPA contracts with multiple MCOs, the visits and revenues associated with each MCO must be reported separately.

28. MCVR Form and Instructions (cont’d) • FQHC Visits Paid by MCO/IPA: • Enter the total number of visits paid by the MCO/IPA to the FQHC (Column A for Medicaid and Column F for FHP). In order the count as a visit for purposes of determining your managed care supplemental payment rate, the FQHC must have received payment from the MCO/IPA for that visit and included such amounts in Column B for Medicaid and Column G for FHP. • Only visits that would have been paid at the Prospective Payment System (PPS) rate code under Medicaid fee-for-service should be reported. • If the MCO pays the FQHC for more than one visit per day, report all MCO payments for that day, but only one (threshold) visit. • Group counseling and off site visits should not be reported.

29. MCVR Form and Instructions (cont’d) • MCO/IPA Payments to FQHC • Enter the dollar amount of payment received by your FQHC from' the MCO/IPA for the report calendar year (January - December) in Column B for Medicaid and Column G for FHP. This must include any capitation payments, as well as fee-for-service payments received by the FQHC from the MCO/IPA. • Financial incentive payments received by the FQHC from the contracting MCO/IPAs are not included in the calculation of managed care supplemental payments under the Balanced Budget Act (BBA). Therefore, do not include any bonus payments made to the FQHC in Column B for Medicaid or Column G for FHP. (A Bonus is a financial incentive payment above and beyond the amount otherwise due to a provider under the terms of the contract and made to the provider according to terms and conditions spelled out in the contract.) • If the FQHC receives a global payment that includes services other than those that would have been billed at the FQHC PPS rate, (such as a global fee for prenatal/delivery/postpartum) only report the portion of MCO reimbursement related to the FQHC PPS rate.

30. MCVR Form and Instructions (cont’d) • Withhold Adjustment (if applicable) • Enter any amount of withhold from the FQHC payments by the MCO/IPA, not reported in Column C for Medicaid and Column H for FHP. (A Withhold is a portion of a baseline payment that would otherwise be due to a provider but is withheld under the payment terms of a contract, which is partially or totally returned to the provider under agreed-to terms and conditions.)

31. MCVR Form and Instructions (cont’d) MCVR Reporting Form: Note: Column K represents the average of both Medicaid and FHP managed care revenue per visit and is utilized in the Shortfall payment rate calculation.

32. MCVR Form and Instructions (cont’d) MCVR Reporting Form: Calculation of Managed Care Shortfall Payment Rate -

33. MCVR Form and Instructions (cont’d) Real Life Applications - • How do you access “paid” visits from the Practice Management System? • How do you compile paid visits and payments – • By MCO? • By MCO and Government Program (e.g. Medicaid and FHP)? • By IPS and MCO and Government Program?

34. Poll Question 7 How many of the rosters you receive from your MCOs segregate members by Medicaid, FHP and CHP?

35. Poll Question 8 Do you update your Practice Management System on a monthly basis for active members by MCO and government program as indicated on the rosters?

36. Polling Question Number 9 Do remittance advices from IPAs (e.g. Doral Dental, Block Vision) indicate for each member the underlying MCO with whom the IPA has a subcontract?

37. Determining the MCVR Data Validation The information on submitted MCVR reports may be validated by the DOH: • Medicaid paid supplemental claims billed by FQHCs for the period, MCO encounter data showing paid FQHC visits, MCO Medicaid Managed Care Operating Reports (MMCORs) which list contracted FQHCs and paid visits, or any other data sources available to DOH. For example, an FQHC's reported average managed care rate on the MCVR report may be verified using the actual proportion of visits paid by each MCO for the prior period, based on the FQHC's billed supplemental payments for that period. • DOH may choose to accept the MCVR report and contract documentation as submitted, based on the attestation ofdata accuracy signed by the FQHC's CEO. The MCVR report is subjectto future audit by the Office of the Medicaid Inspector General (OMIG). • If,however, the information on MCVR reports or contracts is so inadequate that a shortfall rate can not be established the FQHC may be deemed ineligible for the time period in question.

38. Summary and Best Practices • Design systems NOW to capture all of the information required for reporting on the MCVR. • Establish procedures for recognizing “paid” visits in the Practice Management System. • Only bill the Shortfall Payment rate for “paid” claims. • Work with MCOs to provide the data necessary to properly complete the MCVR. • Regular review your Managed Care contracts and Shortfall Payment rate billing for compliance as part of your corporate compliance activities. • Monitor/Project increases and decreases in managed care revenue per visit, and its implications on patient revenue, both currently and in to the future. • Be prepared when the OMIG comes a knockin’!

39. Questions

40. Contact Information • Kate Breslin, CHCANYS – Director of Policy KBreslin@CHCANYS.org • Peter R. Epp, CPA, RSM McGladrey – Managing Director Peter.Epp@rsmi.com • Helen Pfister, Esq., Manatt Phelps & Phillips, LLP – Partner HPfister@Manatt.com • Scott Morgan – RSM McGladrey – Director Scott.Morgan@rsmi.com • Lynn Sherman, Charles B. Wang CHC – CFO LSherman@CBWCHC.org