Maryland Medicaid Expansion and Safety Net Providers

1. Maryland Medicaid Expansion and Safety Net Providers Charles J. Milligan, JD, MPH Deputy Secretary, Health Care Financing April 24, 2013

2. Outline • Continuity of care • Capacity building for safety net providers • Delivery system reforms • Remaining uninsured populations

3. Continuity of Care

4. Continuity of Care • Four major issues with continuity of care when individuals will move between Medicaid and the Exchange: • Continuity at the health plan level • Continuity at the provider level • Continuity for benefits covered in both benefit packages that might involve utilization/authorization • Continuity across programs when the benefit packages might vary • Maryland has focused on all four

5. Continuity of Care • Legislation passed in 2012 requiring the study of continuity of care protections and engagement of a stakeholder advisory committee • The final report presented options, including provisions to ensure continuity of care in specific situations: • Transition in the course of treatment • Moving to a new managed care organization (MCO) carrier where the current provider is not in-network • The cost of adding these protections was estimated by an actuary to be: • $0.07 per member per month more for qualified health plans (QHPs) • $0.05 per member per month for Medicaid MCOs

6. Continuity of Care • Beginning in 2015, Maryland law requires that “receiving” commercial carriers and MCOs must: • Abide by earlier prior authorizations for treatment (of covered benefits) • Allow out-of-network care to complete a course of treatment • Honor both of these requirements the lesser of 90 days or the completion of the course of treatment • Why should Federally Qualified Health Centers (FQHCs) be concerned with this? • Churn between Medicaid and QHPs will be high • There are certain health conditions that churning people are likely to experience that FQHCs’ deal with frequently • After 90 days, no assurance that FQHCs will be allowed to continue treating if they are not in-network

7. Churn Rate, 12-Month Medicaid Population,FY 2011

8. Distribution of Selected Conditions among the 12-Month Population Losing Medicaid Eligibility

9. Distribution of Selected Conditions among the12-Month Population Gaining Medicaid Eligibility

10. Capacity Building for Safety Net Providers

11. Building Capacity in Maryland’s Safety Net Community • Responding to the recommendations of the Health Care Reform Coordinating Council (HCRCC), the Community Health Resources Commission (CHRC) developed a business plan in February 2012 that provided recommendations for how the state could promote the readiness of safety net providers as Maryland implements the Affordable Care Act. • What should be expected of traditional safety net providers in an environment in which more people have insurance coverage? • How can the capacity of these providers be leveraged and fostered?

12. Key Findings of CHRC Business Plan • More than 65% of safety net providers indicated they are “fairly ready” for health care reform with only 8% extremely ready. • Approximately 15% of safety net providers and 22% of health departments reported fully implementing electronic medical record (EMR) systems. • Needs/requests for technical assistance were diverse and varied. • The favored methodologies for providing assistance including customized/individualized training, learning collaboratives, and peer-to-peer initiatives.

13. Key Recommendations of Business Plan • Provide technical assistance and support related to “mechanics” of health reform legislation. • Catalyze innovative public-private partnerships that will leverage additional private resources. • Work with Maryland’s Health Department (which includes Medicaid), the Governor’s Workforce Investment Board, and other agencies to support statewide plans for workforce development. • Assist community health resources by facilitating access to data and interpreting or translating this data to meet customized needs. • Support efforts to develop expanded systems for eligibility and enrollment of uninsured and underinsured patients.

14. Safety Net Providers and Potential Areasof Technical Assistance

15. Facilitating Safety Net and Health Plan Relationship Building • “Meet and Greet” Sessions (“Mixers”) will be held later this Spring, sponsored by the CHRC • Regional sessions will allow participating MCOs and QHPs, and safety net providers, to begin discussions on contracting • Information on expected enrollment • Information on Medicaid and commercial carrier requirements • Technical assistance overview • Carriers will be encouraged to attend these sessions in order to identify community providers who are available to contract within their service area.

16. Complementary Concept:Health Access Impact Fund • CHRC and private foundations share similar grantees and “constituencies,” i.e., FQHCs, free clinics, behavioral health providers, and school-based health centers. • Create a Health Access Impact Fund by pooling public funding from the CHRC with private funding (local philanthropic partners) to create a “public-private partnership” to support specific projects to build capacity of the safety net infrastructure. • The Fund could be used to award grants and/or support contracts to provide technical assistance in specific areas such as credentialing, contracting, and billing/EMR/practice management.

17. Delivery System Reforms

18. Delivery System Reform • Multi-payer Patient Centered Medical Home (PCMH) • Launched April 2011 with 53 separate practices, including 339 providers • Covers 300,000 lives • Medicaid and commercial payers • Variety of practice types (FQHCs; private practices; hospital-employed) • State plans to add Medicare under State Innovation Model • Health Home (ACA Section 2703) • Focus on specialty behavioral health – mental illness and substance abuse • Build out “PCMH” model from behavioral health medical home • Linkage to social supports (employment, housing, criminal justice, education) • FQHCs can participate

19. Remaining Holes in the Safety Net

20. Remaining Holes in the Safety Net • Despite the expansion of Medicaid and insurance reforms, some people under age 65 will remain uninsured. • Undocumented aliens • People who choose the tax penalty rather than obtaining health insurance • In addition, some Medicaid-covered benefits will fall outside the benefits in QHPs in the Exchange • These groups and benefits will still need to be served, and safety net providers , like FQHCs, will likely be the point of access into care.

21. Charles J. Milligan, JD, MPH Deputy Secretary, Health Care Financing Charles.Milligan@maryland.gov