Medicaid State Agency Contracting and Oversight of Managed Care Organizations

1. Medicaid State Agency Contracting and Oversight of Managed Care Organizations OCTOBER 24, 2011 Alan SchaferSenior AssociatePhoenix – 2325 East Camelback

2. CHCS’ top ten mileposts for states • Centers for Health Care Strategies (CHCS) –Profiles of State Innovation: Roadmap for Managing Long-Term Supports and Services (November 2010) • Identified ten top practice categories of the states interviewed for developing a managed long-term supports and services (MLTS) program (AZ, HI, TN, TX and WI) • Highlighted State best practices that contribute to providing “high-quality, consumer-focused and cost-effective care”

3. CHCS’ top ten MLTS mileposts for states • Communicate a clear vision for MLTS to promote program goals • Engage stakeholders to achieve buy-in and foster smooth program implementation • Use a uniform assessment tool to ensure consistent access to necessary long-term supports and services (LTSS) • Structure benefits to appropriately incentivize the right care in the right setting at the right time. Structure benefits to appropriately incentivize the right care in the right setting at the right time • Include attendant care and/or paid family caregivers in the benefit package

4. CHCS’ top ten MLTS mileposts for states, continued • Ensure that program design addresses the varied needs of beneficiaries • Recognize that moving to risk-based managed care is a fundamental shift in how the state and managed care organizations think about LTSS financing, and plan accordingly • Develop financial incentives to influence behavior and achieve program goals • Establish robust MCO oversight and monitoring requirements • Recognize that performance measurement is not possible without LTSS-focused measures

5. States establish operational responsibilities of MCOs • Develop an adequate provider services network • Case management • Quality management • Utilization management • Integration of services (e.g., acute and LTC, Medicare/Medicaid) • Member and family support • Pay claims and process encounters • Grievance and appeals

6. State oversight of MCOs • MCOs are expected to manage their performance • MCOs to meet state performance expectations • Self-monitor operations and clinical performance, using multiple data points (data driven) • Manage administrative subcontractors (e.g., claims) • Develop and implement interventions designed to improve operational or clinical performance • Evaluate effectiveness of interventions and adjust as necessary to achieve excellence • MCOs are partners with the state Medicaid agency • Both must recognize that members and providers are valued partners • Both must strive to eliminate inefficient/burdensome MCO policies/processes • MCOs to collaborate and share best practices.

7. Operational responsibilities of MCOs State must monitor MCO compliance via: • Audits/reviews of MCO operations and finances • Analysis of MCO contractual deliverables (e.g., timely delivery of HCBS) • Clinical performance measures • Quality improvement projects • Provider network monitoring • Claims payment timeliness and accuracy • Grievance and appeal monitoring

8. States’ roles with providers • Give providers a voice in the ongoing development of managed care • Strive to eliminate inefficient/burdensome state regulations and MCO contract requirements • Allowing for provider/MCO innovations • Ensuring MCOs pay providers and resolve provider disputes timely

9. Emerging trends – states’ implementation of managed care • Hold rates at FFS levels for a limited number of years • Primary goal is not to achieve cost savings through reduced provider rates • Cost savings result from improved quality of care related to integrated/ coordinated care • Includes all populations (non-LTC and LTC) • ID/DD • Non-LTC and LTC • Behavioral health • SMI • Integrating Medicare and Medicaid funding (CMS initiative)

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