Apple Health Medicaid Managed Care Program Overview Preston

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Apple Health (Medicaid) Managed Care Program Overview Preston W. Cody, Division Director Health Care

Apple Health (Medicaid) Managed Care Program Overview Preston W. Cody, Division Director Health Care Services November 16, 2015

Introduction Preston Cody, Division Director Health Care Services Division Washington State Health Care Authority

Introduction Preston Cody, Division Director Health Care Services Division Washington State Health Care Authority 2

Overview Introduction Overview Objectives What is Managed Care? Managed Care History Managed Care in

Overview Introduction Overview Objectives What is Managed Care? Managed Care History Managed Care in Washington • Demographics • Managed Care Churn • Managed Care Quality and Contract Monitoring • Rate Setting • Potential Challenges • • Network Adequacy • Current WA Initiatives • State Innovation Grant • Healthier Washington • Fully Integrated Care • Behavioral Health Organizations • Regional Service Areas • Earlier Enrollment • Foster Care Managed Care 3

Objectives • Provide an introduction to managed care in Washington • Provide overview of

Objectives • Provide an introduction to managed care in Washington • Provide overview of Managed Care program operations • Discuss initiatives to improve the health care system in the State of Washington • General conversation about Washington States Medicaid Managed Care experience 4

What is Medicaid Managed Care? • Managed Care is a health care delivery system

What is Medicaid Managed Care? • Managed Care is a health care delivery system organized to manage cost, utilization, and clinical and service quality • Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services • By contracting with MCOs, states can reduce Medicaid costs and better manage utilization of health services • MCO contracts with the State Medicaid Agency are profit-limited contracts • MCOs strive to reinvest cost savings through shared savings programs and provider partnerships • Improvement in health plan performance, health care quality, and outcomes are key objectives of Medicaid managed care 5

Some Facts about the History of Managed Care • One of the earliest references

Some Facts about the History of Managed Care • One of the earliest references to managed health care in the country dates back to 1910 in Tacoma, Washington • In 1947, 400 families organized to form Group Health Cooperative of Puget Sound • California was the first state to move its Medicaid population into a managed care model in the early 1970 s • In the US approximately 80% of Medicaid enrollees are served through managed care • Medicaid Managed Care delivery systems and program implementation are regulated by 42 CFR 438 and various federal authorities 6

Medicaid Managed Care in Washington • Health Care Authority (HCA) is the single state

Medicaid Managed Care in Washington • Health Care Authority (HCA) is the single state Medicaid agency in Washington, which means it holds the authority and receives payment from the federal government for Medicaid • HCA and Department of Social and Health Services (DSHS) have agreements in place that places management and oversight of most behavioral health programs within DSHS • Since 1987, Washington has utilized managed care for physical health coverage (through 1932 a) – originally “Healthy Options” and now “Apple Health” • Since 1993, the state has operated its mental health Medicaid benefit via a 1915 b waiver - through the RSNs • Both authorities require enrollment in managed care 7

Medicaid Managed Care in Washington Today • 1. 8 million Washingtonians enrolled in Apple

Medicaid Managed Care in Washington Today • 1. 8 million Washingtonians enrolled in Apple Health (Medicaid) and approximately 85% are enrolled in managed care – Others to transition into managed care overtime • 6 Medicaid Managed Care Plans are contracted with the state to deliver physical health and mild to moderate mental health services on a county by county basis • Molina Healthcare of Washington, Community Health Plan of Washington, United. Healthcare, Coordinated Care, Amerigroup, Columbia United Providers (CUP) 8

Role of MCOs in Washington • MCOs provide coordinated care through a defined network

Role of MCOs in Washington • MCOs provide coordinated care through a defined network of health care systems and providers • MCO role goes far beyond paying claims and approving or denying authorization for services. . . MCOs invest significant time and resources to: – – – Facilitate Care Management Assure Clinical and Service Quality Build Provider Networks Engage & Partner with Communities Leverage Data and Technology Monitor & Maintain Compliance (Tea. Monitor) 9

Building Provider Networks • Contract with providers to ensure the availability of a sufficient

Building Provider Networks • Contract with providers to ensure the availability of a sufficient number and type of providers within a required distance to meet the diverse needs of the members • To engage providers, most MCOs offer a continuum of payment approaches including value based models for provider partners to provide opportunities to share savings and be rewarded for high quality care • Networks are routinely monitored to ensure Access & Availability standards are maintained 10

Community Engagement • MCOs partner with community-based organizations and agencies at the local level

Community Engagement • MCOs partner with community-based organizations and agencies at the local level to increase health care coverage, improve health literacy, drive health education campaigns and build better connections across the service delivery continuum • MCOs hire local and regionally based staff and resources 11

MCOs’ Role and Contributions to ACHs • MCOs are a local resource and thought

MCOs’ Role and Contributions to ACHs • MCOs are a local resource and thought partner – MCOs have dedicated staff and subject matter experts serving on ACH boards, councils and workgroups across the state – MCOs participate with HCA and Healthier WA on ACH discussions – MCOs partner with other health care stakeholders to plan and prepare for ACH work – MCOs work collaboratively with each other as a sector 12

Care Management • Utilization Management: – Right Care: Medically Necessary – Right Time: Pursue

Care Management • Utilization Management: – Right Care: Medically Necessary – Right Time: Pursue Appropriate lower level interventions first – Right Provider/Right Care: Pay for quality/performance and Evidence Based Practices • Case Management for High Needs Members – Complex case management, care coordination, disease management, and health education – Health Homes as example of strong community based care management 13

Leveraging Data and Technology • Advanced healthcare analytics and data. • Information Exchange and

Leveraging Data and Technology • Advanced healthcare analytics and data. • Information Exchange and Interoperability • Examples: – Claims-based data – Link 4 Health (Clinical Data Repository) – Real-time ED/admission based data (Pre. Manage/EDIE) – Patient registry – Shared cost savings analysis 14

Demographics Managed Care Eligibles and Managed Care Enrollees by County – October 2015 Reflects

Demographics Managed Care Eligibles and Managed Care Enrollees by County – October 2015 Reflects Enrollees Only 2936 10, 934 2, 981 11, 476 Island 3, 746 122, 276 4, 058 Jefferson 6, 036 38, 811 41, 549 94% Grays Harbor 93% Kitsap 17, 524 13, 372 19, 104 94% 92% 46, 787 49, 622 94% 163, 425 173, 665 5, 033 94% Wahkiakum 94% Thurston Pacific 4, 713 Lewis 826 94% Kittitas Douglas Grant 7, 908 28, 896 96% 88, 718 42, 803 96% 44, 831 Clark 91, 487 95, 346 County enrollment in managed care is voluntary. 179 156 115% 2, 265 Whitman 5, 898 7, 580 6, 077 7708 98% 92% 94% 97% 27, 247 Franklin Benton Skamania Adams Yakima 85, 156 Cowlitz 26, 531 123, 263 2, 504 94% 27, 723 7, 616 115, 799 2, 342 97% 20, 717 96% 15 Pierce 96% Lincoln 19, 066 28, 852 775 95% 91% Spokane 10, 467 20, 278 324, 931 3, 297 10, 397 10, 180 19, 564 309, 239 12, 578 3, 003 9, 657 Chelan King Mason Pend Oreille 93% 96% 5, 669 90% Snohomish 127, 198 92% 1, 392 95% 96% Stevens 1, 258 11, 983 Skagit 28, 217 Clallam 11, 324 95% 26, 981 Ferry Okanogan 40, 887 San Juan 98% 95% 38, 922 Whatcom 95% 28, 251 96% Garfield 12, 641 Columbia 824 13, 303 95% Walla 904 91% Asotin 4, 714 5046 93% Klickitat 2, 403 471 94% 499 94% Source: ODS Data Warehouse, CLNT-802. 2, Run Date: 11/03/2015 ODS Data Warehouse, MC-849. 1, Run Date: 11/02/2015 Currently eligible managed care clients are in black font. Currently enrolled managed care clients are in red font. The ratio of enrolled to eligible is expressed as a percentage.

January-September 2015 Enrollment Trends The charts display enrollment over a 9 month period. Enrollment

January-September 2015 Enrollment Trends The charts display enrollment over a 9 month period. Enrollment continues to increase for most programs through the end of September 2015: • AHAC (Adult expansion population) shows significant increase of 18%. This program was initiated January 1, 2014 • AHF (Family program) or the ‘welcome mat’ group has increased by 5% in large part due to outreach efforts in 2014 to ensure those eligible for Medicaid made application for services • AHBD had a slight decrease of 1% while CHIP has a slight increase of 2% 16 Apple Health Demographic Analysis, October, 2015

AHAC Enrollment (as of November 1, 2015) *Transactions may contain client duplicates and decrease

AHAC Enrollment (as of November 1, 2015) *Transactions may contain client duplicates and decrease per month due to loss of eligibility, causing retro changes. 17 AHAC Enrollment November 1, 2015

Apple Health Program Enrollment By Health Plan *Enrollment as September 1, 2015 18 Apple

Apple Health Program Enrollment By Health Plan *Enrollment as September 1, 2015 18 Apple Health Demographic Analysis, October 2015

Enrollment By Age Bracket The percent of enrollment by age is similar across health

Enrollment By Age Bracket The percent of enrollment by age is similar across health plans, except for the birth to 19 year old category. Both Molina Healthcare (MHC) and Community Health Plan (CHPW) have a much larger market share in this category. This is the result of two factors. First, managed care enrolled mostly women and children from its inception until July 2012 when the SSI Blind/Disabled (a mostly adult population) was added to managed care. Both MHC and CHPW, longstanding plans in the marketplace served a higher percentage of the women/child population. Second, in July 2012 three new MCOs entered the marketplace and received a higher share of the adult blind/disabled population. HCA methods for assigning new enrollees during this period of transition rewarded new plans, resulting in higher enrollment of this population to new managed care entrants. 19 Apple Health Demographic Analysis, October, 2015

Enrollment By Gender • Gender is an important determinant of services that will need

Enrollment By Gender • Gender is an important determinant of services that will need to be provided, as well as programs that need developed • Female enrollment in Apple Health is 10% greater than male enrollment • The distribution of gender patterns across health plans are similar; however, AMG has more male enrollees than female enrollees 20 Apple Health Demographic Analysis, October, 2015

Gender by Age Group and Program • Using gender and age grouping data to

Gender by Age Group and Program • Using gender and age grouping data to inform policymakers of the Apple Health population is crucial for future budgeting and planning at multiple levels 21 Apple Health Demographic Analysis, October, 2015

Enrollment By Race • Providing client race is voluntary on Apple Health program applications

Enrollment By Race • Providing client race is voluntary on Apple Health program applications • Collecting this information is crucial to ensure appropriate programs and services are available for clients • The population of Medicaid individuals is generally homogeneous and is reflective of the race distribution in the statewide population • 25% of the client population’s race is unknown either because it was “Not Reported” or the client indicated “Other Race” 22 Apple Health Demographic Analysis, October, 2015

Enrollment Breakdown by Race and Ethnicity • • 1% of clients indicate they are

Enrollment Breakdown by Race and Ethnicity • • 1% of clients indicate they are of mixed race A client who self-identifies as a member of one or more minority groups is counted in each of those minority categories, and is counted once in the Any Minority column. Clients who identify as White with no minority group membership are tallied under White Non-Hispanic Only column. Some Medicaid clients will not show up in the percentages because they have an unknown race 23 Apple Health Demographic Analysis, October, 2015

Managed Care Enrollment By County • • Managed care population by county aligns with

Managed Care Enrollment By County • • Managed care population by county aligns with population centers in the State of Washington with King and Pierce counties having higher enrollment followed by Snohomish and Spokane counties The analysis of county population provides important information that can be used to determine provider network adequacy and client needs in different areas 24 Apple Health Demographic Analysis, October, 2015

Enrollment By Preferred Spoken Language (Other Than English or Spanish) • English and Spanish

Enrollment By Preferred Spoken Language (Other Than English or Spanish) • English and Spanish language numbers were 1, 192, 644 and 128, 163 respectively • For 5% (64, 750) of Apple Health enrollment, the primary language is not known to HCA • Receiving information in an individual’s primary language enhances one’s ability to understand act on information provided to the individual • HCA requires MCOs to translate materials if 5% or more enrollees speak a specific language other than English 25 Apple Health Demographic Analysis, October, 2015

Health Plan and County Preferred Spoken Language • Health Plans have the same top

Health Plan and County Preferred Spoken Language • Health Plans have the same top two languages English and Spanish • County analysis shows the top two measureable languages as English and Spanish except in Spokane and Stevens counties, where it is English and Russian 26 Apple Health Demographic Analysis, October, 2015

Enrollment by Federal Poverty Level (FPL) and Income Bracket • • • 27 Apple

Enrollment by Federal Poverty Level (FPL) and Income Bracket • • • 27 Apple Health Demographic Analysis, October, 2015 Clients whose application indicates they have no income is represented on the chart as $0 (zero) Income is another important determinant in a client’s ability to access healthcare Both gross income and the FPL provide an important picture of the Apple Health population

 FPL Groupings By Race • • • The largest portion of the population

FPL Groupings By Race • • • The largest portion of the population is below 25% of the FPL and make up 45% of the overall population The second largest portion of the population is between 101 -133% of the FPL and make up 14% of the population With poverty identified as a barrier to health care access, this information is crucial to ensure health care services and transportation programs are in place 28 Apple Health Demographic Analysis, October, 2015

Average Medicaid Managed Care Client FPL and County Unemployment Rate • • The county

Average Medicaid Managed Care Client FPL and County Unemployment Rate • • The county unemployment rates (Medicaid and non-Medicaid) were obtained from the Employment Security Department (ESD) as of August 2015 The highest unemployment exists in Ferry (10%), Pend Oreille (9%), Grays Harbor (8%), Lewis (8%) and Mason (8%) 29 Apple Health Demographic Analysis, October 2015

Churn • Without MCO plan lock-in churn can be expected 30

Churn • Without MCO plan lock-in churn can be expected 30

71 Health Plan Outgoing Churn (September 2015) 31 Managed Care Health Plan Churn October,

71 Health Plan Outgoing Churn (September 2015) 31 Managed Care Health Plan Churn October, 2015

33 Health Plan Incoming Churn (September 2015) 32 Managed Care Health Plan Churn October,

33 Health Plan Incoming Churn (September 2015) 32 Managed Care Health Plan Churn October, 2015

Health Plan Churn Percentage Per County Based on County Enrollment (September 2015) Average Churn.

Health Plan Churn Percentage Per County Based on County Enrollment (September 2015) Average Churn. 70% 33 Managed Care Health Plan Churn October 2015

MCO Monitoring • • • CFR/EQR Requirements for states Structured monitoring of MCOs Performance

MCO Monitoring • • • CFR/EQR Requirements for states Structured monitoring of MCOs Performance Improvement Projects 2015 Monitoring results of calendar year 2014 Select Performance Measure and Survey data 34

CFR/EQR Requirements for States Mandatory Activities • Review of MCOs conducted by an external

CFR/EQR Requirements for States Mandatory Activities • Review of MCOs conducted by an external quality review organization (annual EQR report) • Structured monitoring of MCOs (HCA) • Annual validation of MCO clinical and non-clinical performance improvement projects (PIP) (HCA) • Annual validation of MCO performance measures (aka HEDIS audit by EQRO) 35

CFR Requirements for States Optional Activities • Validate MCO encounter data • Surveys (Consumer

CFR Requirements for States Optional Activities • Validate MCO encounter data • Surveys (Consumer Assessment of Healthcare Providers and Systems) • Additional performance measures • Additional PIPs and Focused quality studies 36

Structured Monitoring of MCOs • Coverage and authorization • Areas reviewed based of services

Structured Monitoring of MCOs • Coverage and authorization • Areas reviewed based of services (utilization on federal requirements management) and monitoring • Enrollee Rights protocols: • • Grievance System Availability of services Practice Guidelines Coordination and Credentialing continuity of care Timely Claims Payment Program Integrity Subcontracts Quality assessment and Enrollment and performance Disenrollment improvement Health Information Systems 37 • •

2015 Monitoring Results 38

2015 Monitoring Results 38

2015 Monitoring Report 39

2015 Monitoring Report 39

Well-Child Visits – 3 -6 Years of Age 40

Well-Child Visits – 3 -6 Years of Age 40

Adolescent Immunizations 41

Adolescent Immunizations 41

CAHPS – Child and Child with Chronic Conditions Survey 42

CAHPS – Child and Child with Chronic Conditions Survey 42

Finance Capacity • MCOs are risk-bearing entities • MCOs have risk-adjusted rates • MCOs

Finance Capacity • MCOs are risk-bearing entities • MCOs have risk-adjusted rates • MCOs are profit-limited. The State Medicaid agency sets a maximum profit. Profits greater than the limit must be returned to the Medicaid Agency • MCOs maintain sufficient reserves as required by the Office of the Insurance Commissioner • MCOs have payment model expertise • MCOs have actuarial resources in order to validate that rates are actuarially sound 43

Rate Setting Process • The U. S. Centers for Medicare and Medicaid Services (CMS)

Rate Setting Process • The U. S. Centers for Medicare and Medicaid Services (CMS) mandates that rates paid to Medicaid-funded MC plans must be based on actual cost experience and be certified as actuarially sound. An independent actuary firm, Milliman, analyzes and certifies the AH rates • Rate changes are implemented at the start of, and effective for the remainder of each Calendar Year (CY). The total impact of the CY 2016 rate change across SFY 2016 and SFY 2017 is estimated at $470. 2 million ($302. 0 million GF-F and $168. 2 million GF-S) 44

Managed Care Rate Setting • Apple Health (AH) premium payments (rates) will account for

Managed Care Rate Setting • Apple Health (AH) premium payments (rates) will account for nearly half of the Washington Health Care Authority’s (HCA) total budget in State Fiscal Year (SFY) 2016. • Total AH per member per month (PMPM) premiums - including all services, funds and rate groups - are projected to increase by about 7 percent from SFY 2015 to 2016 • AH rates are increasing because projected costs are increasing, overall about five percent from 2014 to 2015 • About $11 of the total $14 increase - nearly 80 percent - is due to pharmacy cost increases 45

AH Adult Cost Trend 2014 2015 Change 2014 to 2015 TOTAL $375 $372 -$4

AH Adult Cost Trend 2014 2015 Change 2014 to 2015 TOTAL $375 $372 -$4 -0. 9% Hospital IP $79 $78 -$1 -1. 0% Hospital OP $66 $63 -$4 -5. 4% Physician $59 $58 -$1 -1. 0% Drugs $62 $72 $10 16. 1% Other $8 $7 -$1 -15. 6% Sub-capitation $25 $19 -$6 -24. 9% Benefit change $1 $2 $1 56. 1% Pass-through $31 $26 -$6 -17. 7% Admin / tax $44 $47 $4 8. 5% Cost Component 46 % Change 2014 to 2015

Blind / Disabled Cost Trend 2014 2015 Change 2014 to 2015 TOTAL $905 $994

Blind / Disabled Cost Trend 2014 2015 Change 2014 to 2015 TOTAL $905 $994 $89 9. 8% Hospital IP $211 $210 -$2 -0. 7% Hospital OP $136 $128 -$8 -5. 7% Physician $112 $109 -$2 -2. 0% Drugs $229 $290 $61 26. 5% Other $42 $47 $5 12. 1% Sub-capitation $6 $12 $5 85. 7% Benefit change $8 $7 -$1 -13. 5% Pass-through $77 $100 $23 30. 2% Admin / tax $84 $91 $7 8. 4% Cost Component 47 % Change 2014 to 2015

Historical Rates in the Blind / Disabled and COPES Rate Groups • The following

Historical Rates in the Blind / Disabled and COPES Rate Groups • The following graph shows that the annual projected rate trend from July 2012 to December of 2016 is +2. 9% • The initial MCO contract to serve blind and disabled clients saved over $100 million in 2012 over fee-for -service 48

Components of 2014 to 2015 AH Cost Increases Projected Per Member Per Month (PMPM)

Components of 2014 to 2015 AH Cost Increases Projected Per Member Per Month (PMPM) Costs Rate Component TOTAL Hospital Inpatient Physician Drugs Hospital Outpatient Administration Pass-through Other Medical 2014 $289 $65 $64 $48 $47 $32 $23 $9 2015 $302 $65 $64 $59 $47 $35 $24 $9 49 Dollars $14 -$1 $0 $11 $0 $3 $1 $0 Change 2014 to 2015 Percent of Total Percent Change 4. 7% 100. 0% -0. 9% -4. 4% -0. 6% -3. 0% 22. 3% 78. 9% 0. 4% 1. 2% 9. 3% 22. 0% 2. 5% 4. 3% 1. 3% 0. 9%

Potential Challenges • Integration of services (behavior and physical health) • Network adequacy –

Potential Challenges • Integration of services (behavior and physical health) • Network adequacy – Distance, time and count • • Provider contracting and payment expectations Non-participating providers Encounter data quality Transition from fee-for-service to managed care – Contractual arrangements • Voluntary service areas 50

Network Adequacy Federal Requirements Requires the State to ensure: • 42 CFR § 438.

Network Adequacy Federal Requirements Requires the State to ensure: • 42 CFR § 438. 207(d) – (a) Basic rule. The State must ensure, through its contracts, that each MCO, PIHP, and PAHP gives assurances to the State and provides supporting documentation that demonstrates that it has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care under this subpart • 42 CFR § 438. 206(a)(b) – (a) Basic rule. Each State must ensure that all services covered under the State plan are available and accessible to enrollees of MCOs, PIHPs, and PAHPs – (b) Delivery network. The State must ensure, through its contracts, that each MCO, and each PIHP and PAHP consistent with the scope of the PIHP's or PAHP's contracted services, meets the following requirements: 51

Network Adequacy Washington State Law Requires the MCO: • WAC 182 -538 -067(1)(c) Managed

Network Adequacy Washington State Law Requires the MCO: • WAC 182 -538 -067(1)(c) Managed care provided through MCO’s – (1) Managed care organizations (MCOs) may contract with the department to provide prepaid health care services to eligible clients. The MCOs must meet the qualifications in this section to be eligible to contract with the department. The MCO must: • (a) Have a certificate of registration from the office of the insurance commissioner (OIC) that allows the MCO to provide the health care services; (b) Accept the terms and conditions of the department's managed care contract; (c) Be able to meet the network and quality standards established by the department; and • WAC 284 -43 -200(1)(4) Network Adequacy – (1)A health carrier shall maintain each plan network in a manner that is sufficient in numbers and types of providers and facilities to assure that all health plan services to covered persons will be accessible without unreasonable delay…. – (4) The health carrier shall establish and maintain adequate arrangements to ensure reasonable proximity of network providers and facilities to the business or personal residence of covered persons…… 52

Monitoring Health Plans Networks • • Monitoring Activities ― Various statistics weekly – call

Monitoring Health Plans Networks • • Monitoring Activities ― Various statistics weekly – call center, outreach activities, assessments (CMS monitoring calls) ― Network adequacy reports ― Quarterly, upon a material change to the network or based on HCA request ― HCA uses Geo Access for analysis ― MCO’s that fail to meet standards do not receive assignment ― MCO’s are required to report loss of material providers ― HCA evaluates impacts and will take action as necessary – Monitor complaints to resolution — MCOs required to report on enrollee/provider complaints regarding access to care Onsite technical assistance monitoring annually with required corrective action plans – Includes reviewing provider contracts – Contractually required MCO quarterly quality assurance review • Review 25% of combined network – Verify contact information, address, phone number etc. Open or closed panels 53 • Report to HCA biannually

Analysis of Network Assignment • • • Enrollment only • • • Inadequate network

Analysis of Network Assignment • • • Enrollment only • • • Inadequate network • Demonstrates sufficient provider network to receive all eligible enrollees Plan name appears on enrollment form HCA auto-enrolls Demonstrates a mostly sufficient provider network to receive all eligible enrollees, but lacks sufficiency in one or more categories Plan name appears on enrollment form HCA won’t auto-enroll Does not demonstrate a sufficient provider network to receive eligible enrollees. Plan name will not appear on enrollment form 54 Top 6 provider categories include: 1. Hospital 2. Primary Care Provider 3. Pharmacy 4. Obstetric/Gynecologist 5. Pediatrics 6. Behavioral Health Top 10 specialty provider categories include: 1. Cardiologist 2. Gastroenterology 3. General Surgeon 4. Neurologist 5. Oncologist 6. Ophthalmologist 7. Orthopedics 8. Otolaryngology 9. Physical Medicine Rehab 10. Pulmonologist

Sample Network Summary 55 Behavioral Pediatric 99. 45 98. 39 100. 00 94. 96

Sample Network Summary 55 Behavioral Pediatric 99. 45 98. 39 100. 00 94. 96 94. 08 44. 01 100. 00 97. 71 100. 00 95. 85 100. 00 OB PCP 98. 93 98. 39 100. 00 97. 47 45. 70 100. 00 99. 26 99. 82 82. 12 99. 22 100. 00 Pharmacy Hospital 74. 11 79. 77 70. 37 98. 46 99. 76 98. 39 99. 86 99. 81 94. 85 99. 99 56. 60 51. 48 78. 73 99. 64 50. 05 99. 79 0. 00 100. 00 12. 15 16. 44 99. 29 99. 71 100. 00 95. 84 25. 53 99. 25 73. 90 93. 37 93. 72 23. 94 100. 00 Pediatric Behavioral 70. 98 81. 91 99. 51 98. 39 99. 76 99. 81 100. 00 97. 47 99. 99 45. 70 51. 48 99. 79 0. 00 50. 05 100. 00 0. 00 16. 44 99. 89 99. 76 100. 00 82. 12 99. 25 97. 62 92. 54 93. 72 100. 00 MCO B OB PCP Hospital County ADAMS ASOTIN BENTON CHELAN CLALLAM CLARK COLUMBIA COWLITZ DOUGLAS FERRY FRANKLIN GARFIELD Pharmacy MCO A 99. 51 89. 05 99. 45 92. 21 99. 76 98. 46 98. 39 100. 00 99. 81 99. 99 97. 42 94. 96 99. 99 99. 79 95. 43 94. 08 78. 73 100. 00 44. 01 100. 00 100. 00 95. 94 99. 89 99. 65 97. 71 99. 56 100. 00 95. 84 97. 62 25. 23 95. 85 78. 79 100. 00 98. 91 100. 00 99. 22 100. 00 11. 27 100. 00 37. 46

Managed Care Contract MCO provider contracts must : • Provide all medically necessary specialty

Managed Care Contract MCO provider contracts must : • Provide all medically necessary specialty care in and out of health plan network • Ensure no balance billing for covered services • Ensure enrollees’ timely access to all covered services within established distance standards • Consider cultural, ethnic, race, and language needs • Ensure comparable provider access to commercial markets or Medicaid’s Fee-for-Service 56

Current Initiatives • Current Initiatives – State Innovation Grant • Healthier Washington – Behavioral

Current Initiatives • Current Initiatives – State Innovation Grant • Healthier Washington – Behavioral Health Organizations • Chemical Dependency and Mental Health Services – Fully Integrated Care in Southwest Washington – Regional Service Areas • Regional networks and purchasing • Accountable Communities of Health – Earlier Enrollment – Foster and Adoption Support Children enrolled in a single statewide Managed Care plan 57

State Innovation Grant • Reduce avoidable use of intensive services and settings—such as acute

State Innovation Grant • Reduce avoidable use of intensive services and settings—such as acute care hospitals, nursing facilities, psychiatric hospitals, traditional long term services and supports and jails • Improve population health—focusing on prevention and management of diabetes, cardiovascular disease, pediatric obesity, smoking, mental illness, substance use disorders, and oral health • Accelerate the transition to value-based payment—while ensuring that access to specialty and community services outside the Indian Health System are maintained for Washington’s tribal members • Ensure that Medicaid per-capita cost growth is two percentage points below national trends—Washington’s Medicaid costs are historically well below the national average 58

State Innovation Test Models • Early Adopter of Medicaid Integration (Payment Model 1) –

State Innovation Test Models • Early Adopter of Medicaid Integration (Payment Model 1) – The state will test the degree to which integrated financing can bring together physical and behavioral health services to deliver whole-person care • Encounter-based to Value-based (Payment Model 2) – The model will test how increased financial flexibility can support promising models that expand care delivery options such as email, telemedicine, group visits and expanded care teams • Accountable Care Program and Multi-Purchaser (Payment Model 3) – Washington will work with the University of Washington Accountable Care Network, and the Puget Sound High Value Network LLC to test a new accountable delivery and payment model, known as the Accountable Care Program • Greater Washington Multi-Payer (Payment Model 4) – Washington will test integrated data platform capacity to allow providers to coordinate care, share risk and engage a sizeable population across multiple payers 59

Behavioral Health Organizations • Chemical dependency and mental health services provided by a managed

Behavioral Health Organizations • Chemical dependency and mental health services provided by a managed care entity • High needs clients who meet established access to care standards • Transition step to fully integrated care in 2020. 60

Fully Integrated Care • Goal is to integrate physical health, mental health and substance

Fully Integrated Care • Goal is to integrate physical health, mental health and substance use disorder services statewide under MCOs by 2020 – Includes separate crisis services contract • Early adopter region set to go live April 2016 • Statewide health care performance measures used across systems – 52 measures that will help determine how well the health care system is performing in both quality and cost 61

Regional Service Areas • Effective April 2016 Washington will divide the state Medicaid services

Regional Service Areas • Effective April 2016 Washington will divide the state Medicaid services into 10 Regional Service Areas (RSA) • Accountable Communities of Health will be established – Establish collaborative decision-making on a regional basis to improve health and health systems, focusing on social determinants of health, clinical-community linkages, and whole person care – Drive physical and behavioral health care integration by making financing and delivery system adjustments, starting with Medicaid 62

Regional Service Areas Map 63

Regional Service Areas Map 63

Earlier Enrollment • HCA currently enrollees clients into managed care prospectively, thus resulting in

Earlier Enrollment • HCA currently enrollees clients into managed care prospectively, thus resulting in fee-for-service expenditures • Applicants can shop for plans on the State exchange when applying • In April 2016, HCA will enroll clients into managed care the day they are determined eligible – Improve continuity of care – Reduce churn – Reduce auto-assignments 64

Foster and Adoption Support into Managed Care • The HCA is procuring a single

Foster and Adoption Support into Managed Care • The HCA is procuring a single managed care entity to provide services under a single plan – To provide a system of consistent, coordinated health care services. • Physical health care services starting April 2016 • Fully integrated services effective October 2018 65

References • Health Care Authority (HCA) www. hca. wa. gov • HCA Managed Care

References • Health Care Authority (HCA) www. hca. wa. gov • HCA Managed Care http: //www. hca. wa. gov/medicaid/healthyoptions/pages/healthyoptions. a spx • HCA Managed Care Contract http: //www. hca. wa. gov/medicaid/healthyoptions/Pages/contracts. aspx • HCA Managed Care Reports http: //www. hca. wa. gov/medicaid/healthyoptions/Pages/reports. aspx • Preston. Cody@hca. wa. gov 360 -725 -1786 66

THANK YOU 67

THANK YOU 67