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Medicaid Transformation. Facilitated by Alabama Primary Health Care Association. Session Overview. Statutory RCO Requirements RCO Planning Principles Statewide RCO regions Timeline and Anticipated Next Steps. Medicaid System Transformation. - PowerPoint PPT PresentationTRANSCRIPT
Facilitated by
Alabama Primary Health Care Association
Medicaid Transformation
Session Overview
Statutory RCO RequirementsRCO Planning PrinciplesStatewide RCO regionsTimeline and Anticipated Next Steps
Medicaid System Transformation
“Will not expand Medicaid under the current system”…Governor Robert Bentley
Alabama Legislature – SB 340Provides for the delivery of medical services to Medicaid beneficiaries on a managed care basis through regional care organizations or alternate care providers
Medicaid System Transformation
• Managed Care (Risk Based) • Medicaid will contract with qualified
organizations (RCO or ACP) where the organization assumes risk for the cost of services covered under the contract and incurs loss if the cost of services exceeds the payment under the contract (10/1/2016)
Medicaid System TransformationRegional Care Organizations•An organization of health care providers that contracts with Medicaid to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of the state and meets requirements of enabling statute
Medicaid System Transformation
Alternative Care Providers (ACP)•A contractor, other than a RCO that agrees to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of the state pursuant to a risk contract; traditional commercial MCO
Medicaid System Transformation
• ACP Triggers• Medicaid may contract with an alternate
care provider if:– The RCO fails to meet contract requirements– If no organization has been certified as an
RCO or probationary RCO by October 1, 2016
– If no RCO is willing to accept the contract
Medicaid System Transformation• Collaborators• Private health carriers, third party
purchasers, provider, health care center, health care facility, state and local gov. entity, or other public payers, corporations, individuals and consumers who are expecting to collectively cooperate, negotiation or contract with another collaborator or RCO
Statutory RCO RequirementsMedicaid Responsibilities 1.Establish statewide managed care regions2.Establish policy and process for application and
certification as collaborators; certify qualified collaborators
3.Establish criteria for probationary and full certification of RCOs; certify qualified RCOs
Statutory RCO RequirementsMedicaid Responsibilities 4.Establish quality standards and minimum service delivery network requirements5.Establish and support statutory quality assurance and improvement provisions6.Establish requirements for HIT, data analytics, quality of care, quality improvement measurement and standards
Statutory RCO Requirements
Medicaid Responsibilities
7.Conduct initial readiness audits and ongoing financial audits 8.Monitor federal Medicaid regulatory compliance throughout implementation and management to assure FFP is maintained
Statutory RCO RequirementsMedicaid Responsibilities
9.Establish procedures to safeguard integrity of claims payment and protect against wrongful denial of claims 10.Establish policy and process to address grievances of enrollees and RCO or ACP
Statutory RCO Requirements
Governance Structure
12 members risk-bearing members8 non-risk bearing (statutory) members3 community representatives
Statutory RCO RequirementsGovernance
•Risk-bearing Members (12)•Participants bear risk by contributing cash, capital, or other assets to the RCO or contract to treat Medicaid beneficiaries at a capitated rate per beneficiary even if the RCO does not reimburse the participant
Statutory RCO Requirements
Governance•Non-Risk-bearing Members (8)•Participants that do not represent risk bearing members include 5 medical professionals providing care to Medicaid patients in that region
3 of these will be primary care physicians; 1 from APHCA/ALNMA, 2 from regional board of health
Statutory RCO Requirements
Remaining 2 medical professionals include an optometrist and pharmacist
• None of the non-risk bearing professionals can be risk bearing or be employed by a risk bearing organization
Statutory RCO RequirementsGovernance
Community Representatives (3)Participants shall include:Chair of the citizens’ advisory committeeAnother citizens’ advisory committee member elected by the committee (must be member of AL Arise or AL Disabilities Leadership CoalitionBusiness executive nominated by Chamber of Commerce in the region
Statutory RCO Requirements• Citizens’ Advisory Committee• Committee will advise the Board
on ways the organization may be more efficient in providing quality care and carry out other functions and duties assigned to it by the RCO and approved by Medicaid
At least 20% shall be Medicaid patients enrolled in the RCO
Planning Principles
1. Any Willing Provider - A provider may contract with any RCO to provide services in a Medicaid region if the provider is willing to accept the payments and terms offered comparable providers
Medicaid Redesign Principles
2. Provider Reimbursement Floor – established by AMA for providers inside and outside of the region; may be higher for in region providers, but must be at least the Medicaid floor (current rate?) to prevent RCOs from unfairly excluding providers outside of the region
Medicaid Redesign Principles3. Every RCO will contract with Children’s
Hospital of Birmingham, UAB Hospital, & other hospitals as necessary to ensure specialty services remain available
4. Maternity Care Program will be included in RCO services and capitation
5. PCN scope of case management will be included in RCO services and capitation
Medicaid Redesign Principles6. Capitation amount for each region will be
region specific. 7. 700,000 out of 900,000 Medicaid patients will
be covered by RCOs 8. Family planning and dentistry will not
participate in RCOs during phase 1 9. LTC will not be included in RCOs
Statewide Medicaid Regions
1. Market demand will determine the number of RCOs per region; each will have a minimum of 60,000 eligibles; larger regions help to minimize risk
2. Regions not modeled after any existing government regions or districts; other Medicaid regions will transition into RCO regions (i.e., maternity care)
Statewide Medicaid Regions
3. Regional organization intended to maintain hospital and physician referral patterns/patient relationships; minimize border crossover issues (also, see any willing provider)
4. Patient residence establishes basis for RCO assignment and capitation
• Draft Map; final adoption to occur by October 1, 2013
• Public Hearing
Timeline and Next Steps
• Public comments for policies through Administrative Procedures Act (35 days for public comment)
• Opportunity for Public Hearing
Timeline and Next StepsOctober 1, 2013- Establish/Adopt Medicaid Managed Care RegionsOctober 1, 2014- Organizations seeking to become a RCO must have governing board and structure approved by MedicaidApril 1, 2015- Probationary RCOs must demonstrate ability to establish adequate medical service delivery network
Timeline and Next Steps
October 1, 2015- Probationary RCOs must meet financial requirementsOctober 1, 2016- Probationary certification expires; must demonstrate capability of providing services pursuant to a risk contract
Timeline and Next StepsNext StepsRules around Collaboration – possible emergency rule submitted in SeptemberProvisional Certification – possible rules submitted by January 2014 (requirements, application content, risk bearing tests)
Timeline and Next Steps
Next StepsRCO Certification – final rules possible by April 2014AMA open to RCO applications for provisional status possibly from April – August 2014
Provider Activities1.Understand RCO system design, requirements, timeline2.Internally assess your role within the planning, development, implementation of RCO and ongoing program3.Collaborate as allowed under statute with others at appropriate time4.Educate patients at appropriate time
Questions
Alabama Primary Health Care AssociationSharon Parker, RN CVRN, CHTS-CP
Chief Quality [email protected]
334-386-3985