KanCare Managed Care Kansas Style

Steve GieberKansas Council on Developmental Disabilities

July 8, 2014

IDD Services Pre-KanCare27 (CDDO) Community Developmental Disability

Organizations DD Reform Act 1997 (Non-Risk Managed Care) Determine eligibility Determine level of need $$

1997-2014 over 250 + new for profit (CSP) Community Service Providers

Targeted Case Management provided by CDDO, CSP, or Case Management Companies

State-Wide Waiting List

State paid the providers (FFS)fee for service

Kansas Manage Care Is:Capitated

Per member-per month paid to MCOs

Integrated (needs vs. wants)Both long term services and health services

Managed by three different MCO’s with different rules and processBilling

Appeals and grievances POWER OF 3Data Systems

Post KanCareCDDO’s Gatekeeper

CSP Provide Service

Case Managers Case Management

The Waiver agency and the Medicaid Agency split policy and oversight fragmented

MCO’s Provide care coordinationPay the providersDetermine level of service need with Case Managers

MANAGED CARE NO-NO’S

 Who Controls? Medical Model vs. Individual Directed (PCP)

Projecting savings without a track record

Not addressing WAITING LIST in the plan

Not taking into account the learning curve

Insufficient State Oversight (revolving door)

Public (ICF) Intermediate Care Facilities and Institutions not included in the plan

LTSS DD Carve-OutFamilies and Self-Advocates caused a carve-out

for over a year

Individuals and families were afraid of loss

Advocates were asking “How Can YOU Have It ALL”Better health outcomesLower costNo cuts to services or ratesWhile paying for another level of administration

Kansas Council on Developmental Disabilities (KCDD) Initial Position

Advocate for a delay in KanCare DD until pilot project test the premise establishment of effective oversight protect people’s current and future access to

services.

Advocate for proper legislative oversight

Advocate for sufficient state agency oversight

Advocate for Waiting List Plan

KCDD Current Position

Belief vs. Fact or TruthSave money ($1 Billion over 5 years)better health outcomesNo cut in services or rates

Premise should be tested

Pilot should test what is going to be implemented

Decision based on fact not belief

Pilot RecommendationsBased on a true test “ `Pilot one and two”

“Pilot” was voluntary for both the provider and individual Individuals enrolled in the pilot services were the same MCOs/Providers were not paid to participate Reporting was only by the state agency MCOs were not at the table early enough Billing was not tested till late in the process Care Coordinators were not on board or trained Systems had not been developed to provide anything

different

The DroneParticipated in the “Pilot” that wasn’t

Managed Care is different in each state

KanCare is capitated, integrated care, managed by one of three MCO’s

The “Pilot” wasn’t capitated, wasn’t integrated and was paid/managed by the state

Providers experienced significant payment issues during the “Pilot”

DD Council Changing RoleFrom Funder to Collaborator/Influencer

Served on the “Pilot” Committee

Served on (CSI) Consumer/Systems Issues

Commented on the Centers for Medicaid Services Waiver Amendments

Served on the Friends and Family Committee

Encouraged past Partners in Policymaking Graduates to serve on other committees.

DD Council Role Provide testimony to the Legislative Oversight committee and

other committees

Provide & encourage comments to both the State and Federal officials on the 1115 and 1915c waivers over 100 on first and over 50 on the carve in

Research and share information with people with IDD, families and providers

Continue to identify areas that need additional safeguard and protections for people

Continue to monitor outcomes

Advocate for system protections i.e. payment system loss of service

Results of KCDD & Advocacy Efforts

Delayed implementation

Removal of “edits” from the MCOs billing processProviders are currently getting paidMoved the problem into the future

Many of the 1115 Waiver special terms and conditions covered in the 109 pages are from advocacy efforts

The elimination of the underserved Waiting List for 1,700 people

Additional oversight and changes in systems

Increase consumer involvement and input

Positives Outcomes from Managed Care

Some additional Dental Care Services

MCO United Healthcare’s Foundation committed $1.5 million for employment over the next 3 years

Willingness to break down some of the silos around employment between the state agencies

Current Council Activities on KanCare

Systems work on employment barriers

Engaging CSPs on preventing abuse, neglect and exploitation

Provide Self-Advocacy training on abuse, neglect and exploitation

Monitoring outcomes of Managed Care to make sure it does no harm

“Kansas Leadership Center” leadership training for self-advocates to be more effective leaders

Key Provisions 1115 Waiver Special Terms and Conditions

State must allow enrollments up to cap

Individual may change based on experience with MCO

Independent Ombudsman Coverage model Resolving problems, services coverage access rights

Earmark Cost Savings to increase number of slots

1,700 people on Underserved List needs met within 6 months

State must review Beneficiary Complaints Grievances & Appeals

Websites to Watchhttp://www.kancare.ks.gov Kansas state site

http://www.kancareddwatch.com funded and operated by family members of people with IDD enrolled in KanCare

http://www.KCDD.org Kansas Council on Developmental Disabilities website

Please contact us to be added to our advocacy email list

Year one Summary 2013P4P

Claims processing no paymentsEncounters ½ paymentCustomer service full paymentGrievances and Appeals ¾ payment

Average claim denied all services 15.58% highest percentage in Hospital admissions and Pharmacy

Value of services avoided $1.15 million 2 reporting

Medicaid Program Integrity

GAO-14-341 May 2014

Increased oversight neededSystems in place to audit Fee for Service System lacking for auditing Managed Care PlansStates need to audit payments made by and to MCO’s

CMS current Payment Error Rate Measurement less than ½ of %

MCO’s in Kansas turned edits off

Fraud estimated at 5.8% or $14.4 billion in 2013MCO’s identify fraud could reduce PMPM payments

MCO’s don’t want to appear to vulnerable

States are responsible for oversight and recovery

What We Know Right NowThe state is claiming savings of $55-250 Million first

year.

The three MCOs lost $110 million on the first year

Millions of past due claims not paid from year one

More difficult to get data/ Transparency Compromised

The state is moving forward with a new assessment tool to determine eligibility

“in lieu of services” new term lacks transparency

Bottom line for DD Councils

Be true to Disability Act VAULES

Be open to adjusting ROLES

Develop new partnerships and collaborations

Continue to promote decision by FACT not BELIEF

Support the “EMPLOYMENT PUSH”

Create opportunities to lead