medicaid managed care in ohio— a status report office of children & families executive...
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Medicaid Managed Care in Ohio
—A Status Report
Office of Children & FamiliesExecutive Leadership Council
June 15, 2006
Office of Children & FamiliesExecutive Leadership Council
June 15, 2006
Medicaid Managed Care● Goals:
Share the implementation plan and timeline for the statewide expansion of the Medicaid Managed Health Care Program.
Discuss the impact of program expansion on PCSAs.
Gather input regarding PCSA issues concerns related to mandatory Medicaid managed care.
Today’s Presentation● Medicaid Today● Why Managed Care Program Expansion?• Medicaid Managed Care Today• Program Expansion-Status Update
CFC Statewide Expansion ABD Statewide Expansion
• PCSA Issues and Concerns
Medicaid Today Covered Eligibility Categories
• COVERED FAMILIES & CHILDREN (CFC) (Also known as Healthy Start and Healthy Families) Children (Up to age 19) Pregnant Women Families (Parents & Children) Total Covered ~ 1.2 million
• AGED, BLIND & DISABLED (ABD) Seniors (65 & over) People with disabilities Total Covered ~ 440,000
Medicaid TodayProgram Facts
Nationally• Larger than Medicare • 53 Million Americans covered• $300 Billion in expenditures• Main payer for long term care
Ohio• Coverage for 2 million Ohioans
(1 in 6) including:− 1 million children (1 in 3
births)− 490,000 low income
parents• Pays for 70 percent of all nursing
home care• $12 billion program• 25% of state budget• Largest payer of claims in the
state
Why Managed Care Program Expansion?
Legislative Mandate
Added Program Value
Cost Savings
Why Managed Care?Legislative Mandate
● The Ohio Commission to Reform Medicaid recommendation:─ Establish a statewide care management program
for all Medicaid consumers by:▪ Expanding the current full-risk program to all
CFC consumers statewide, and ▪ Applying a care management approach to
selected ABD populations.
● Ohio’s 2006-2007 Budget Mandate─ Governor, House of Representatives, & Senate─ Final Budget Mandate: Transform Ohio Medicaid
by implementing the full-risk, managed care model for all CFC consumers, as well as a portion of the ABD population.
Why Managed Care?Added Program Value
● Key Managed Care Plan Benefits Include:
Focused attention on prevention and care coordination within a Medical Home setting
Advice and direction for medical issues via a 24/7 nurse hotline
Help in accessing services through a dedicated call center and a provider directory listing PCPs, hospitals, and specialists
Additional services for consumers with special health care needs including case management
Why Managed Care?Added Program Value
• Some MCPs may provide more services and benefits than the regular Medicaid fee-for-service (FFS) program offers. These might include:
Transportation, e.g. cab fare, shuttle services, etc.
Extended hours for member services (after 4:30 PM and/or weekends)
Annual eye exams for adults
Additional routine dental visits
Why Managed Care?Added Program Value
• Additional services continued:
Gifts/gift certificates for obtaining prenatal care
Gifts/gift certificates for getting immunizations and/or keeping Healthchek
Waiver of co-payments
Why Managed Care?Added Program Value
• Accountability/Quality of Care Contracting MCPs are held accountable to
standard levels of performance for
− Access− Quality− Consumer satisfaction− Administrative capacity
Performance is monitored through various oversight and assessment activities, e.g. independent external quality review.
Why Managed Care?Cost Savings
• The use of managed care has resulted in savings to the Ohio Medicaid Program.
The SFY 2003 cost savings were approximately $55 million.
The SYF 2004 cost savings were approximately $72 million
Managed care reduces overall costs by 3-5% when compared to the fee-for-service delivery system.
Why Managed Care? Cost Savings
Ohio Medicaid Expenditures by Provider CategorySFY 2004
Source: OHP 2005 Annual Report
Why Managed Care?Ohio Per Member Per Month Costs
Source: OHP 2005 Annual Report
Why Managed Care? Cost Savings
Medicaid Eligibles vs. Costs by Category of EligibilitySFY 2004
Source: OHP 2005 Annual Report
Managed Care Today● Began contracting with Health
Maintenance Organizations (HMOs) in 1978─ Medical Foundation of Bellaire (Belmont Co.)─ HealthAmerica (Cuyahoga Co.)
● 697,475 CFC Medicaid enrollees
● Approximately 75% of enrollees are children
● MCPs Operating in 17 counties: 12 mandatory: Butler, Clark, Cuyahoga, Franklin, Hamilton,
Lorain, Lucas, Mahoning, Montgomery, Stark, Summit, Trumbull
5 voluntary: Clermont, Greene, Pickaway, Warren, Wood
● ODJFS Contracts with 9 MCPs: AMERIGROUP, Buckeye, CareSource, Gateway, MediPlan, Molina Healthcare, Paramount, QualChoice Health Plan, Unison
Program Status UpdateCFC Statewide Expansion
● Procurement Approach
County vs. Regional Approach
8 regions
2-3 MCPs per region
Regions phased in
500,000 additional CFC Medicaid consumers enrolled with this expansion by December 31, 2006
CFC Statewide ExpansionPreliminary MCP Selections (by Region)
Central Region (2 Plans)*CareSource Molina
East Central Region (3 Plans)
CareSource Unison Buckeye
North East Region (3 Plans)CareSource WellPoint QualChoice
North East Central Region (3 Plans)
CareSource WellPoint Unison
North West Region (3 Plans)Paramount WellPoint Buckeye
South East Region (3 Plans)CareSource Molina Unison
South West Region (3 Plans)CareSource AMERIGROUP Molina
West Central Region (3 Plans)
CareSource AMERIGROUP Molina
* A targeted RFA has been released to secure a third MCP for this region.
CFC Statewide ExpansionPreliminary MCP Selections (by Region)
• Central Region Applications submitted 6/6/06− Anthem Blue Cross Blue Shield Partnership
Plan of Ohio, Inc. (WellPoint) − Unison Health Plan of Ohio, Inc.
• Northeast Region− Anthem / Qualchoice Purchase− WellCare of Ohio, Inc.
Program Status UpdateCFC Statewide Expansion
● Counties Making up the East Central Region (9)
Ashland StarkCarroll SummitHolmes TuscarawasPortage WayneRichland
Program Status UpdateCFC Statewide Expansion-# of
Eligibles
Ashland 4,817
Carroll 3,248
Holmes 2,388
Portage 11,151
Richland 14,058
Stark 38,730
Summit 54,561
Tuscarawas 9,642
Wayne 8,762
Total 147,357
MCPs in the East Central
• Buckeye Community Health Plan, Inc. − Debra Collins, VP of Contracting− (614)220-4900 Ext. 24114− [email protected]− www.centene.com
• CareSource− Provider Recruitment Connection− (877) 725-4577− [email protected]− www.care-source.com
• Unison Health Plan of Ohio, Inc. − Amanda Hewett − (614) 890-6853− [email protected]− www.unisonhealthplan.com
Program Status UpdateCFC Statewide Expansion
● Procurement Timeline Highlights August, 2005 – Letters to interested
stakeholders (including providers) announcing program expansion
September, 2005 - Minimum provider panel requirements released
November 30, 2005 – RFA released January 6, 2006 – Due date for MCP Letters of
Intent February 7, 2006 - Applications due March 17, 2006 – Announcement of
MCPs (no more than 3) selected to enter readiness review phase
August to December, 2006 - Enrollment of consumers
Exempted Populations• Certain CFC consumers may choose to be
exempted from enrollment into an MCP. These are children under nineteen (19) years of age who are: Eligible for Supplemental Security Income
(SSI) Receiving federal foster care maintenance or
federal adoption assistance under Title IV-E In foster care or out of home placement Receiving services through the Ohio
Department of Health’s Bureau of Children with Medical Handicaps (BCMH)
Frequently Asked Questions
MCP Membership Card
• MCP members do not receive monthly cards.
• A permanent ID card is issued on the first day of initial enrollment.
• The ID card includes:− MCP Name− Member Name− MMIS Billing Number− Effective Date of Coverage− MCP’s Emergency Procedures/Contact− Toll-free Member Services Number− Name of Member’s PCP
Frequently Asked Questions
New Member Information
• Members receive the following information: Member Handbook Provider Directory Member’s Rights New Member Materials How to Notify their MCP about Current
Health Care Needs How to Change PCP Population Groups Not Affected
Frequently Asked Questions
Enrollment Process
ODJFS/Selection Services Contractor• Current Contractor -- Automated Health Systems (AHS) • AHS has served as the SSC since 1998• Extensive experience providing healthcare information to Medicaid consumers in NJ, NY, OH, PA, WV, WI • Provides consumers with information on doctors, hospitals, and other providers contracting with MCPs• Assist consumers with making selection of the plan that best meets their needs
• Toll-Free 1-800-605-3040; • TTY 1-800-292-3572• Hours: Monday – Friday, 8 AM to 8 PM
PCSA Issues for Statewide Expansion
• Short Term Limit administrative burden for PCSA staff Remove any barriers to access to care Residence of eligibility information
– CRIS-E vs. FACSIS Disenrollment of children from MCP when in
custody– PCSA must develop a process for handling
monthly notification to PAMSS for disenrollment (OAC 5101:3-26-02.1)
– Staff training
– PAMSS Assistance
PCSA Issues for Statewide Expansion
• Long Term PCSAs must develop long term
policies for how they wish to interact with MCPs
Issues for consideration in policy development– Statewide Expansion of Managed Care– Change in Administration– Conversion to SACWIS– Recommendations from Medicaid Study
Council
ABD Statewide Expansion● Proposed Procurement Timeline
RFA released on May 31, 2006
Letter of Intent Due June 30, 2006
Applications due September 1, 2006
Preliminary selections for readiness review announced September 29, 2006 (estimated)
December 1, 2006 – Enrollment of consumers (estimated)
ABD Statewide Expansion● Excluded ABD populations
Dual-Eligibles (Medicare/Medicaid)
Children 20 years of age and under
Waiver Service Consumers
Institutionalized Consumers
Consumers with a Spend-down
ABD Statewide Expansion
● Proposed Procurement Process− Maintain regional approach− Applicants must submit applications for
a minimum number of regions that total in excess of 45,000 ABD consumers
− Applicants already selected for the CFC expansion have this requirement waived
125,000 ABD Medicaid consumers enrolled with this expansion by December 31, 2006
Questions and Answershttp://www.jfs.ohio.gov/ohp/bmhc/statemhc.stm
(Statewide Expansion Website)
http://www.jfs.ohio.gov/ohp/bmhc/pro-man-care.stm (Providers and Managed Care Website)
http://www.jfs.ohio.gov/ohp/bmhc/con-man-care.stm(Consumers and Managed Care Website)
http://www.jfs.ohio.gov/ohp/bmhc/mhcri.stm(Reports and Information Website)
Jeff Corzine Bureau of Managed Health Care
On the
Web at: