pcp powerpoint-afmc 03.21 · reynolds medicaid payment consent decree. as a result, pcps continue...
TRANSCRIPT
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3/25/19
Speakers:• Jennifer Morales, MPH
Medical Assistance Manager, DHS Division of Medical Services
• Lainey MorrowMedicaid Public Information Specialist, DHS Office of Communications and Community Engagement
• PASSE Representativeso Bryan Meldrum, Arkansas Total Care, VP Provider Networks
o Shelly Rhodes, Empower Healthcare Solutions, Provider Relations Manager
o Jason Miller, Summit Community Care, President of Summit Community Care
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The PASSE Model of Care is a State health plan created to meet the
needs of approximately 43,000 Medicaid recipients with complex
behavioral health, developmental, or intellectual disabilities. Three
PASSEs have formed to manage care for these clients.
Phase II of the PASSE Model of Care began on March 1, 2019.
Starting March 1, 2019, providers stopped billing Medicaid for these clients. Providers began billing the individual PASSEs. Claims submitted to MMIS for PASSE clients will be rejected.
Provider-led Arkansas Shared Savings Entity
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PASSE Enrollment Population includes only:‒ Individuals receiving services through DD Waiver‒ Individuals who are on the DD Waiver Waitlist and receiving Medicaid
State Plan services‒ Individuals who are in private DD Intermediate Care Facilities‒ Individuals that have a Behavioral Health Diagnosis and have received
an Independent Assessment that determines they need services in addition to counseling and medication management.
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WhoisservedbythePASSEs?
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Arkansas Total Care (also known as ATC INC)
www.arkansastotalcare.com | 1-866-282-6280
Empower Healthcare Solutions www.getempowerhealth.com | 1-866-261-1286
Summit Community Care (also known as APC PASSE LLC)
www.summitcommunitycare.com | 1-844-405-4295
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WhoarethePASSEs?
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PASSEFunctions• Beneficiaries enrolled in a PASSE are still Medicaid beneficiaries.• This model does not change a person’s eligibility for Medicaid;
it changes how these services are paid for. • The PASSE is similar to an insurance group and covers health care
services for its members. Services must be available statewide.• The PASSEs assumed full risk and are responsible for working with
members to create and update the Person Centered Services Plan (PCSP).• PASSE are responsible for paying claims for all medical services covered
by Medicaid for PASSE members.• Medicaid enrolled Service Providers should submit claims to the PASSE
to which the Medicaid beneficiary has been assigned.• PASSEs have enrolled providers in their network but are required to pay
out of network providers 90% of the current fee schedule for 6 months.• Arkansas Medicaid Consent Decree must be honored by PASSEs,
therefore physicians covered must be paid the current Medicaid fee schedule whether they are in network or out of network.
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MemberIdentificationThroughPASSEIDCardEach client has been sent a new ID card from his or her PASSE resembling one of these:
* Clients need to keep both this new PASSE card and their Medicaid card on hand for appointments.
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MemberIdentificationThroughProviderPortalAR Medicaid Service Providers can access the DXC Provider Portal to verify Medicaid eligibility, to find out if a client has been assigned to a PASSE, and if so to find out which PASSE the client has been assigned to.
First, go to the DXC Provider Portal:https://portal.mmis.arkansas.gov/armedicaid/provider/Home/tabid/135/Default.aspx
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MemberIdentificationThroughProviderPortal(Continued)
Enter provider User ID and click "Log in."* Register or create an account if this is your first time logging in.
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MemberIdentificationThroughProviderPortal(Continued)
Click the "Eligibility" tab. Enter the BeneficiaryMedicaid ID, Date of Birth, and click "Submit."
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MemberIdentificationThroughProviderPortal(Continued)
Scroll down to see the "Managed Care Assignment Details“.
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HelpingProvidersConnecttotheMember’sPASSEIf clients or providers need help, DHS and each PASSE has staff on hand, ready to help.
Arkansas Total Care(also known in the system as ATC INC)
Empower Healthcare Solutions
Summit Community Care(also known in the system as
Arkansas Provider Coalition or APC PASSE LLC)
1-866-282-6280
1-855-429-1028
1-844-462-0022
AssistanceforProviders:
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HelpingProvidersConnecttotheDHSPASSEProviderCallCenterThe PASSE Provider Call Center will be staffed with DHS employees who will be able to answer questions or assist providers with issues that cannot be resolved in your call.
• DHS PASSE Provider Call Center Line 1-888-889-6451
• Call Center email [email protected]
• Call Center hours ‒ 2/19/19 through 5/31/19 Monday-Friday 8:00 am-6:00 pm
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WhatifClientsneedhelp?If clients need help, give them the following numbers.
Arkansas Total CareEmpower Healthcare Solutions
Summit Community Care
1-866-282-62801-866-261-12861-844-405-4295
First,askiftheyhavecalledtheirPASSE:If they have questions about services covered, about something they need, or to contact their care coordinator, they should call their PASSE first.
PASSE Beneficiary Support 1-833-402-0672IftheyjustneedinformationorwanttoswitchPASSEs,theycancall:
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WhatifClientsneedhelp?If clients need help, give them the following numbers:
The Ombudsman Office handles any concerns that PASSE membersmay bring to its attention. A client might want to call:
IftheycalledtheirPASSEandstillhaveanissue:
PASSE Ombudsman Office 1-844-843-7351
• If their care coordinator can't connect them with the services they need• If a care coordinator hasn't contacted them at least
once per month.• If they have concerns their PASSE can't help with.
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CareCoordination• Approximately 36,600 PASSE beneficiaries participated in the PCMH
or PCP program from March 1, 2018 to February 28, 2019.
• Federal Managed Care rules do not allow care coordination payments
to be paid for the same member under both the PASSE and the PCMH
program.
• The PMPM payment from the PCMH or PCP program may have been
lost, but you are no longer required to perform the care coordination
activities.
• PASSE members that were previously enrolled in the Arkansas PCMH
program now receive care coordination through their current PASSE
provider.
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CareCoordination• The PASSEs receive a PMPM capitated payment that includes care
coordination. PASSE Care Coordinators must at least provide:
ü Access to a care coordinator 24/7, 7 days a week
ü Monthly/Quarterly contact requirements
ü Assignment to a PCP and confirm that the member is seeing the PCP as needed
ü Follow up within 7 business days if an ER visit or discharge from hospital occurs
ü Health education and coaching
ü Coordination with other healthcare providers for diagnostic, ambulatory care, and hospital services
ü Medication management
ü Assistance with social determinants of health and promotion of activities focused on the health of the patient their community.
ü Leading the development of the Person Centered Service Plan (PCSP) 17
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PersonCenteredServicePlan• The PASSE is responsible for the creation, monitoring, and updating of
the Person Centered Service Plan (PCSP).
• The Person Centered Service Plan indicates the following:ü Medical services in amount, duration, and scope sufficient to meet the needs of the
member;ü HCBS services including, if appropriate, LTSS services ü The member’s goals, strengths, needs, and preferences and;ü A crisis plan for the member.
• The PCSP development meeting must be attended in person by the member or parent/legal guardian, member’s primary caregivers, the care coordinator, and anyone else the member desires to attend such as HCBS service providers, professionals who have conducted evaluations or assessment, friends, and family who support member.
• Development of the PCSP is separate and not the same function as Utilization Management. Authorizations of medically necessary services come from a licensed professional and not a care coordinator.
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WhyshouldPCPsjoinaPASSE?• No authorizations from PCPs are required for members to access in-
network specialty care. Some specialist offices may still require a referral from a PCP, but that would not be a PASSE requirement.
• PCPs are asked to be “the access to care gateway” but with less paperwork required.
• Members are encouraged to always see their PCP first.
• Increased coordination of care with this population under this model.
• Removed the limitation on provider visits (previously 12/year).
• Removed the limit on monthly prescriptions (previously 6/month)
• PCPs can be included in the development of the Person Centered Service Plan (PCSP) process
• Your current Medicaid beneficiaries enrolled in the PASSE still need you under the PASSE model. 19
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EthicalTransitionofClients• PCP’s who choose not to contract with a PASSE can submit claims to their patients’
PASSEs and receive payment at the rates set under the Arkansas Medical Society v. Reynolds Medicaid payment consent decree. As a result, PCPs continue to get the current Medicaid rate if out of network.
• As an Arkansas Medicaid Provider, should a PCP choose to not join a PASSE the PCP is required by the current provider manual to :
‒ Provide the PASSE beneficiary an advanced written notice at least 30 days prior to not providing the beneficiary services or keeping scheduled appointments.
‒ Provide in writing that the enrollee has 30 days in which to enroll with a different PCP.
‒ Continue as the enrollee’s primary care physician during the 30 days or until the individual transfers to another PCP, whichever comes first.
• Medicaid enrolled providers may not charge a Medicaid beneficiary who is a PASSE member for a covered service simply because the provider has declined to join a PASSE network.
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HowcanaPCPjoinaPASSE?Each PASSE should be able to provide you more information about how to join their networks. Once a provider receives information from the PASSEs, the provider can choose to join any and all PASSEs. How a provider chooses to participate is a business decision.
• PASSE Provider Relations Contact Info
‒ Arkansas Total Care: Chepeka McKinney, Senior Contract Negotiator501-954-6117 [email protected]
‒ Empower: Shelly Rhodes, Provider Relations Manager501-813-9031 [email protected]
‒ Summit: Kristy Oropeza, Network Development844-648-9538 [email protected] 21
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OpenDiscussionwithPASSERepresentatives
•Arkansas Total Care‒ Bryan Meldrum, VP Provider Networks501-954-6139 [email protected]
• Empower‒ Shelly Rhodes, Provider Relations Manager501-813-9031 [email protected]
• Summit‒ Jason Miller, President of Summit Community Care501-304-6958 [email protected]
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