presentation to the society of hematology oncology

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Michigan Association of Health Plans

Rick MurdockExecutive DirectorMichigan Association of Health Plans

MICHIGAN SOCIETY OF HEMATOLOGY ONCOLOGY

OCTOBER 19, 2009


WHO WE ARE The Michigan Association of Health Plans

(MAHP) is an industry voice for 19 health care plans

Members cover over 2.4 million Michigan residents (Including over 1.1 million Medicaid beneficiaries)

Our mission: Advocate for health care that is High quality Affordable Accessible

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Aetna AssurantCareSource MichiganGrand Valley Health PlanGreat Lakes Health Plan/United Health CareHealth Alliance PlanHealth Plan of Michigan, Inc. HealthMarkets, IncHealthPlus of MichiganMcLaren Health Plan

Midwest Health Plan Molina Healthcare of

MichiganOmniCare Health PlanParamount Care of MichiganPhysicians Health Plan-Mid-

MichiganPriority Health ProCare Health PlanTotal Health Care, Inc.Upper Peninsula Health Plan

Michigan Association of Health Plans 3


WHO WE ARE National leaders in excellence

U.S. News & World Report/NCQA rankings show Michigan's health plans among the best in the country

5 of the nation's top 50 commercial plans 4 of the nation's top 25 Medicaid plans

(and 11 in the nation’s top 50 Medicaid Plans) 2 of the nation's top 25 Medicare plans

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HEALTH MAINTENANCE ORGANIZATIONS Authorized under Chapter 35 of the Insurance Code

Specific regulatory responsibilities and obligations Required to provide a comprehensive benefit plan as defined in statute Required to join the financial and delivery aspects of health care through

arrangements (contracts) with selected providers

HMOs emphasize preventive care, services essential to good health

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HEALTH MAINTENANCE ORGANIZATIONS

HMOs are paid capitation, (per member per month) to deliver benefits described in contracts with purchasers and certificate of coverage

Are at 100% risk for coverage Along with benefits negotiated with the purchaser, HMO must also provide

mandated HMO benefits contained in Chapter 35

HMOs nationally accredited by the National Committee on Quality Assurance (NCQA) via independent auditing process --results of which used by State of Michigan and employers for purchasing decisions

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HEALTH MAINTENANCE ORGANIZATIONS Annual audited data is collected and forwarded to NCQA for

performance purposes and annual rankings (HEDIS data set)

Evidence-based practices key to HMO philosophy

Demonstrate effectiveness of programs, practices and products Most HMOs participate with the Michigan Quality Improvement

Committee (MQIC) to develop common sets of guidelines for providers

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HEALTH MAINTENANCE ORGANIZATIONS

The State of Michigan contracts with HMOs for Medicaid services (over 1.1 million Medicaid beneficiaries), and as option for State active employees and retirees

Role of HMOs in the Market Place: Large market (>50 employees) Small market (2-50 employees) Individual Market Medicaid/Medicare Targeted Programs for Michigan’s Uninsured

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ABOUT 1.1 MILLION UNINSURED IN MICHIGAN

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WHAT WE HAVE LEARNED IN MICHIGAN Not all Employers and businesses are

same Competition works to hold down rates Medicaid is cost-effective option for

uninsured Choices are important

Our members offer a variety of options Do need to level playing field so all insurers

can offer more options

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What is new for Medicaid Plans in Michigan Medicaid Rebid during FY 09--effective for

FY 10 Contracts Some differences in service areas in FY

10--but overall number of plans constant (14)

Choice of Plans in more counties MDCH Website for Health Plan by County:

http://www.michigan.gov/mdch/0,1607,7-132-2943_4860-41361--,00.html

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What is new for Medicaid Plans in MichiganThe Performance Monitoring Standards

Quality of Care Access to Care Customer Services Claims Reporting and Processing Encounter Data Provider File reporting

MDCH Website for Performance Issues: (contract & appendices)

http://www.michigan.gov/documents/contract_7696_7.pdf

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What is new for Medicaid Plans in MichiganContinued Requirement on Out-of-network

Claims.Out of Network Claims must be paid at established

Medicaid fees in effect on the date of service for paying participating Medicaid providers as established by Medicaid policy. If Michigan Medicaid has not established a specific rate for the covered service, the Contractor must follow Medicaid policy for the determination of the correct payment amount

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Medicaid Plans in Michigan In 2000, the Michigan Legislature enacted MCL 400.111i to allow

Medicaid providers to file clean claims with the Commissioner against Medicaid HMOs for timely payment. Ordinarily a clean claim must be paid within 45 days after receipt of the claim by the qualified health plan. A "clean claim" must meet certain criteria set forth in the legislation and must be submitted on form FIS 278 which can be accessed through the website for DLEG's Office of Financial and Insurance Regulation (OFIR). Additional information on clean claims is available at ﾊ http://www.michigan

.gov/cis/0,1607,7-154-10555_12902_35510_36782---,00.html.

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http://www.michigan.gov/cis/0,1607,7-154-10555_12902_35510_36782---,00.html



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Michigan Association of Health PlansQuestions?

www.mahp.org

presentation to the society of hematology oncology

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