Provider Forum - 2015

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• Montana Health CO-OP Intro/Update – Karen• ACA update – Open Enrollment 2014-2015 -

Karen• NCQA & Inovalon – Barbara• High Performance Network (HPN) – Barbara• Referrals (Air Ambulance) – Katrina/Chad• Claims & Utilization Management (UM) - Barbara• Formulary - Isaac• Rosters - Isaac• Q & A

Today’s Agenda

Montana Health CO-OP/Intro and Update

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CO-OPs: Intent and Purpose

• Formed as an alternative to the “Public

Option”

• Provide more competition among payors

• Strong consumer focus: member governed

• Not-for-profit: use any profits to lower premiums, improve benefits, or improve health care

• Not sponsored by insurer or government

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Who is MHC?

• Montana’s member-operated health insurance CO-OP

• Home-grown (Helena-based)• Funded via federal start-up loans• State regulated

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CO-OPs: Intent and Purpose

Currently approved CO-OPs:

23 currently funded and under contract, 3 expanding = 26 states

Montana Idaho

New Mexico Arizona Iowa/Nebraska Nevada Oregon (2) Colorado Utah Tennessee South Carolina Illinois

Massachusetts New Hampshire

Maine Kentucky West Virginia Connecticut Wisconsin New York New Jersey Michigan Ohio Louisiana Maryland

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MHC Updates

• Expanded into Idaho 2015 (OE2)• Mountain Health CO-OP• YourHealthIdaho.org (state-run

Marketplace)• Member services centralized in MT• Products very competitively priced

• Link Care and Access Care products

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Current MHC Member Stats

• Approaching 45,000 members (27-30K in MT)

• Approximately 110 groups• 2650 members enrolled in group plans

• 90% of MHC members enrolled via Marketplace

• MHC captured approx. 45% of Marketplace

• Large percentage of members in their 30s

ACA Update – Open enrollment 2014-2015

OE 1 Results:10

ACA OE1 - Montana11

In Montana – after 2013-14 Open Enrollment:

• Net increase of 30,000 people with health insurance – approx. population of Butte

• Uninsured reduced from 20% of state population to 16.9%

• Statewide: • 26,429 increase in individual market• 8,739 increase in Medicaid program• 5,150 (insureds) decrease in small

group market

ACA OE2 - Montana12

In Montana – after 2014-15 Open Enrollment:

• 54,266 enrolled in plans via Marketplace• 41% new to the Marketplace • 85% receiving tax credits to offset

premium costs.

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% Increase in QHP Sign-ups from OE1 to OE2

NCQA

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Quality and NCQA

QHPs are required to achieve and maintain NCQA accredited

NCQA (National Committee for Quality Assurance): a private, not-for-profit organization dedicated to improving health care quality. NCQA develops quality standards and performance measures for a broad range of health care entities.• HEDIS- Medical Record Reviews- INOVALON• Risk Adjustment Medical Records- INOVALON• Stringent guidelines: Credentialing, Site Visits,

CAQH• Disease Management, Wellness and Health

Promotions

High Performance Network (HPN)

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HPN Goals

• To create value through quality outcomes, efficiency and service

• Move from silo health care delivery to integrated and coordinated care for population members thus eliminating gaps in care, redundancy and waste

• To “bend the cost curve” for healthcare • To reward the value based services and

align financial incentives to achieve the measured goals

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Activities

• Development a HPN/ACO Formalizing legal entity

• Allows for engagement of disparate physician practices with a focus on quality improvement

• Single organization structure with Regional Service Areas

• Health Care provider leadership of HPN • Opportunity to participate in CMS innovation

projects like ACO/shared savings programs • Restructure of Pay for Performance program

and reimbursement methodologies for self funded and fully insured individuals and employers

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HPN Structure RSO (Regional Service Organization)

HPN

RSO1 RSO2 RSO3

CHC (PCP)

Clinic (PCP)

Acute Care

Hospital

CAH

Specialist Clinic

Clinic (PCP)

CAH

Specialist Clinic

Acute Care

Hospital 1

Acute Care

Hospital 2

Clinic

(PCP)

Specialist Clinic

CAH

Acute Care

Hospital

RHC(PCP)

CAH

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Technology enables system to identify gaps in preventative care; use of Evidenced Based Medicine (EBM) standards

• Patient proactively contacted • Better outcomes and lower future costs • Examples: Colon cancer screening,

mammography, osteoporosis screening, AAA screening, pneumonia vaccine, prostate screening, diabetes screening, eye exams, PCP appointments

RSO (Regional Service Organization)

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Gain Share

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HPN Operational Challenges

• Ability to share data for defined patient population when participants have: Disparate electronic medical records systems

• Various practice management systems • Non standard clinical nomenclature • Separate patient identifiers • Differing methods for disease

identification & performance measures

Referrals (Air Ambulance)

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HELP Flight is our ONLY in-network air transport provider.

Costs can be excessive if out-of-network air transport is used.

HELP Flight is In-Network!

25© Sisters of Charity of Leavenworth Health System, Inc. All rights reserved.

2015

HELP Flight Referrals

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Highlight’s of Program

• HELP: Helicopter Emergency Lifesaving Program• Established in 1979 Hospital based program• CAMTS accredited (Commission on Accreditation of

Medical Transport System)• Great Safety record more than 20 years without an

incident• Scene calls 150 mile radius from Billings with Roto-

Wing (RW)

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Services provided

• Adult and Pediatric services-Medical, Trauma• Neonatal Transport Team-Neonatal Registered nurses

on the flight FW• Maternal Flight Transport –high risk pregnancies FW• Flight Respiratory Therapist• Flight Registered Nurses• Flight Paramedics

• Our team is specially trained and experienced in critical and emergency pre-hospital care.

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Services Provided (con’t)

• Non emergent transfers to other facilities• Communication Center• Partner with Metro and Edwards for pilots and

mechanics• Under Medical direction of a Board-Certified

Emergency Physician

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Aircraft

• Beechcraft Super King Air B-200-fully equipped air ambulance that can transport patients throughout the country.

• Roto-Wing EC-135 P2+- fully equipped air ambulance helicopter that can transport patients within 150 mile radius of Billings, MT.

• Thanks for allowing us to come and share what we can provide when it comes to caring for your patients and customers.

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HELP Flight is In-Network!

Claims & UM

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Utilization Management

UM - a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments.• Altius Utilization Management Department• All In-Patient services need prior authorization –

allow 10 Business days before services are rendered, if possible

• Listing or out-patient services on web site • Nurses & Coordinators• Members can access the UM dept via Customer

Service by calling the number on the back of the member ID card.

• Direct access to UM department by calling 800-879-0234 (toll-free).

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Claims

Claim/Customer Service/Eligibility Questions:• 855-488-0622 (Toll Free)• mhccustomerservice@cvcy.com

Paper Claims:MHC Claim DepartmentP.O. Box 7147London, KY 40742

Electronic Claim submission 25133 Emdeon

Pre-Authorization:• 800-879-0234 (Toll Free)

Montana Health CO-OP: Member Services and Claims Processing

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Serving our members

Updated web presence with convenient access to member services.

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Serving our members

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Serving our members - Altius

My Online Services offers members the ability to:• View claims, EOBs and

benefit usage details• Access health and

wellness tools• Research cost of care

data• Request, display, print

member ID card• Search for doctors,

hospitals and providers within the network.

Health Plan Networks

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Connected CareNarrow Network Exclusions are: Billings

Clinic, Community Medical Center & Monida Network providers in the Missoula ProperAccess Care

Open Network including Billings Clinic, Community Medical Center and

any Monida Network ProvidersEngage (coming in OE3 – 2016)

HPN Providers onlyOut-of-Network

Connected Care & Access Care

Naturopath7

Nurse Practitioner365

Chiropractic72

Dentist 23

LCPC185

LCSW86

Physician Asst329

Physicians1697

Psy175

Physical Therapy

10%

Optician44

Access Care - Providers

7 facilities

11 facilities

47 out of 48 facili-ties

Access Care - Facilities

Mental Health, Children's, etc. Main HospitalsCritical Access Hospitals

Naturopath7 Nurse Practitioner

347

Chiro-practic

72Dentist

23LCPC185

LCSW86

Physician Asst288Physi

cians1441

Psy175

Physical Therapy

293Optician

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Connected Care - Providers

Mental Health, Children's, etc.

7 Facilities

Main Hospitals9 Facilities –

Excluding Billings Clinic

and Community Medical Center

Critical Access Hospitals

47 out of 48 Facilities

Connected Care - Facilities

RX Formulary

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Administered by Express Scripts Use Express Scripts for mail order! Pharmacy Support Email - Provider Inquiry

pharmacysupport@cvty.com 855-488-0622 (Option 1, and then 1) Pharmacy information available via

MHC.coop

Pharmacy

Provider Rosters

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• Current Provider Rosters• Web Site Current• Any Demographics Changes to Providers • Item to include:

• Tax ID• Mailing and Business address• Licensure• NPI Number• Phone Number

Please direct roster changes to Isaac Heinitz: iheinitz@mhc.coop

Provider Rosters

Montana Health CO-OP: Online Provider Services

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Serving our Providers

Convenient link via MHC website to online provider services.

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Serving our Providers

• View member eligibility

• Submit authorization and referrals

• View claim status and request adjustments

• Download and print remittance advices

• Resource library• Benefits• Interqual criteria

Directprovider.com allows secure access to critical information. This innovative tool is available for Montana Health CO-OP plans and provides direct connection for up-to-date information.

On the horizon…

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ACA on the horizon…

• Tax implications become evident (penalties) for those who didn’t have health insurance in 2014.

• Legislature has approved Medicaid expansion in Montana.

• Upcoming Supreme Court Case (King v. Burwell) to determine whether tax credits are legal for those who buy insurance via federally facilitated exchanges (Montana). Oral arguments were heard March 4; ruling expected this summer.

• OE3 Dates: November 1, 2015 – Jan. 31, 2016• 2016 New rules in effect for businesses. (50-99

employees – must provide insurance).

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Medicaid Expansion in MTSenate Bill 405

• Covers adults up to age 64 earning 138% FPL ($16,200)• Effective date: Possibly January 2016, pending federal

approval.• 27,000 – 45,000 Montanans could enroll over next 4 yrs.

$1 billion in federal funds flow into MT; MT pays about $6 million. Feds pay 100% in 2016, down to 90% over next 4 years.

• Premiums: 2% of a person’s annual income.• Coverage: Medicaid covers basic medical and dental,

includes physician & hospital visits, mental health, etc.• Personal Asset Limits: Participants can own a home,

one light vehicle and have up to $50K in cash resources. Additional costs apply if assets exceed these limits.

Q&A

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Barbara Kamerzelbkamerzel@mhc.coop

406-447-5777Web Resources:

mhc.coophealthcare.gov

montanahealthanswers.com

Thank you!