Kaiser Family Foundation Survey on State Medicaid Managed Care ...

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Pennsylvania and South Carolina) reported that the administrative fees are at risk. The services providedunder administrative services contracts range from activities like case or care management and diseasemanagement to outreach/education, enrollment broker services, and claims administration.Appendix 11 provides a state-by-state list of PCCM administrative services contracts.Enhanced PCCM programsA growing number of states operate Enhanced PCCM (EPCCM) programs. In recent years, inprograms they characterize as “enhanced PCCM,” a growing number of states have placed additionalcontractual requirements on PCPs to strengthen care coordination and management. The followingnine states reported that they have an EPCCM program: Arkansas, Colorado, Georgia, Montana,North Carolina, Oklahoma, Pennsylvania, Rhode Island, and South Carolina. Included among theenhancements they have added within their PCCM programs are disease management services,coordination/integration of physical and mental health care, case management for high-cost/highriskenrollees (e.g., medically complex children, individuals with disabilities), and linkages betweenprimary care and community-based services for targeted groups. State EPCCM programs continue toevolve as states adopt new hybrid forms of care delivery and financing.Georgia’s EPCCM program, Service Options Using Resources in a Community Environment (SOURCE), serves thefrail elderly and disabled with chronic health conditions. SOURCE was established to integrate primary,specialty, and home and community-based care, with the goal of eliminating care fragmentation, increasingtreatment compliance, reducing emergency room, hospital, and nursing home admissions due to preventablemedical complications, and reducing the need for long-term institutional care. Eligible individuals enroll in aSOURCE site as their primary care provider. A case manager works with the enrollee and his or her primary careprovider to act as a link between medical care and home and community-based services. SOURCE operates ona fee-for-service model.North Carolina’s EPCCM, Community Care of North Carolina (CCNC) is built on the medical home model. Acrossthe state, there are 14 Community Care Networks consisting of physicians, nurses, pharmacists, hospitals,health departments, social service agencies and other community organizations. These private non-profitnetworks are responsible for managing the care of Medicaid enrollees and use a variety of management toolsto improve performance including: implementation of best practices, disease management, management ofhigh-risk patients, and management of high-cost services. In addition to fee-for-service providerreimbursement and PCP management fees, each Community Care Network also receives a management feebased on the number of Medicaid enrollees in the network.Pennsylvania’s EPCCM program, ACCESS Plus, includes a Disease Management component in which telephonicand field-based disease case management services are provided. Other enhancements include a requirementthat the ACCESS Plus vendor provide enhanced physical health/behavioral health coordination through lettersof agreement established with behavioral health MCOs and behavioral health providers. The ACCESS Plusvendor is also financially responsible for meeting quality metrics and an agreed-upon, guaranteed percentagesavings for members with the conditions subject to Disease Management.30 00
States with non-comprehensive PHPsKey Section Findings:Half the states contract with non-comprehensive PHPs, separate from their MCO and PCCMprograms, to provide some services. The services most commonly provided by these PHPs areinpatient and outpatient behavioral health care and substance abuse treatment, followed bydental care, non-emergency transportation, and prescription drugs – all services that arefrequently carved out of MCO contracts.The vast majority of Medicaid enrollees receiving behavioral health services through a noncomprehensivePHP were in plans that specialize in serving Medicaid. Not-for-profit, nonpubliclytraded, and local plans were also strongly dominant.Compared with Medicaid enrollees receiving behavioral health care through a PHP, thosereceiving dental care through a PHP were more likely to be in plans with mixed enrollment, forprofitplans, and plans affiliated with a national company.Half the states (25) reported contracting with non-comprehensive PHPs to provide some Medicaidbenefits in FY 2011. These states reported a total of 190 PHPs contracts. These contracts may be withPrepaid Inpatient Health Plans (PIHPs) responsible for some or all inpatient hospital services (includinginpatient mental health services), or with Prepaid Ambulatory Health Plans (PAHPs) that provide abenefit package that includes no inpatient services. Payment to non-comprehensive PHPs is on acapitated, at-risk basis. The states that contract with non-comprehensive PHPs for one or morecategories of service include states that rely largely on MCOs to deliver care to Medicaid beneficiariesbut carve these services out, as well as states that operate largely on a fee-for-service basis.Dimensions of non-comprehensive PHPsMost non-comprehensive PHPs provide inpatient or outpatient behavioral health or substance abusetreatment services, but they may also provide other single categories of service. Fifteen statesreported that they provide inpatient and outpatient behavioral health services, respectively, throughnon-comprehensive PHPs (Table 9); the next most commonly reported PHPs were those providingoutpatient or inpatient treatment for substance abuse. The 11 states that reported enrollment data fornon-comprehensive PHPs providing only behavioral health (and sometimes substance abuse treatmentservices) accounted for 7.9 million Medicaid enrollees in 87 plans, by far the largest number of enrolleesin any type of non-comprehensivePHP. Other PHP contracts coverdental care, non-emergencytransportation, prescription drugs,and vision care. In addition, atleast one state reported providingeach of the following types of carethrough a non-comprehensivePHP: maternity care; services formentally retarded/developmentally disabledbeneficiaries; primary care, diseasemanagement, and chronic care.Table 9: Medicaid Services Provided through Non-Comprehensive PHPsType of serviceNo. of states providingservice through PHPInpatient behavioral health 15Outpatient behavioral health 15Outpatient substance abuse treatment 11Inpatient behavioral health detoxification 7Dental care 7Non-emergency transportation 7Prescription drugs 6Vision care 231
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Page 3 and 4: kaisercommission onmedicaidand theu
Page 5 and 6: Table of ContentsExecutive Summary
Page 7 and 8: EXECUTIVE SUMMARYMedicaid, the publ
Page 9 and 10: party enrollment brokers to provide
Page 11 and 12: HEDIS©, CAHPS©, and state-specifi
Page 13: ConclusionFor over 30 years, state
Page 16 and 17: from the recession and the slow rec
Page 18 and 19: A note on Medicaid managed care ter
Page 20 and 21: Managed caremodelTable 1: Medicaid
Page 23 and 24: States are increasingly mandating m
Page 25 and 26: States with Medicaid MCOsKey Sectio
Page 27 and 28: States have “auto-assignment” a
Page 29 and 30: excess of a specified threshold for
Page 31 and 32: Dental care and outpatient and inpa
Page 33 and 34: the second trimester, and within th
Page 35: eported that they limit PCP panel s
Page 39 and 40: Measuring, monitoring, and improvin
Page 41 and 42: seven states required 10 measures o
Page 43 and 44: CAHPS© surveys. North Carolina is
Page 45 and 46: Special initiatives to improve qual
Page 47 and 48: public health efforts to reduce dis
Page 49 and 50: Medicaid managed long-term care and
Page 51 and 52: (e.g., need to credential Adult <st
Page 53 and 54: In many states, broader efforts foc
Page 55 and 56: Looking ahead: Medicaid managed car
Page 57 and 58: ConclusionFor over 30 years, state
Page 59 and 60: APPENDIX 2: Summary of Medicaid Man
Page 61 and 62: Program Name(e.g., Popular Name, 19
Page 63 and 64: APPENDIX 3: MCO Contracts, Plan Cha
Page 65 and 66: State(No. ofcontracts)NameEnrollmen
Page 67 and 68: State(No. ofcontracts)NameEnrollmen
Page 69 and 70: APPENDIX 5: MCO Capitation Rate-Set
Page 71 and 72: APPENDIX 7: MCO Network Adequacy Re
Page 73 and 74: State Primary Care Obstetric Care S
Page 75 and 76: APPENDIX 9: Providers Recognized as
Page 77 and 78: APPENDIX 11: PCCM Administrative Se
Page 79 and 80: APPENDIX 13: Initiatives to Improve
Page 81 and 82: I. MANAGED CARE OVERVIEW1. Total Ma
Page 83 and 84: 4. Enrollment Requirements.a. We ar
Page 85 and 86: ii. Please indicate whether the fac
Page 87 and 88:
c. Required Providers: We are inter
Page 89 and 90:
IV. NON-COMPREHENSIVE PREPAID HEALT
Page 91 and 92:
. Does your state use CAHPS© surve
Page 93 and 94:
VI. SPECIAL INITIATIVESAll states s
Page 95 and 96:
Appendix I: Managed Care Contracts1
Page 97:
Appendix II: Clinical Quality Perfo
Page 100:
1330 G S T R E E T NW, W A S H I N
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