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

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II. COMPREHENSIVE RISK-BASED MANAGED CAREPlease check one of the two boxes below. If you check the first box, please complete the remaining questions inthis section. If you check the second box, please skip to Section III. PRIMARY CARE CASE MANAGEMENT.My state does or will contract with a comprehensive RB-MCO in FY 2011.My state does not and will not contract with acomprehensive RB-MCO in FY 2011.1. RBMC Contractors Continue to next question . Go to Section III. PRIMARY CARECASE MANAGEMENT.a. Please indicate in the table below, by contractor type, the number of comprehensive RB-MCOs and the estimatedmarket share of total Medicaid managed care enrollment in October 2010. (Please note that a plan may fallwithin more than one of the listed categories.)RB-MCO TypeNumberof MCOsMarket Sharei. Medicaid-only (or predominantly Medicaid/CHIP) %ii. Mixed Medicaid/commercial enrollment %iii. Provider-owned %iv. Non-profit %v. For-profit %vi. Publicly traded %vii. Local (non-national) %viii. National %b. Please list in Appendix I, Table 1 the names of the comprehensive RB-MCOs in your state.Comments:2. Insurance Regulationa. What are the insurance licensure requirements for comprehensive RB-MCOs in Medicaid in your state?b. Does the state exempt any of the following types of comprehensive RB-MCOs from the normal state insurancesolvency requirements (as allowed under federal Medicaid law)?HMOs? PSNs/PSOs 1 ? HIOs 2 ?c. Is there an external appeals process for RB-MCO enrollees (other than the state fair hearing requirement)?Comments:3. Plan Selectiona. Does your state use an enrollment broker vendor to facilitate plan selection?i. If “yes,” name the enrollment broker vendor as of October 1, 2010:b. Does your state use an auto-assignment process for enrollees who fail to select a plan?i. If “yes,” over the past year, approximately what percentage of enrollees is auto-assigned on an averagemonthly basis? % (If the percentage varies significantly by program and/or geographic area, pleaseexplain under “Comments.”)1 Provider Service Networks or Provider Sponsored Organizations.2 Health Insuring Organization.K A I S E R C O M M I S S I O N O NMedicaid and the Uninsured5HEALTH MANAGEMENT ASSOCIATES
ii. Please indicate whether the factors listed in the table below are included in the state’s auto-assignmentalgorithm. (Check all that apply)A. Geographic considerations G. Related family member assignmentB. Plan capacity H. Plan quality performanceC. Balancing enrollment among plans I. Plan costD. Encouraging new plan entrants J. Other performance measures (please specify)E. Previous plan assignmentF. Prior PCP in network K. Other factor (please specify)Comments:c. Subject to federal requirements, may RB-MCOs conduct outreach and marketing activities?4. Paymenta. Please indicate which process(es) you use to set capitation rates. If different processes are used for differentprograms, please briefly describe under “Comments.”Capitation Rate-Setting Methodology(Check all that apply)i. Competitive bids iii. Negotiationii.Comments:Competitive bids withinactuarially determined rangesiv.Administrative rate-setting(using actuaries)v. Other :b. Please indicate whether capitation rates vary by any of the factors listed below. (Check all that apply)i. Age iii. Eligibility category v. Health Statusii. Gender iv. Geography vi. Other:c. If rates are risk-adjusted for health status, please indicate the system used (Check all that apply):CDPS MedicaidRx ACGs CRxGs DxCGs Other (please specify):d. Please indicate in the table below any retrospective risk-sharing arrangement used by the state. If your state hasdifferent policies for different programs, please briefly describe under “Comments.”Risk Sharing Arrangements(Check all that apply)i. Optional state-sponsored stop-loss/reinsurance v. Required state-sponsored stop-loss/reinsuranceii. Optional commercial stop-loss/reinsurance vii. Required commercial stop-loss/reinsuranceiii. Risk corridors (shared savings/loss) viii. Risk poolsiv. Condition-specific risk arrangement x.. Other:Comments:e. Is there a pay-for-performance aspect to reimbursement? If “yes”:i. Indicate the type of incentive used (Check all that apply): Bonus payment Capitation withholdShared savings Other (please specify):ii. Please briefly describe on what basis an RB-MCO can earn a payment based on performance:K A I S E R C O M M I S S I O N O NMedicaid and the Uninsured6HEALTH MANAGEMENT ASSOCIATES
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kaisercommission onmedicaidand theu
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kaisercommission onmedicaidand theu
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Table of ContentsExecutive Summary
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EXECUTIVE SUMMARYMedicaid, the publ
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party enrollment brokers to provide
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HEDIS©, CAHPS©, and state-specifi
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ConclusionFor over 30 years, state
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from the recession and the slow rec
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A note on Medicaid managed care ter
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Managed caremodelTable 1: Medicaid
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States are increasingly mandating m
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States with Medicaid MCOsKey Sectio
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States have “auto-assignment” a
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excess of a specified threshold for
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Dental care and outpatient and inpa
Page 33 and 34: the second trimester, and within th
Page 35 and 36: eported that they limit PCP panel s
Page 37 and 38: States with non-comprehensive PHPsK
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: 4. Enrollment Requirements.a. We ar
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
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Kaiser Family Foundation Survey on State Medicaid Managed Care ...

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