Biannual Managed Care Stakeholder Meeting Jami Snyder, Associate Commissioner Medicaid and CHIP Services Department

January 5, 2017

Rules of Engagement ♦ Please silence your cell phones ♦ One 10 minute break ♦ Questions ♦ Please stand and wait for the microphone ♦ Off-site questions need to be sent to the following email address: ♦ [email protected] ♦ Subject: Stakeholder Meeting JAN 2017

♦ Webinar attendees, please use the Question Box on your dashboard ♦ Off-site questions will be answered by MCS Staff after the meeting via email

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Agenda ♦ Medical and Social Services (MSS) Update ♦ Medicaid Update ♦ STAR Kids Update ♦ Provider Enrollment ♦ SB 760 Network Adequacy Implementation ♦ MCO Quality and Value Based Payment Initiatives ♦ CMS Managed Care Regulations Implementation ♦ Open Discussion and Questions 3

Welcome Jami Snyder, Associate Commissioner Medicaid and CHIP Services Department (MCS)

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Medical and Social Services Update Gary Jessee, Deputy Executive Commissioner Medicaid and Social Services Division (MSS)

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Medicaid Update Jami Snyder, Associate Commissioner Medicaid and CHIP Services Department (MCS)

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2017 Medicaid and CHIP Goals ♦ Cultivate employee development and engagement ♦ Facilitate meaningful stakeholder engagement ♦ Foster the continued expansion of managed care and the advancement of the Texas managed care model ♦ Maximize the use of data to drive decision making ♦ Ensure ongoing compliance with federal and state mandates, including Medicaid managed care regulations ♦ Refine and stabilize Medicaid / CHIP operational and administrative functions 7

2017 Priority Projects ♦ Centers for Medicare and Medicaid Services Managed Care Rule Implementation ♦ 188 regulation sections under review ♦ Corresponding contract/policy changes will occur from March 2017 through September 2018 ♦ Areas of interest: ♦Mental health parity ♦Beneficiary protections ♦Network adequacy 8

2017 Priority Projects ♦ Healthcare Transformation Waiver Extension and Operations Maintenance ♦ HHSC will request an additional 21 months of level funding for the UC and DSRIP pools ♦ Continuation of the managed care provisions of the 1115 Waiver through September 30, 2019

♦ Integrity of Encounter Data ♦ Partnering with Inspector General in review of MCO encounter data ♦ HHSC is currently determining standard encounter data element requirements

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2017 Priority Projects ♦ Managed Care Carve-In Projects ♦ September 1, 2017: Medicaid for Breast and Cervical Cancer & Adoption Assistance and Permanency Care ♦ September 1, 2018: Texas Home Living (TxHML; STAR+PLUS) ♦ September 1, 2021: ♦Consumer Living Assistance and Support Services (CLASS), ♦Deaf Blind with Multiple Disabilities (DBMD), ♦Home and Community-based Services (HCS) waivers ♦Members that live in community-based Intermediate Care Facilities for Individuals with an Intellectual Disability (STAR+PLUS)

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2017 Priority Projects ♦ Meaningful External Stakeholder Engagement ♦ December 2016, survey was sent to external stakeholders (146 responses received) ♦ Staff are currently compiling and analyzing results

♦ Medicaid Management Information System Modernization Effort ♦ MMIS re-procurement negotiations are ongoing ♦ Targeting an agreement in principle by February 1, 2017

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2017 Priority Projects ♦ Pay for Quality (P4Q) Redesign ♦ Guiding principles: ♦Simple and easy to understand ♦Allows plans to track their performance ♦Rewards high performance / improvement ♦Promotes transformation and innovation

♦ Enhanced program to be implemented on January 1, 2017 (incorporated into contract on September 1, 2017) ♦ Will be paired with expectation for acceleration of value-based purchasing efforts 12

2017 Priority Projects ♦ Provider Re-enrollment ♦ 89 percent compliance as of December 8, 2016 ♦ Disenrollment date: February 1, 2017

♦ Re-procurement of Major Medicaid and CHIP Services Contracts ♦ Operational start dates: ♦ SEP 2018:

CHIP Rural & Hidalgo

♦ JAN 2019:

STAR+PLUS Statewide

♦ MAR 2019:

Medicaid & CHIP Dental

♦ MAR 2020:

STAR & CHIP Statewide 13

2017 Priority Projects ♦ Use of Data to Drive Performance, Enhance Quality, and Reduce Cost ♦ Integration of data analysis into Medicaid steering committee ♦ Expansion of analysis to assess system performance as well as compliance ♦ Examples: ♦STAR+PLUS UR review and recoupment ♦Provider geo-mapping to determine adequacy standards for specialty providers 14

STAR Kids Update Kari Brock, STAR Kids Specialist MCS, Policy and Program

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Overview ♦ Senate Bill (S.B.) 7, 83rd Legislature, Regular Session, 2013 ♦ STAR Kids is a capitated managed care program to provide Medicaid benefits to children and young adults with disabilities ♦ Implemented November 1, 2016

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Enrollment ♦ November total – 163,662 ♦ MDCP ♦ IDD waivers ♦ YES

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Service Coordination ♦ Levels are assigned from 1 to 3 ♦ Levels are determined by member need ♦ Named service coordinator ♦ Face-to-face and telephonic contact frequencies

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STAR Kids Screening and Assessment (SK-SAI) Comprehensive Needs Assessment ♦ Acute services ♦ Long term services and supports (LTSS) ♦ Medical Necessity and RUG ♦ Completed annually, at minimum ♦ Approved by Texas Medicaid Health Partnership

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Continuity of Care ♦ Authorizations ending October and November 2016 ♦ Existing prior authorizations ♦ Out of network providers ♦ Referrals ♦ Young adults turning 21 before January 2017

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Operational Dashboard Key Indicators ♦ Number of complaints received by MCO ♦ Number of assessments scheduled by MCO ♦ Number of calls received at MCO call centers ♦ HHSC tracked member and provider complaints

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Successes ♦ SK-SAI ♦ A Service Coordinator’s Perspective

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What is next? ♦ Completion of STAR Kids Screening and Assessment (SK-SAI) for all members ♦ MCOs will continue to identify and contract with providers ♦ HHSC will continue monitoring the MCOs and assisting providers and families ♦ ICHP STAR Kids Quality Survey

♦ STAR Kids Advisory Committee

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10 Minute Break

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Provider Enrollment KJ Scheib, Deputy Associate Commissioner MCS, Operations

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Provider Enrollment ♦ ACA Enrollment for Billing Providers ♦ September 24, 2016 – Deadline ♦Applications submitted by this date to ensure continued claims payment

♦ Disenrollment ♦Services through this date will be paid ♦Disenrollment date – February 1, 2017

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Enrollment status ♦ TMHP ♦ 265,500 complaint TPIs / in process ♦ 31,100 non-complaint / no application ♦ ~89% compliance (includes in process)

♦ Pharmacy (VDP) ♦ 4474 compliant / in process ♦ 73 non-compliant / no application but eligible* ♦ 99% compliance to date 27

Enrollment status ♦ Long Term Care – (DADS) ♦ 3362 compliant and in progress providers ♦ 530 non-compliant providers ♦ ~86% compliance to date

♦ Notification letters sent week of November 14th

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MCO Networks ♦ Confirm networks meet contractual standards ♦ Send notifications to providers ♦ Coordinate care with clients ♦ Data on affected STAR Kids Clients

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Ordering, Referring and Prescribing ♦ Medicaid ORP – October 2017 ♦ Claims edit requiring the NPI of the ORP provider ♦ Affects claims for all services, other than Part D Medicare, that requires an order or referral

♦ CMS Extends compliance date for prescribing providers for Part D services – January 2019

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On Going Re-Enrollment ♦ Work with TMHP on data pulls ♦ Work with Texas Association of Health Plan Vendors ♦ Work with Associations

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Questions?

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SB 760 Network Adequacy Implementation Update Allen Pittman, MSSW, Program Manager MSC, Project Advisory & Coordination Team

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SB 760 Background ♦ Requires HHSC to establish minimum access standards for managed care organization (MCO) provider networks for specific provider types ♦ Requires MCOs to create an expedited credentialing process for specific provider types identified by HHSC ♦ Requires MCOs to regularly update and publish provider directories on their websites ♦ Other requirements, include Ombudsman coordination with the DADS to provide information and support services to clients 34

Network Adequacy ♦ SB 760 and recent CMS rules require Texas to develop time and distance standards for specific provider types ♦ MCOs must ensure members have timely access to quality healthcare through a network of providers designed to meet the needs of the population served ♦ HHSC received feedback during stakeholder meeting in Fall 2015 & Summer 2016 and through written comment ♦ New network adequacy standards will be included in March 2017 managed care contracts 35

MCO Contract Changes ♦ Standards based on county level, initially derived from Medicare Advantage mileage and travel time ♦ County designations will now include metro, micro, and rural ♦ Existing standards include urban and rural

♦ Implementation of travel time standards ♦ Stepped approach to monitoring and contract remedies that allow 18 months for MCOs to achieve full compliance with adopted standards ♦ HHS my consider exceptions to standards in limited circumstances

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Time and Distance Standards Provider Type

Specialty Care Provider

Distance in Miles

Travel Time in Minutes

none

Metro 30

Micro 30

Rural 75

Metro 45

Micro 45

Rural 80

none none none none none none none none none none none none none

30 10 10 20 30 20 30 20 20 20 30 30 30

30 20 20 35 60 35 60 35 35 35 45 45 60

30 30 30 60 75 60 75 60 60 60 60 60 75

45 15 15 30 45 30 45 30 30 30 45 45 45

45 30 30 50 80 50 80 50 50 50 60 60 80

45 40 40 75 90 75 90 75 75 75 75 75 90

75 75 30 urban 75 rural 75

none none none

30 75 30

60 75 30

60 75 75

45 N/A 45

80 N/A 45

75 N/A 90

none

30

30

75

45

45

90

Endodontist, Periodontist, and Prosthodontist Orthodontist

75

none

75

75

75

90

90

90

75

none

75

75

75

90

90

90

Oral Surgeons

75

none

75

75

75

90

90

90

Cardiovascular Disease ENT (otolaryngology) General Surgeon OB/GYN (non-PCP) Ophthalmologist Orthopedist Pediatrician Psychiatrist Urologist Other Physician Specialties

Occupational, Physical, or Speech Therapy Nursing Facility Main Dentist (general or pediatric) Pediatric Dental Dental Specialists

Proposed

30 urban 75 rural 30 none 30 75 75 75 75 75 75 75 75 75 75

Behavioral Health-outpatient Hospital- Acute Care Prenatal Primary Care Provider

Current Managed Care Contracts Distance in Travel Time Miles

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Next Steps and Consideration ♦ HHSC continues to refine the approach to measuring travel time ♦ Assumptions include: ♦ Measuring based on personal vehicle from member’s residence to provider location ♦ Standardization of travel time analysis ♦ Calculation using ARC GIS

♦ Texas is a large and geographically diverse state. ♦ Standards support development and maintenance of adequate networks while accounting for areas that do not have some types of providers

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Resources ♦ Email: [email protected]

♦ Website: https://hhs.texas.gov ♦ Click Services ♦ Click “Medicaid and CHIP” under Health ♦ Click “Provider Information” ♦ Click Senate Bill 760 39

Questions?

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MCO Quality and Value Based Payment Initiatives Andy Vasquez, Deputy Associate Commissioner MCS, Quality & Program Improvement

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MCO Quality and Value Based Payments Topics ♦ Overview: Value-Based Payments and Alternative Payment Models ♦ HHSC VBP Initiatives ♦ Keys to Success ♦ HHSC Healthcare Quality Strategy

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MCO Quality and Value Based Payments Overview ♦ Goal: Move away from volume-based payment models towards models that link healthcare payments to quality or value ♦ Related terms: ♦ Value-Based Payments (VBP) / Value-Based Contracting (VBC) ♦ Alternative Payment Models (APM) ♦ Quality-Based Payments ♦ Payment Reform 43

Don Berwick, Tom Nolan, and John Whittington are credited with first describing the Triple Aim in 2008 for the Institute of Healthcare Improvement (IHI)

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MCO Quality and Value Based Payments VBP Continuum

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MCO Quality and Value Based Payments HHSC VBP Initiatives ♦ MCO/DMO Pay for Quality (P4Q) ♦ MCO Performance Improvement Projects (PIPs) ♦ Hospital Pay for Quality Program ♦ MCO VBC with Providers ♦ Delivery System Reform Incentive Payment Program (DSRIP) ♦ Network Access Improvement Program (NAIP) ♦ Quality Incentive Payment Program (QIPP) ♦ HHSC-MCO Contract VBP Requirements

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MCO Quality and Value Based Payments HHSC VBP Initiatives – P4Q ♦ The redesigned P4Q program: ♦ Is simpler and easy to understand ♦ Allows plans to track their performance and predict losses, to the degree possible ♦ Rewards high performance and improvement ♦ Promotes transformation and innovation leading to better health outcomes 47

MCO Quality and Value Based Payments HHSC VBP Initiatives – P4Q ♦ MCO’s will earn or lose money based on three factors: ♦ Within-year performance ♦ Year-to-year individual plan improvement ♦ Bonus Pool

♦ To be implemented January 2018

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MCO Quality and Value Based Payments HHSC VBP Initiatives – QIPP ♦ QIPP encourages nursing facilities to improve the quality and innovation of their services, using the CMS 5-star rating system as its measure of success for the following 4 measures: ♦ High-risk long-stay residents with pressure ulcers ♦ Long-stay residents who received an antipsychotic medication ♦ Long-stay residents experiencing one or more falls with major injury ♦ Long-stay residents who were restrained

♦ To be implemented September 2017 49

MCO Quality and Value Based Payments Wrap-up: Keys to Success ♦ Clients/Consumers must always come first ♦ Accountability at all levels ♦ Align financial and clinical models between multiple payers, provider types, and populations ♦ This is a complex and long term endeavor that is occurring in a dynamic state, federal, commercial environment – plan accordingly 50

MCO Quality and Value Based Payments Wrap-up: Keys to Success ♦ Build in administrative simplification and maintain it ♦ Timely, comprehensive data and enhanced analytics ♦ Evolve valuation and measurement processes

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MCO Quality and Value Based Payments Multiple Payers

Medicare Quality Measures and Initiatives (ACOs, Hospital Value Based Purchasing, Hospital Readmissions Reduction Program, MACRA)

RHP DSRIP Hospital and Other Performing Providers Quality Measures and Initiatives

Commercial Carriers Medicaid Fee for Service Programs

Quality Measures and Initiatives

Medicaid and CHIP MCO Quality Measures and Initiatives (P4Q, MCO VBP, PIPs)

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MCO Quality and Value Based Payments VBP Likely to Survive Post-ACA 18 health systems call on Trump, Congress not to 'reverse course' on value-based care 'The only path to achievable sustainable value-based payment is by aligning private sector and public sector efforts,' the group wrote December 9, 2016 The 43-member Health Care Transformation Task Force this week sent a letter to President-elect Donald Trump, congressional leadership, and other officials urging them to continue efforts to promote value-based care. In the letter, the task force—which includes health systems, insurers, patient advocacy organizations, and other groups— wrote that there has been broad bipartisan consensus on the need to promote value-based payment systems to increase quality and lower costs.

Source: www.advisory.com/daily-briefing/2016/12/09/18-health-systems-call-on-trump

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Healthcare Quality Strategic Plan CMS National Healthcare Quality Strategy

Source: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html

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Healthcare Quality Strategic Plan Texas Healthcare Quality Strategy - Priorities ♦ Keeping Texans well throughout their lifespan ♦ Serving individuals in the least restrictive setting ♦ Keeping patients safe and free from harms caused in the delivery of care ♦ Promoting the most effective practices to improve outcomes for individuals with chronic diseases ♦ Attracting and retaining world class providers and other health care professionals 55

Healthcare Quality Strategic Plan Texas Healthcare Quality Strategy - Subpopulations ♦ Individuals with complex health care needs ♦ Individuals eligible for long term services and supports ♦ Individuals with mental health and/or substance use disorders ♦ Individuals age 65 years and over ♦ Pregnant women and mothers ♦ Newborns and children ♦ Uninsured ♦ All Texans 56

MCO Quality and Value Based Payments Question? ♦ Links at HHS.Texas.Gov: ♦ Quality Improvement ♦ 1115 Transformation Waiver ♦ MCO Pay for Quality (P4Q) ♦ LTC Quality ♦ QIPP

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CMS 2016 Final Managed Care Regulations Emily Zalkovsky, Deputy Associate Commissioner MCS, Policy & Program

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Overview ♦ Analysis Process and Implementation Timeframe ♦ Regulatory Guidance Currently in Process ♦ Regulatory Guidance Under Review ♦ Next Steps ♦ Questions

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Analysis Process ♦ HHSC has split the regulation into 188 rules for analysis ♦ Analysis includes: ♦ Review of required contract changes ♦ Impact to members, MCOs, providers, and the agency ♦ Plan to implement to maintain compliance

♦ Anticipate changes to MCO contracts by Spring 2017 onward ♦ HHSC will communicate changes via the contract amendment process, regular communication to MCOs, and stakeholder meetings 60

Contract Changes ♦ MCOs are required to be compliant with all federal regulations ♦ See UMCC Attachment A. Article 7. Governing Law & Regulations; Section 7.02 MCO responsibility for compliance with laws and regulations

♦ If a regulation requires a contract change, MCOs can expect to see the proposed language six months before the effective date ♦ HHSC is developing an implementation plan on how to operationalize the rules and will develop MCO guidance as appropriate 61

Implementation Timeframe CMS Effective Date

Actual Date (if applicable)

Immediately

May 6, 2016

60 days after publication (compliance date)

July 5, 2016

No later than rating period for contracts starting on or after July 1, 2017 No later than July 1, 2018 No later than rating period for contracts starting on or after July 1, 2018 No later than 3 years from the date of a final notice published in the Federal

Proposed Contract Language

Contract Effective Date

Spring 2017

September 1, 2017

Fall 2017

March 1, 2018

Spring 2018

September 1, 2018

May 6, 2019

March 1, 2019

Register No later than rating period for contracts starting on or after July 1, 2019

Spring 2019

September 1, 2019

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Regulatory Guidance in Process

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Regulatory Guidance in Process ♦ Network Adequacy ♦ Beneficiary Support System ♦ Screening and Enrollment & Revalidation of Providers

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Beneficiary Support System ♦ 42 CFR 438.71 ♦ Compliance date of September 1, 2019 ♦ States must develop and implement a beneficiary support system: ♦ Provides choice counseling ♦ Assistance understanding managed care ♦ Process for resolving issues

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Beneficiary Support System ♦ Texas already has an independent consumer support system (ICSS) in place that operates independent of the MCOs ♦ The ICSS consists of the following: ♦ HHSC’s Medicaid / CHIP Division ♦ Office of the Ombudsman (Ombudsman) ♦ The state’s managed care Enrollment Broker (MAXIMUS) ♦ Community support from the Aging and Disability Resource Centers (ADRCs)

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Screening and Enrollment & Revalidation of Providers ♦ 42 CFR 438.602(b) ♦ Compliance date of September 1, 2018 ♦ The state must screen, enroll, and periodically reevaluate all network providers in accordance with the requirements of part 455

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Screening and Enrollment & Revalidation of Providers ♦ Texas Medicaid provider enrollment compliance as of December 20, 2016: ♦ Acute Care: ♦ Pharmacies: ♦ LTSS:

89.0% 98.5% 84.0%

♦ Next steps ♦ Additional streamlining of provider enrollment process ♦ Staggering of re-enrollment 68

Regulatory Guidance Under Review

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Medicaid Managed Care Quality Rating System ♦ 42 CFR 438.334 ♦ Compliance date in 2021 ♦ CMS will publish additional guidance specifying the measures and methodologies in 2018 ♦ CMS will develop the standards through a public input process ♦ Reviewing possibility of using current report card system ♦ Dependent on CMS approval

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Grievance and Appeal System ♦ 42 CFR 438.402 ♦ Compliance date of September 1, 2017 ♦ Aligns Medicaid managed care with Medicare Advantage ♦ MCOs may only have one level of appeal

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Parity in Mental Health and Substance Use Disorder Benefits ♦ 42 CFR 438.3(e) and 438.3(n) ♦ Compliance date of July 5, 2016 ♦ Regulation requires: ♦ The capitation rate must include: ♦ Services outlined in the State Plan ♦ Utilization and actual cost of in lieu of services ♦ Services deemed by the state as necessary for compliance with federal mental health parity requirements

♦ States must provide services to enrollees in compliance with existing mental health parity requirements, as well as new requirements effective on October 2, 2017 ♦ This section applies to CHIP (see 457.1201(l))

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Managed Care Enrollment ♦ 42 CFR 438.54 ♦ Compliance date of July 5, 2016 ♦ States that select health plans for beneficiaries and enroll them passively ♦ Must notify beneficiaries ♦ Provide them a 90-day period to change plans

♦ HHSC is exploring options related to this provision

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Care Coordination of Services for Enrollees ♦ 42 CFR 438.208(b)(3) and (c) ♦ Compliance date of September 1, 2017 ♦ MCOs are required to make best efforts to conduct an initial screening of new enrollees’ needs within 90 days of enrollment ♦ MCOs must implement processes to comprehensively assess Medicaid enrollees who need LTSS or have special health care needs

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Next Steps ♦ HHSC will continue to evaluate impact and implementation plans to ensure compliance with the Medicaid managed care final regulation ♦ Regular updates will be provided to MCOs and stakeholders ♦ Contract amendments will include updates to align with new requirements

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Questions ♦ Please submit any questions or comments related to the managed care regulations to: [email protected]

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Open Discussion & Questions Jami Snyder, Associate Commissioner Medicaid and CHIP Services Department (MCS)

Next Semi-annual Stakeholders Meeting: 12 JUL 2017 77