managed care changes basic health and healthy options alison robbins washington state health care...
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Managed Care ChangesBasic Health and Healthy
OptionsAlison RobbinsWashington State Health Care Authority September 18, 2012
Procurement Process
• Conducted in 2011 – 2012• New contracts signed March 2012• Program changes implemented July
1, 2012• Exiting Plans: Group Health
Cooperative, Regence BlueShield, Asuris NW Health, Kaiser, Columbia United Providers.
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Healthy Options Plans for 2012
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• Amerigroup/Real Solutions
• Community Health Plan of Washington
• Coordinated Care Corporation
• Molina Healthcare of Washington
• UnitedHealth Care Community Plan
Effective 8-1-2012 Service Areas for Healthy Options, Children’s Health Insurance Program,
Healthy Options Blind/Disabled, and Healthy Options Foster Care Programsas of 6-5-12
Garfield
Pend Oreille
Spokane
Walla Walla Asotin
Columbia
Stevens
Whitman
Ferry
Lincoln
Franklin
Adams
Douglas
Grant
Benton
Yakima
Klickitat
Chelan
San Juan
Whatcom Okanogan
Skagit
King
Kittitas
Snohomish
LewisPierce
Skamania
ClallamIsland
Clark
Cowlitz
KitsapMason
Wahkiakum
Pacific
Jefferson
Grays Harbor
AMG CCC CHP MHC UHC
CCCCHP MHCUHC
CCCCHP MHCUHC
CHPCCC MHCUHC
CCC CHP MHCUHC
CCCMHCUHC
CHPMHCUHC
CCC CHP MHC UHCAMG
CCCCHPMHCUHC
CCCCHP MHCUHC
AMG CCC CHP MHC UHC
CHPMHC
AMG CCC MHCUHC
CCC UHC
CHPCCC MHCUHCAMG
AMG CCC CHP MHC UHC
AMG CCC CHP MHC UHC
MHC
AMG CCC CHP MHC
AMG CHP MHCAMG CCC CHP UHC
AMG CCC CHP MHC UHC
CCCUHC
CHP MHCUHC CCC
CCCCHP MHCUHC
CHPMHC
CCCUHC
AMG CCC CHP MHCUHC
CCC CHP MHC UHCAMG
CHP MHCUHCAMG
County enrollment in managed care is voluntary.
Thurston
CCC UHC
AMG CHP MHCCCC
AMG CCC CHP MHC UHC
AMG CCC MHC UHC
AMGMHCUHC
CCCCHP MHCUHC
AMG CCC CHP MHC UHC
CCC, CHP, MHC, UHC
AMG CCC MHC
Division of Developmental Disabilities
• Enrollment in Healthy Options will not impact:– The services you are currently receiving
from DDD– Your case management with DDD– Your eligibility for DDD
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Medicaid Healthcare Services
• Fee for Services • Healthy Options managed care
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Medicaid Managed Care
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• Health Plans must ensure:– Guaranteed access to a Primary Care
Provider– Choice of multiple Primary Care
Providers and Specialists– 24/7 access to a Nurse Advice Line– Coordination of care among providers
and systems of care: for example, between medical and mental health systems
– Prescription coverage
Ensuring plan readiness
• Comprehensive readiness reviews of each health plan• Examination of contractual and quality requirements
• Bi-weekly plan training sessions• Bi-weekly individual health plan meetings• Ad hoc meetings as requested
• Bi-weekly network development assessment
• Agency staff response to plan questions• Review of plan materials
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New Eligible Clients
New population added to managed care: • Categorically Needy SSI Blind and Disabled:
• Medicaid Only• Mandatory Enrollment – must enroll in managed
care unless client meets exemption requirement
• Voluntary enrollment for foster care children• Foster children may enroll but are not required to
enroll
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Exempt from Managed CareMedicaid Only, Blind/Disabled clients will enroll except clients:• Living in institutional settings • Enrolled in Chronic Care Management Programs• Enrolled in the Program of All-Inclusive Care for the
Elderly (PACE)• On hospice• American Indians/Alaska Natives• Enrolled in the Washington Medicaid Integration
Partnership (WMIP)• Enrolled in the Medically Intensive Children’s Program
(MICP)• Third Party Insurance
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Healthy Options enrollment process
• Clients receive:• Notice of enrollment in a health plan and
instructions on how to change plans;• Enrollment Handbook with information about
Healthy Options• Enrollment form
• Enrollments effective the first of the following month: Changes for November 1 can be made until October 30.
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How you can help• Know what to tell clients
• Check eligibility for Healthy Options• Find out which plan(s) each doctor or specialist
contracts with:• Help determine appropriate plan • Help enrolling in or changing plans• Help clients contact providers or plan for help
coordinating care• Report issues to the plan and/or HCA
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Care Management Expectations of Plans
Stronger contractual requirements• To assist new enrollees:
• Rxs written prior to enrollment • Get care from non-par providers or new PCP
• Transitional care requirements to mitigate risk of re-hospitalization/re-institutionalization
• Care coordination with focus on integrated care between physical and behavioral health
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Care Management Expectations
• Intensive Care Management for enrollees with special health care needs (ESHCN)• Identification of ESHCN• Initial Health Screen-Initial Health Assessment• Treatment plans
• Quality Assurance and special programs
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Managed Care Facts
• Enrollees:– May change plans every month – most
don’t– Are allowed to get second opinions
through the plan– New Enrollees: May keep current
prescriptions, care plans and providers for 90 days or until accessed by the new plan
– There is no balance billing; no co-pays for Medicaid clients15
Exemption/Disenrollment
• WAC 182-538-130 currently undergoing revision;
• Requests reviewed on case by case basis by HCA medical consultant
• Clients who contact MACSC will be directed to work with the plan to receive services
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Third Party Insurance
• What is “Third Party Insurance”– Third party insurance provides insurance benefits
comparable to Healthy Options – it may be Medicare, TriCare, or an insurance like Group Health or Premera
• Clients with third party insurance are exempt from enrollment in Healthy Options• Call 1-800-562-3022 ext. 16134
• Monday 7:30 – 4:30• Tuesday – Friday 7:30 – 1:00
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How to Enroll
• Medicaid clients can make plan choices now by using the ProviderOne system
• https://www.waproviderone.org/client
• Call the IVR at 1-800-562-3022
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Health Plan Contact Information
Customer Service: 1-877-542-8997Website: www.uhccommunityplan.com Provider Line - 1-877-542-9231Website: http://www.uhccommunityplan.com/health-professionals
Customer Services: 1-800-600-4441Website: www.amerigroup.comProvider line - 1-800-454-3730Website: http://washington.joinagp.com
Customer Service: 1-800-440-1561Website: www.chpw.orgProvider line - 1-800-440-1561Website: http://www.chpw.org/for-providers/
Customer Service: 1-877-644-4613Website: www.coordinatedcarehealth.com Provider line - 1-877-644-4613Website: http://www.coordinatedcarehealth.com/for-providers/become-a-provider/
Customer Service: 1-800-869-7165Website: www.molinhealthcare.com Provider line - Phone: 1-800-869-7175Website: http://www.molinahealthcare.com/medicaid/providers/wa/Pages/home.aspx
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Questions
• Basic Health and Healthy Options Managed Care• http://www.hca.wa.gov/managed_care
• Healthy Options• http://hrsa.dshs.wa.gov/HealthyOptions/
• Basic Health• http://www.basichealth.hca.wa.gov
• Contact us:• Managed Care mailbox: hcamcprograms@hca.wa.gov
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