Importance of Medicaid

• 2010 Kentucky Medicaid provided coverage to more than 787,000 individuals—approximately 18% of our total population, many whom represent vulnerable populations—the disabled, mentally ill, elderly and children. (1)

• At $32,076 per year, Kentucky’s per capita income is 80% of the national average—ranking Kentucky 47th among the states. Given the fact that Medicaid eligibility is based in part on income, there is strong reliance on Medicaid in Kentucky. (2)

• Medicaid provides approximately $5.4 billion annually to the Commonwealth’s healthcare economy and is important to the revenue stream of many hospitals, nursing homes, pharmacies, physicians, schools and other health care providers. (3)

(1) http://chfs.ky.gov/NR/rdonlyres/20366749-9BD0-4C8D-ABB1-EE0CA807BF30/0/MS264FY2011.pdf(2) http://www.census.gov/compendia/statab/rankings.html(3) http://www.statehealthfacts.org/profileind.jsp?ind=177&cat=4&rgn=19

April 7, 2011Request for ProposalCabinet for Health and Family Services

Timeline

July 7, 2011Gov. Beshear announcesCentene, Conventry & Wellcare selected as MCO’s for Kentucky

????CMS Approval

October 1, 2011Implementation

Must have

Manage Care Organization’s (MCO’s)

Accountable Care Organization’s(ACO’s)

ConventryCenteneWellCare

Family Practitioner’s can only belong to one ACOMoney follows the patientDoes this mean 2/3rd’s of Medicaid patients will leave a practice

PassportBeing ImplementedStatewide(not regional)

Implemented in In Jefferson County since 1997, now 16 counties

Passport Health Plan is a provider-sponsored HMO. The University of Louisville Medical School Practice Association, University of Louisville Medical Center, Jewish and St. Mary's Healthcare, Norton Healthcare Inc., and The Louisville/Jefferson County Primary Care Association (which includes the Federally Qualified Health Centers and The Louisville Metro Department of Health and Wellness) established University Health Care, Inc.

AmeriHealth Mercy manages approximately 1.5 million Medicaid and State Children’s Health Insurance Program (SCHIP) members in eight states including Pennsylvania, New Jersey, Kentucky, Indiana, California, Arizona, Virginia, and South Carolina. AmeriHealth Mercy Health Plan is a healthcare ministry of the Sisters of Mercy in affiliation with AmeriHealth HMO, Inc.

The Plan serves approximately 165,000 members in the Commonwealth of Kentucky, which is comprised of the following 16 counties: Jefferson, Oldham, Trimble, Carroll, Henry, Shelby, Spencer, Bullitt, Nelson, Washington, Marion, Larue, Hardin, Grayson, Meade, Breckinridge.

http://www.passporthealthplan.com/contact/index.aspx

Kentucky Medicaid will use

Auto-Selection to place recipients into

1 of 3 MCO’s

of Kentucky

http://www.kentuckyspirithealth.com/become-a-provider/

http://coventryhealthcare.com/health-care-solutions/medicaid/index.htm

http://kentucky.wellcare.com/

■ CoventryCares of Kentucky, a division of Coventry Health and Life Insurance Co., a subsidiary of Coventry Health Care Inc. Coventry companies provide Medicaid managed-care services in eight states: Florida, Maryland, Michigan, Missouri, Nebraska, Pennsylvania, Virginia and West Virginia. ■ Kentucky Spirit Health Plan, a subsidiary of Missouri-based Centene Corp., which has 27 years' experience managing Medicaid plans. It provides services in 12 other states: Arkansas, Arizona, Florida, Georgia, Illinois, Indiana, Maryland, Mississippi, Ohio, South Carolina, Texas and Wisconsin. ■ WellCare of Kentucky, a part of WellCare Health Insurance of Illinois, which serves 2.2 million members in seven states: Florida, Georgia, Hawaii, Illinois, Mississippi, New York and Ohio.

Physicians Practicing in Kentucky

• Will have to re-credential, even if already credentialed with Kentucky medicaid.

• What happens if a physician is not accepted into these panels?

Federal and State law prohibits discrimination of provider by physician educational preparation or boarding

Part E—Miscellaneous ProvisionsDEFINITIONS OF SERVICES, INSTITUTIONS, ETC.[545]

Sec. 1861. [42 U.S.C. 1395x] For purposes of this title—

(r) The term “physician”, when used in connection with the performance of any function or action, means

(1) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action (including a physician within the meaning of section 1101(a)(7))

Sec. 1101. [42 U.S.C. 1301](7) The terms “physician” and “medical care” and “hospitalization”

include osteopathic practitioners or the services of osteopathic practitioners and hospitals within the scope of their practice as defined by State law.

304.17A-300 Provider-sponsored integrated health delivery network --Qualifications -- Fees -- Network subject to provisions of other subtitles.

(1) A provider-sponsored integrated health delivery network may be created by health care providers for the purpose of providing health care services.

(2) No person shall in this Commonwealth be, act as, or hold itself out as a provider sponsoredintegrated health delivery network unless it holds a certificate of filingfrom the commissioner. Each provider-sponsored integrated health delivery networkthat seeks to offer services shall first be certified by the department.

(3) To qualify as a provider-sponsored integrated health delivery network, an applicantshall submit information acceptable to the department to satisfactorily demonstratethat the provider-sponsored integrated health delivery network: (a) Is licensed and in good standing with the licensure boards for participating providers; (b) Has demonstrated the capacity to administer the health plans it is offering; (c) Has the ability, experience, and structure to arrange for the appropriate level and type of health care services; (d) Has the ability, policies, and procedures to conduct utilization management

activities; (e) Has the ability to achieve, monitor, and evaluate the quality and cost effectiveness of care provided by its provider network; (f) Is financially solvent; (g) Has the ability to assure enrollees adequate access to providers, including geographic availability and adequate numbers and types; (h) Has the ability and procedures to monitor access to its provider network; (i) Has a satisfactory grievance procedure and the ability to respond to enrollees'

inquiries and complaints;

KRS 304.17A-300 Provider-sponsored

Integrated health delivery network

KRS Chapter 446.012 Inclusion of osteopaths within

references to physicians in statutes

446.012 Inclusion of osteopaths within references to physicians in statutes -- Inclusion of Bureau of Osteopathic Specialties within references to American Board of Medical Specialties in statutes.

(1) Any reference in the Kentucky Revised Statutes to "medical doctor," "M.D.," or "physician" shall be deemed to include a doctor of osteopathy or D.O., unless any

of those terms is specifically excluded.

(2) Any reference in the Kentucky Revised Statutes to the American Board of Medical Specialties shall include the Bureau of Osteopathic Specialties, unless either of those terms is specifically excluded.

Effective: July 14, 2000 History: Created 2000 Ky. Acts ch. 413, sec. 5, effective July 14, 2000.

KRS 304.17A-275 Health benefit plan not to discriminate against physician on basis

of degree in medicine or osteopathy.

Notwithstanding any other provision of law, no health benefit planshall discriminate with respect to employment, staff, privileges, or

theprovision of professional services against a physician licensed to practice medicine on the basis of whether the physician holds amedical doctor (M.D.) or doctor of osteopathy (D.O.) degree.

Effective: July 14, 2000 History: Created 2000 Ky. Acts ch. 413, sec. 4, effective July 14, 2000. Legislative Research Commission Note (7/14/2000). Although 2000 Ky. Acts ch.

413, sec. 4, indicated that a new section of KRS Chapter 17A was being created, it is clear from the subject matter of the section that it was intended instead to create a new section of Subtitle 17A of KRS Chapter 304. Under KRS 7.136(1), this manifest

clerical or typographical error has been corrected by codifying the section in Subtitle 17A of KRS Chapter 304.

Any Willing Provider

• Earliest form of state managed care regulation • Permit all providers to participate in the network if they agree

to accept the plan's contract terms, such as payment rates, quality monitoring, and other conditions.

Any Willing Provider Laws

PRO’s• increase patient choice of providers, • reduce patient travel times,• allow local businesses like

pharmacies to compete with big national chains.

CON’s• raise costs by both limiting insurers'

ability to negotiate lower prices in exchange for patient volume and increasing insurers’ administrative costs

• lower quality by reducing opportunities to restrict networks to the highest quality providers.

• Earliest form of state managed care regulation • Permit all providers to participate in the network if they agree

to accept the plan's contract terms, such as payment rates, quality monitoring, and other conditions.

KRS 304.17A-270 Nondiscrimination against provider in geographic coverage area.

A health insurer shall not discriminate against any provider who is located within the geographic coverage area of the health benefit plan and who is willing to meet the terms and conditions for participation established by the health insurer, including the Kentucky state Medicaid program and Medicaid partnerships.

Effective: April 10, 1998 History: Created 1998 Ky. Acts ch. 496, sec. 13, effective April 10,

1998.

AWP law

Kentucky Association of Health Plans, Inc. v. Miller, 71 U.S.L.W. 4259, 538 U.S.

United States Supreme Court upheld two

Kentucky statutes that prohibit health insurers from discriminating against providers who are willing to meet the insurers’ terms and conditions for panel participation.

• MCO’s must have provider lists to the secretary of the cabinet by August 14 2011• Intent doesn’t mean signed contract• Must contact each MCO otherwise you will not be considered

Conventry Health Care, Inc. Kentucky Spirit (Centene) Wellcare656 Chamberlin Avenue 1019 Majestic Drive, Suite 206 http://kentucky.wellcare.com/provider/defaultFrankfort, KY Lexington, KY 40513 (need to fill out letter of intent)

(855) 300-5528 (866) 643-3153 (877) 389-9457