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Managed Care Changes Basic Health and Healthy Options. Alison Robbins Washington State Health Care Authority September 18, 2012. Procurement Process. Conducted in 2011 – 2012 New contracts signed March 2012 Program c hanges implemented July 1, 2012

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managed care changes basic health and healthy options

Managed Care ChangesBasic Health and Healthy Options

Alison Robbins

Washington State Health Care Authority

September 18, 2012

procurement process
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.
healthy options plans for 2012
Healthy Options Plans for 2012
  • Amerigroup/Real Solutions
  • Community Health Plan of Washington
  • Coordinated Care Corporation
  • Molina Healthcare of Washington
  • UnitedHealth Care Community Plan
slide4

AMG CCC CHP UHC

AMG CCC CHP MHC

UHC

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

AMG CHP MHC

CCC

Whatcom

Okanogan

Ferry

Stevens

Pend Oreille

AMG CHP MHC

CHP MHC

UHC

AMG

CHP MHC

UHC CCC

CCC CHP MHC UHC

AMG

Skagit

San Juan

CHPMHC

AMG CCC CHP MHC

Chelan

Clallam

Snohomish

Island

MHC

AMG CCC CHP MHC UHC

Spokane

CCC

CHP

MHC

UHC

Jefferson

AMG CCC CHP MHC UHC

Lincoln

CCC

CHP

MHC

UHC

CCC UHC

CCC

MHC

UHC

Kitsap

AMG CCC CHP MHC UHC

Mason

Grays Harbor

AMG

CCC

MHC

UHC

Douglas

Grant

CHP

CCC

MHC

UHC

AMG

Kittitas

CHP

MHC

UHC

CHP

CCC

MHC

UHC

Adams

Whitman

King

AMG CCC CHP MHC UHC

CCC CHP MHC

UHC

AMG CCC MHC UHC

AMG CCC CHP MHC UHC

Yakima

Pierce

Thurston

Pacific

Lewis

CCC

CHP

MHC

UHC

Franklin

Garfield

AMG CCC CHP MHC UHC

CCC CHP MHC UHC

AMG

AMG CCC MHC

CCC

CHP

MHC

UHC

Benton

Columbia

CCC

CHP

MHC

UHC

CCC

CHP

MHC

UHC

AMG CCC CHP MHC UHC

AMG

MHC

UHC

Wahkiakum

Cowlitz

Skamania

CHP

MHC

CCC

UHC

CCC UHC

Walla Walla

Asotin

Klickitat

CCC

UHC

Clark

CCC, CHP, MHC, UHC

County enrollment in managed care is voluntary.

division of developmental disabilities
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
medicaid healthcare services
Medicaid Healthcare Services
  • Fee for Services
  • Healthy Options managed care
medicaid managed care
Medicaid Managed Care
  • 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
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
new eligible clients
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
exempt from managed care
Exempt from Managed Care

Medicaid 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
healthy options enrollment process
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.
how you can help
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
care management expectations of plans
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
care management expectations
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
managed care facts
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 clients
exemption disenrollment
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
third party insurance
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
how to enroll
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
health plan contact information
Health Plan Contact Information

Customer Services: 1-800-600-4441

Website: www.amerigroup.com

Provider line - 1-800-454-3730Website: http://washington.joinagp.com

Customer Service: 1-800-440-1561

Website: www.chpw.org

Provider line - 1-800-440-1561Website: http://www.chpw.org/for-providers/

Customer Service: 1-877-644-4613

Website: www.coordinatedcarehealth.com

Provider line - 1-877-644-4613Website: http://www.coordinatedcarehealth.com/for-providers/become-a-provider/

Customer Service: 1-800-869-7165

Website: www.molinhealthcare.com

Provider line - Phone: 1-800-869-7175Website: http://www.molinahealthcare.com/medicaid/providers/wa/Pages/home.aspx

Customer Service: 1-877-542-8997

Website: www.uhccommunityplan.com

Provider Line - 1-877-542-9231Website: http://www.uhccommunityplan.com/health-professionals

questions
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