Medicare. This will mean that Medicaid programs will create
more payments that provide the physician both with opportunities for bonus payments and with risks for failing to meet
certain quality metrics and cost of care goals. These shared
savings plans may likely be tied to a risk adjustment model as
is the case in Medicare, where a severity of illness burden is
incorporated into the shared savings pool. Alternatively states
may adopt bundled payments for specific episodes of care.
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Physician and Provider Appeals — CMS is proposing accelerating the timelines and improving the ease of appeal of an
“adverse benefit determination” (i.e. a denied service). Medicaid
health plans will be required to follow the Medicare timetable
with an appeal heard within 60 days. The physician may submit
the appeal without having the signature of the Medicaid patient.
The health plan now will have only one level of appeal before
exhausting the health plan’s process. After that, the beneficiary
may request a state level Fair Health Panel. That means that
the managed Medicaid plan cannot cause service delays as it
goes through a series of internal appeals. A new feature would
require health plans to continue the medical service while the
appeal is in process. So if a patient were started on a physical
therapy schedule that was denied an extension, the patient
could, under the proposed rule, continue with the therapy until
an appeal is exhausted. A question raised during the comment
periods was whether a patient whose service was denied on
the front end could initiate that service pending the results of
the appeal. At the time of this writing that question was still
pending resolution.
Member Disenrollment — Currently Medicaid beneficiaries
can disenroll from or enroll in a given Medicaid health plan
on a monthly basis without any reason. Under the proposal,
the member is permitted only one disenrollment for the first
90 days. This is to encourage the member to establish a good
doctor-patient relationship. There will be more support tools
for the beneficiary to help with proper selection of a Medicaid
managed care organization and with understanding their benefits and proper use. This is termed a Beneficiary Support System.
Networks and Credentialing — The definition of a primary
care provider is being expanded to include behavioral health
providers and Long Term Services and Support physicians.
Additionally, Managed Medicaid organizations will have to
recruit enough physicians from various specialties to meet
state-generated network adequacy tests inclusive of distance
and time standards. States retaining any fee for service Medicaid functions will need to perform credentialing of physicians
throughout the state. This may be in addition to the credentialing performed by the managed Medicaid organization.
systems; that consumers and patients will now have input into
the quality review process.
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Encounter Forms and Information Data Exchanges — Physicians seeing Medicaid patients will still be required to submit
encounter data, even if they are participating in a share risk
or capitation payment. These encounter forms are used by
DMS in capturing utilization data. At the same time, CMS
is proposing more incentives to the use of information data
exchanges. This is part of the trends toward greater degrees
of interoperable electronic data use. It is in concert with the
Meaningful Use standards.
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CHIP – In Kentucky, the Children’s Health Insurance Program
is known as KCHIP. The proposed regulations will ensure that
the benefits provided will be comparable to those for children
fully enrolled in Medicaid. In that way, if a family on Medicaid
loses that set of benefits because of employment, and the child
is eligible for CHIP, the family will be provided comparable
benefits. This is especially important for the Early and Periodic
Screening, Diagnostic and Treatment (EPSDT) benefits. CHIP
benefit management will be moving increasingly toward managed care processes rather than under Fee For Service Medicaid.
All of these proposed rules—which have now received all external
comments—will be moving Medicaid and CHIP toward a greater
degree of federalization. Still, the government will continue to allow
state-initiated experimentation with new payment models. States
may enhance benefits to meet unique needs in their state, but may
not reduce benefits from federal standards. Any managed care
entity holding a Medicaid contract can do the same. With this and
the consolidation in the private commercial market, health care
coverage clearly is moving toward a more limited set of models.
Reference:
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Federal Register. Proposed Rule: Medicaid and Children’s
Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and
CHIP Comprehensive Quality Strategies, and Revisions Related
to Third Party Liability. June 1, 2015. https://www.federalregister.gov/articles/2015/06/01/2015-12965/medicaid-and-childrens-health-insurance-program-chip-programs-medicaid-managed-care-chip-delivered Accessed July 19, 2015.
Dr. James is the Chief Medical Officer at Bluegrass Family Health &
Population Health for Baptist Health.
Quality of Care — Currently states are required to approve a
quality plan of each Managed Medicaid organization and have
that plan with its results reviewed annually by an External
Quality Review Organization (EQRO). But under the proposed
rules, this effort will be enhanced by public reporting of quality
metrics; the quality measures now must be aligned with those
of Medicare and ones used in the commercial Marketplace
SEPTEMBER 2015
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