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Ohio Medicaid Managed Care Program
 

Ohio Medicaid Managed Care Program

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    Ohio Medicaid Managed Care Program Ohio Medicaid Managed Care Program Presentation Transcript

    • Ohio’s Medicaid Managed Care Program
    • Why Managed Care?
      • Access
      • Consumer satisfaction
      • Quality
      • Policy direction supported by various external commissions & reviews
    • History
      • 1978 – First established in Ohio
      • 1980s-1990s – Approaches explored, lessons learned
      • 2000-2006 – ~13 counties; improvements in approach continue
      • 2007 – Statewide expansion completed for CFC & ABD
        • 8 regions
        • Approximately 1.5 million enrollees
    • Managed Care - 2010
      • Current caseload (February data)
        • CFC – 1,404,549
        • ABD – 117,720
      • Expenditures YTD (March data)
        • CFC – $2.73 billion
        • ABD – $1.20 billion
    • Ohio Medicaid Managed Care: Value Added Benefits for Members
      • Preventive health programs and care coordination services
      • Connect members to primary care providers
      • Advice and direction for medical issues via a toll free 24/7 nurse advice line
      • Assistance in accessing services with a dedicated call center and member handbook
      • Special services, like care management, for members with special health care needs
      • Grievance resolution system
      • Expanded provider networks
      • Transportation services, expanded coverage, and member incentives (may vary by plan)
    • Ohio Medicaid Managed Care Quality Strategy
      • Statewide comprehensive plan that incorporates how ODJFS:
        • Monitors managed care plan compliance with state and federal regulations
        • Evaluates and improves services delivered to consumers enrolled in a managed care plan
      • Framework for communicating approach for ensuring timely access to high quality health care.
      • Federal requirement for the state Medicaid agency to have a Managed Care Quality Strategy.
    • MCP Accountability System
      • Robust accountability system for assessing and improving quality of care to managed care consumers
      • Key program domains:
        • Access
        • Administrative Capacity
        • Consumer Satisfaction
        • Quality
      • Performance measures and minimum established standards
      • Incentives and disincentives are used for program compliance and continuous quality improvement
    • Ohio Medicaid Managed Care Quality Strategy - Summary Access Administrative Capacity Consumer Satisfaction Quality
      • Provider Panel Requirements
      • Grievance and Appeal Monitoring
      • Consumer/Provider Complaints
      • MCP 24/7 Nurse Advice Line
      • Access Performance Measures and Standards
      • Compliance Assessment System
      • MCP Reporting Requirements
      • Program Integrity
      • Financial Performance Measures and Standards
      • Data quality
      • Annual Consumer Satisfaction Survey
      • Managed Care Enrollment Center
      • MCP Member Services Lines
      • Prior Approval of MCP Marketing and Member Materials
      • Quality Assessment and Performance Improvement Program
      • Care Management Programs
      • Clinical Performance Measures and Standards
      • Annual external quality review activities
      • Medicaid Medical Directors Meetings
    • Ohio Medicaid Managed Care Quality Strategy – Access Domain
      • Provider Panel
        • Searchable online directory
        • Monitoring of accuracy of information
        • Provider panel standards
      • Grievance/Appeals
        • Access related reviewed by state staff
        • Training on coding
        • Checked for proper coding
    • Ohio Medicaid Managed Care Quality Strategy – Access Domain
      • Consumer/Provider Complaint
        • On-line provider complaint form
      • MCP 24/7 Nurse Advice Line
      • Access Performance Measures & Standards
        • Adults' Access to Preventive/Ambulatory Health Services (HEDIS)
        • Children's Access to Primary Care [CFC only] (HEDIS)
        • Members' Access to Designated PCP
    • Ohio Medicaid Managed Care Quality Strategy Medicaid Managed Care: ABD Population Members’ Access to Preventive/Ambulatory Health Services (HEDIS)
    • Ohio Medicaid Managed Care Quality Strategy – Administrative Capacity Domain
      • Compliance Assessment System
        • 0 – 100 point system
        • Fines increase as points increase
        • At 100 points ODJFS can terminate agreement
        • There are other enforcement tools
      • MCP Reporting Requirements
      • Program Integrity
    • Ohio Medicaid Managed Care Quality Strategy – Administrative Capacity Domain
      • Financial Performance Measures and Standards
        • Prompt Payment
        • Net worth per Member
        • Administrative Expense Ratio
        • Days Cash on Hand
        • Ratio of Cash to Claims Payable
        • Reinsurance
    • Ohio Medicaid Managed Care Quality Strategy – Administrative Capacity Domain
      • Data Quality
        • Encounter Data Volume (utilization measures)
        • Rejected Encounters
        • Acceptance Rate (encounters)
        • Encounter Data Accuracy Studies
        • Incomplete Outpatient Hospital Data
        • Incomplete Data For Last Menstrual Period (CFC)
        • Generic Provider Number Usage
        • Designated PCP for newly enrolled members
        • Timeliness (monthly)
    • Ohio Medicaid Managed Care Quality Strategy – Consumer Satisfaction Domain
      • Annual consumer satisfaction survey
      • Managed care enrollment center
      • MCP Member Services Lines
      • Prior approval of MCP marketing and member materials
    • Ohio Medicaid Managed Care Quality Strategy – Quality Domain
      • Quality and care management programs
        • Submitted annually by MCPs
        • Reviewed internally by clinical staff
        • Subjected to evidence based review by the external quality review organization
      • Performance Improvement Projects
        • Topics: Members with special health care needs, Dental care, and EPSDT Statewide Collaborative
        • Validated by external quality review organization to ensure compliance with CMS protocols
    • Ohio Medicaid Managed Care Quality Strategy – Quality Domain
      • External Quality Review Activities
      • Federal regulations require the state Medicaid agency to contract with an external quality review organization to:
        • Evaluate quality and accessibility of services provided to managed care plan members.
        • Provide information to the state to design appropriate, effective interventions to improve health care quality and access over time.
      • ODJFS contracts with Health Services Advisory Group
    • External Quality Review Activities (cont.)
      • Overview of EQR activities:
        • Evaluation of managed care plan administrative compliance
        • Validation of MCP performance improvement projects
        • Validation of clinical performance measures
        • Encounter data validation/accuracy studies
        • Consumer satisfaction surveys
        • Quality of life surveys
        • MCP Information systems reviews
        • Program evaluations
        • Statewide quality improvement initiatives
    • Ohio Medicaid Managed Care Quality Strategy – Quality Domain
      • Performance Measures
      • CFC Population
      • Care Management
        • Care Management of High Risk Members
        • Care Management of Members
      • Clinical Performance (HEDIS measures)
        • Comprehensive Diabetes Care (CDC)/Eye exam
        • Use of Appropriate Medications for People with Asthma
        • Perinatal care - Frequency of ongoing prenatal care, timeliness of prenatal care, postpartum care
        • Well-Child Visits – First 15 Mos of Life; 3-6 Years; 12-21 Years
        • Annual dental visits
        • Lead screening for 1 Year and 2 Year Olds
    • Ohio Medicaid Managed Care Quality Strategy – Quality Domain
      • ABD Population
      • Care Management
        • Care Management of High Risk Members
        • Care Management of Members
      • Clinical Performance (HEDIS)
        • Persistence of Beta-Blocker Treatment after Heart Attack
        • Cholesterol Management for Patients with Cardiovascular Conditions/LDL-C screening performed
        • Comprehensive Diabetes Care (CDC)/Eye exam
        • Use of Appropriate Medications for People with Asthma
        • Follow-up After Hospitalization for Mental Illness
        • Condition-specific measures: Congestive heart failure, Coronary arterial disease, Non-mild hypertension, Diabetes, Chronic obstructive pulmonary disease, Asthma, Mental Health, Alcohol and Drug
        • Inpatient Hospital discharge rate
        • Emergency Department utilization rate
        • Hospital Readmission
    • Ohio Medicaid Managed Care Quality Strategy – Quality Domain Medicaid Managed Care: CFC Population Frequency of Ongoing Prenatal Care- Percent Who Received 81% of More of Expected Visits (HEDIS)
    • Overview: Ohio’s Managed Care Program Evaluation
      • Evaluation conducted by Health Services Advisory Group
      • Purpose of Program Evaluation:
        • To evaluate the current design of key managed care program areas
          • Performance measures
          • Pay-for-performance
          • Access-monitoring strategies
          • Data quality strategies
        • To assess the extent of regulations in comparison with other state Medicaid managed care programs
        • To make recommendations with the potential to improve program effectiveness, and strengthen the quality strategy.
      • Results and Follow-Up
          • Ohio’s monitoring strategies are robust and align with other state Medicaid managed care programs
          • Implementation of strategies to enhance the above 4 key program areas