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Presentation to the Society of Hematology Oncology

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  • 1. Michigan Association of Health Plans Rick Murdock Executive Director Michigan Association of Health Plans MICHIGAN SOCIETY OF HEMATOLOGY ONCOLOGY OCTOBER 19, 2009
  • 2. WHO WE ARE
    • The Michigan Association of Health Plans (MAHP) is an industry voice for 19 health care plans
    • Members cover over 2.4 million Michigan residents
      • (Including over 1.1 million Medicaid beneficiaries)
    • Our mission: Advocate for health care that is
      • High quality
      • Affordable
      • Accessible
  • 3.
    • Aetna
    • Assurant
    • CareSource Michigan
    • Grand Valley Health Plan
    • Great Lakes Health Plan/United Health Care
    • Health Alliance Plan
    • Health Plan of Michigan, Inc.
    • HealthMarkets, Inc
    • HealthPlus of Michigan
    • McLaren Health Plan
    • Midwest Health Plan
    • Molina Healthcare of Michigan
    • OmniCare Health Plan
    • Paramount Care of Michigan
    • Physicians Health Plan-Mid-Michigan
    • Priority Health
    • ProCare Health Plan
    • Total Health Care, Inc.
    • Upper Peninsula Health Plan
    Michigan Association of Health Plans
  • 4. WHO WE ARE
    • National leaders in excellence
      • U.S. News & World Report/NCQA rankings show Michigan's health plans among the best in the country
        • 5 of the nation's top 50 commercial plans
        • 4 of the nation's top 25 Medicaid plans
          • (and 11 in the nation’s top 50 Medicaid Plans)
        • 2 of the nation's top 25 Medicare plans
  • 5. HEALTH MAINTENANCE ORGANIZATIONS
    •   Authorized under Chapter 35 of the Insurance Code
      • Specific regulatory responsibilities and obligations
      • Required to provide a comprehensive benefit plan as defined in statute
      • Required to join the financial and delivery aspects of health care through arrangements (contracts) with selected providers
    • HMOs emphasize preventive care, services essential to good health
  • 6. HEALTH MAINTENANCE ORGANIZATIONS
    • HMOs are paid capitation, (per member per month) to deliver benefits described in contracts with purchasers and certificate of coverage
      • Are at 100% risk for coverage
      • Along with benefits negotiated with the purchaser, HMO must also provide mandated HMO benefits contained in Chapter 35
    • HMOs nationally accredited by the National Committee on Quality Assurance (NCQA) via independent auditing process --results of which used by State of Michigan and employers for purchasing decisions
  • 7. HEALTH MAINTENANCE ORGANIZATIONS
    • Annual audited data is collected and forwarded to NCQA for performance purposes and annual rankings (HEDIS data set)
    • Evidence-based practices key to HMO philosophy
      • Demonstrate effectiveness of programs, practices and products
      • Most HMOs participate with the Michigan Quality Improvement Committee (MQIC) to develop common sets of guidelines for providers
  • 8. HEALTH MAINTENANCE ORGANIZATIONS
    • The State of Michigan contracts with HMOs for Medicaid services (over 1.1 million Medicaid beneficiaries), and as option for State active employees and retirees
    • Role of HMOs in the Market Place:
      • Large market (>50 employees)
      • Small market (2-50 employees)
      • Individual Market
      • Medicaid/Medicare
      • Targeted Programs for Michigan’s Uninsured
  • 9. ABOUT 1.1 MILLION UNINSURED IN MICHIGAN
  • 10. WHAT WE HAVE LEARNED IN MICHIGAN
    • Not all Employers and businesses are same
    • Competition works to hold down rates
    • Medicaid is cost-effective option for uninsured
    • Choices are important
      • Our members offer a variety of options
      • Do need to level playing field so all insurers can offer more options
  • 11. What is new for Medicaid Plans in Michigan
    • Medicaid Rebid during FY 09--effective for FY 10 Contracts
    • Some differences in service areas in FY 10--but overall number of plans constant (14)
    • Choice of Plans in more counties
    • MDCH Website for Health Plan by County: http://www.michigan.gov/mdch/0,1607,7-132-2943_4860-41361--,00.html
  • 12. What is new for Medicaid Plans in Michigan
    • The Performance Monitoring Standards
    • Quality of Care
    • Access to Care
    • Customer Services
    • Claims Reporting and Processing
    • Encounter Data
    • Provider File reporting
    • MDCH Website for Performance Issues: (contract & appendices)
    • http://www.michigan.gov/documents/contract_7696_7.pdf
  • 13. What is new for Medicaid Plans in Michigan
    • Continued Requirement on Out-of-network Claims.
    • Out of Network Claims must be paid at established Medicaid fees in effect on the date of service for paying participating Medicaid providers as established by Medicaid policy. If Michigan Medicaid has not established a specific rate for the covered service, the Contractor must follow Medicaid policy for the determination of the correct payment amount
  • 14. Medicaid Plans in Michigan
    • In 2000, the Michigan Legislature enacted MCL 400.111i to allow Medicaid providers to file clean claims with the Commissioner against Medicaid HMOs for timely payment. Ordinarily a clean claim must be paid within 45 days after receipt of the claim by the qualified health plan. A "clean claim" must meet certain criteria set forth in the legislation and must be submitted on form FIS 278 which can be accessed through the website for DLEG's Office of Financial and Insurance Regulation (OFIR). Additional information on clean claims is available at ハ http://www. michigan .gov/cis/0,1607,7-154-10555_12902_35510_36782---,00.html .
  • 15. Michigan Association of Health Plans Questions? www.mahp.org