This document provides an overview and summary of a presentation on planning for success in the transition to Medicaid managed care. The presentation covers the growing trend of states transitioning Medicaid programs to managed care, challenges with integrating high-needs populations, lessons from early adopters, and how providers can plan for success. Key points include that over 70% of Medicaid enrollees are now in managed care plans, states are using managed care to improve outcomes, control costs and test new payment models, and providers should engage with plans, understand contracting and billing requirements, and document any issues that arise.

1. Planning For Success in the Move to Managed Care
Key Considerations for Providers
January 16, 2019
Melinda Dutton| Partner
Manatt Health
mdutton@manatt.com

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Overview of Today’s Agenda
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National Medicaid Managed Care Landscape
Integration of High Needs Populations into Managed Care
What Can We Learn from Early Adopters?
How Providers Can Plan for Success
Questions

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National Medicaid Managed Care Landscape

4. 4
Medicaid Managed Care Continues to Grow
States are increasingly delivering Medicaid benefits through managed care,
both in terms of spending and number of lives.
28%
43%
FY 2013 FY 2016
Medicaid Spending Attributable to
Payments to MCOs, FY 2013 vs. 2016
Medicaid Managed Care Enrollment as a Share of
Total Medicaid Enrollment, 2008-2016
Sources: www.kff.org/medicaid/state-indicator/total-medicaid-mc-enrollment;
www.kff.org/medicaid/issue-brief/data-note-medicaid-managed-care-growth-and-implications-of-the-medicaid-expansion/#footnote-214747-1
70.9%
71.7% 71.5%
74.2% 73.5%
77.0%
80.1%
81.1%
2008 2009 2010 2011 2013 2014 2015 2016

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The Shift to Managed Care
States are choosing to pursue managed care for a number of reasons,
including to improve outcomes and manage costs.
State budget predictability
Accountability for cost and outcomes
Increase access to primary care
Leverage plan resources and capacity to:
 Enhance care coordination and management
 Advance state quality priorities
 Test new payment models tied to value
Special plans for high need enrollees also allow States to integrate and tailor
services, and strengthen the delivery system for special populations

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Most VBP arrangements
to date have focused on
hospitals and large
systems.
Alternative payment
models for BH and I/DD
providers and services
are just beginning to
emerge.
States Using MCOs to Drive Value-Based Purchasing
New York’s DSRIP waiver requires 80-90% of managed care
payments to providers to be paid via VBP by 2020
Arizona sets specific Alternative Payment Methodology
(APM) targets for each of its managed care programs
States increasingly are requiring or encouraging MCOs to adopt VBP arrangements.
New Hampshire withholds 1% of each MCO’s capitated
payments until MCO can prove it has achieved certain
payment reform milestones
Minnesota requires MCOs to share savings with ACO-like
provider organizations (called Integrated Health
Partnerships)
Virginia created "super quality incentives" by aligning
Medicaid MCO incentives with the largest commercial
plan on 10 quality metrics
Source: Analysis conducted by Manatt Health: www.manatt.com/Insights/Newsletters/Manatt-on-Health-Medicaid-Edition/Leveraging-Medicaid-
Managed-Care-to-Advance-Value#Article1

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Capitated Managed Care Across the Country
38 states already contract with comprehensive risk-based managed care
plans; North Carolina is next.
California
Nevada
Arizona
Utah
Idaho
Montana
Wyoming
MaineVermont
New
York
North Carolina
South
Carolina
Alabama
Nebraska
Georgia
Mississippi
Louisiana
Texas
Oklahoma
Pennsylvania
Wisconsin
MinnesotaNorth
Dakota
Ohio
South Dakota
Kansas
Iowa
Illinois
Indiana
Tennessee
Missouri
Delaware
New Jersey
Connecticut
Massachusett
s
Virginia
Maryland
Rhode Island
Hawaii
New Hampshire
Alaska
West
Virginia
Colorado*
New Mexico
Oregon
Washington
Michigan
Arkansas
Kentucky
DC
Capitated MCO Programs
(38 states including DC)
Does not contract
with MCOs (12 states)
Florida
Capitated MLTSS Programs
(18 states)
Sources: Adapted from www.kff.org/medicaid/report/key-findings-on-medicaid-managed-care-highlights-from-the-medicaid-managed-care-market-tracker/;
kff.org/report-section/rebalancing-in-capitated-medicaid-managed-long-term-services-and-supports-programs-introduction/
*About 10% of Medicaid beneficiaries in Colorado are enrolled in a small capitated managed care pilot for physical health services.

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 Dual-eligible beneficiaries
 Beneficiaries with serious mental illness
 Beneficiaries with substance abuse disorders
 Developmentally disabled beneficiaries
 Behavioral health services
 Pharmacy
 School-based health center services
 Long-term services and supports (LTSS)
 Permanent placement in nursing homes
 Hospice care
 Personal care services
 Home health services
 Waiver services (e.g. 1915(b) and (c) waivers)
New Populations and Services Under Managed Care
States are expanding the use of managed care to cover high-need,
high-cost beneficiaries and new benefits.
Populations
Services
Sources: http://files.kff.org/attachment/Report-Results-from-a-50-State-Medicaid-Budget-Survey-for-State-Fiscal-Years-2017-and-2018;
www.medicaid.gov/medicaid/managed-care/downloads/ltss/mltssp-inventory-update-2017.pdf
In FY 2017, inpatient mental health and inpatient/
outpatient SUD services were carved in in 26 of 38
managed care states
In 2017, 24 states provided LTSS services through
a managed care (MLTSS) plan
In FY 2017 and FY 2018, 14 states took action to
carve in new behavioral health services (or plan
to do so)

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Integration of High Needs Populations into Managed Care

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Fully integrated specialty product with enhanced benefit
package for certain high need BH and/or I/DD enrollees
Fully integrated specialty product with enhanced benefit
package for certain high need BH and/or I/DD enrollees
Carve-out fee-for-service (FFS)
Carve-out behavioral health organization (BHO)
Focus on High-Needs/High-Cost Populations:
State Approaches to Behavioral Health and Managed Care
MCOs provide both physical and behavioral health services to
enrollees; MCOs may subcontract with BHOs
MCOs provide both physical and behavioral health services to
enrollees; MCOs may subcontract with BHOs
Integrated
Specialty Plan for
Certain Enrollees
Integrated
Specialty Plan for
Certain Enrollees
Behavioral Health
“Carve out”
Behavioral Health
“Carve out”
“Carve-In”“Carve-In”
Hybrid ModelHybrid Model A mix of the above

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Examples from Other States:
Specialty Plans for Beneficiaries with Significant BH Needs
Arizona
 In 2014-2015, Arizona launched integrated
specialty plans covering physical and BH
services for adults with SMI
 Goal was to improve poor care
coordination and outcomes for this
population
 Other enrollees have been receiving
physical health services through standard
MCOs, and BH services through separate
BH plans
 The State launched eight integrated MCOs
to deliver BH and physical health services
to most other Medicaid enrollees
Statewide in late 2018
New York
 In 2015-2016, New York integrated all adult
Medicaid BH services into mainstream
MCOs
 NY also launched special integrated Health
and Recovery Plans (HARPs) for adults with
significant BH needs
 HARPS offer physical, behavioral, and
HCBS services
 Only mainstream plans can apply to be
HARPs, but not all mainstream plans
operate HARPs
 HARPs function as separate lines of
business
 Care management for all HARP enrollees
is offered through Health Homes
Sources: www.azahcccs.gov/AHCCCS/Initiatives/CareCoordination/behavioralhealth.html, www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Waivers/1115/downloads/az/Health-Care-Cost-Containment-System/az-hccc-pa-behavioral-health-integration-request-02262014.pdf;
www.azahcccs.gov/shared/News/PressRelease/AHCCCSAwardsContractstoManagedCareOrganizations.html; www.health.ny.gov/health_care/medicaid/redesign/behavioral_health

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State Approaches to Intellectual/Developmental Disabilities (I/DD)
Services & Managed Care
At least eleven states currently enroll or plan to enroll the majority of individuals
with I/DD into managed care, using various approaches; other states enroll a more
limited segment of the I/DD population into managed care*
*Pennsylvania offers a fully integrated comprehensive benefit to 158 adults with autism residing in four counties. Missouri enrolls a limited number of individuals
with I/DD who are in adult I/DD waivers into managed care.
Sources: http://www.nasuad.org/initiatives/tracking-state-activity/state-medicaid-integration-tracker;
www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/idd/docs/sipspl_qual_doc_with_attachments_final_draft_for_public_comment_8_3
1_18.pdf; https://www.azahcccs.gov/AHCCCS/Initiatives/AHCCCSCompleteCare/; https://www.dhs.wisconsin.gov/familycare/benpackage.htm
Iowa, Kansas and
New Jersey
I/DD population enrolls in the same comprehensive managed care plans as other Medicaid populations
Plans in Iowa and Kansas cover I/DD waiver services, while New Jersey carves waiver services out
Arizona, New York
(Future) and
Tennessee
I/DD population enrolls in specialized comprehensive managed care plans focused on I/DD population
Plans cover I/DD waiver services
NY recently announced plans to transition its I/DD population and waiver services to comprehensive
managed care plans focused on the I/DD population beginning in 2019
Wisconsin Populations with long-term care needs, including I/DD population, obtain long-term services and supports
(LTSS) via MLTSS limited benefit plans
Plans cover I/DD waiver services, LTSS, and some outpatient mental health and substance abuse services
Virginia Populations with long-term care needs, including I/DD population, enroll in comprehensive managed care
plans focused on LTSS populations that provide physical health services, BH services, and LTSS
I/DD waiver services are carved out
Michigan and
North Carolina
(Current)
Most populations, including I/DD population, enroll in regional BH limited benefit plans for BH and I/DD
services
Plans cover I/DD waiver services
Arkansas (Future)
and North Carolina
(Future)
Beginning in 2019 and 2021, populations in Arkansas and North Carolina, respectively, with I/DD and
intensive BH needs will enroll in specialized comprehensive managed care plans that provide physical, BH
and LTSS services

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Examples from Other States:
Specialty Plans for Beneficiaries with I/DD Needs
 Tennessee offers a special MLTSS program for
adults and children with I/DD
 Enrollment is capped and voluntary;
enrollment in 1915(c) I/DD waivers closed
upon launch
 Program provides acute care, BH, and a range
of family support, employment, and
community living services depending on age
and acuity
 Program was designed to address:
 Fragmentation between physical, BH,
and LTSS services
 Long waiting list for I/DD waivers
 Insufficient employment opportunities
 Wisconsin has a voluntary MLTSS program for
adults with physical or I/DD needs and frail
elders
 Services include adaptive aids, adult day care,
assistive technology/communication aids, daily
living skills training, and more
 Acute care services are covered through
Medicaid FFS and/or Medicare
 Qualifying adults can enroll instead in the
state’s HCBS waiver for self-directed long-term
services and supports
 The state also operates a fully integrated plan,
including Medicare, frail elderly adults and
adults with disabilities, including dual eligibles
 State considered integrating acute and primary
health care services into the program in 2017,
but has not done so to date
WisconsinTennessee
Sources: www.eiseverywhere.com/file_uploads/5f32b2243b39ac100eabd153b9680876_LastFrontier.pdf;
www.tn.gov/content/dam/tn/didd/documents/news/2017/waiver-reform/Amendment_27_ECF_CHOICES.pdf, Wisconsin Family Care 2018 Contract

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What Can We Learn from Early Adopters?

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Lessons Learned from Early Adopters
Build a system, not just a plan.
Conduct a robust stakeholder engagement process
Ensure appropriate policies are in place to minimize and mitigate care disruptions
Tailor program features to reflect the unique needs of the population
Invest in building provider infrastructure and capacity
Anticipate challenges – and be prepared to respond
Go slow and be methodical - enrolling individuals with I/DD and BH in
managed care should be approached with great care.
Intensive planning, targeted programmatic protections, and close collaboration
with families and providers is critical to ensure plans are prepared to meet the
needs of this population.

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How Providers Can Plan for Success

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Planning for Provider Success in Managed Care
Be an active partner.
Consider attributes that make providers attractive to plans in contracting process:
 Respected in the community for quality and integrity
 Breadth of services
 Electronic/IT capability
 Solid reputation with regulators
 Measurable quality outcomes
 Geographic reach
Educate your staff on the “bigger picture” of comprehensive managed care to
ensure a positive experience for beneficiaries and for your team
Maintain an open dialogue and feedback loop, communicating proactively with
the State and plans

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Get the technical details right.
Billing
Contracting
Planning for Provider Success in Managed Care
Know what is required to submit each claim, including the timeframe and the claim
submission process for each plan
Engage in claims testing with each plan prior to billing for services rendered to
ensure that IT systems are functioning properly
Understand each plan’s minimum requirements and be prepared to negotiate
Documenting
Understand how to navigate each plan’s authorization, utilization review, and appeals
processes
Ensure that documentation captures the information needed to effectively
communicate with the plans and complete required reporting
Document issues as they arise to help regulators and plans with real time monitoring
and improvements

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Questions?
Thank You!
Melinda Dutton| Partner
mdutton@manatt.com
Presentation developed by: