arkansas organized care model 10, 2017 · what is a passe? • the provider-led arkansas shared...
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ArkansasOrganizedCareModel
AProvider’sJourneyintoAPASSEOctober,2017
WhatisaPASSE?• TheProvider-LedArkansasSharedSavingsEn5ty(PASSE)isanewmodelof
organizedcarecreatedbyAct775of2017.Providerswillenterintonewpartnershipswitheachotherandanexperiencedorganiza5onthatwillperformtheadministra5vefunc5onssimilartoinsurancecompaniessuchasclaimsprocessing,memberenrollment,andgrievancesandappeals.
• Providerswillretainmajorityownership(atleast51%)ofeachPASSE.UnderAct775,thegoverningbodyofeachPASSEmustincludeseveraltypesofproviderslicensedorcer5fiedtodeliverservicesinArkansasincludingaDevelopmentalDisabili5esServicesspecialtyprovider,aBehavioralHealthServicesspecialtyprovider,ahospital,aphysician,andapharmacist.
• ThePASSEistheen5tythatwillberegulatedbytheArkansasInsuranceDepartment(AID)asarisk-basedproviderorganiza5on.ItwillalsobeaccountabletotheDepartmentofHumanServices(DHS)underfederalmanagedcarerulesthatprovideprotec5onsforMedicaidbeneficiaries.BeginningJanuary1,2019,eachPASSEwillpayforallservices,nototherwiseexcludedinAct775providedtoitsmembersandperformotheradministra5vefunc5ons,verysimilartoaninsurancecompany.
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WhataretherequirementsforbecomingaPASSE?• PASSEsareanewMedicaidprovidertypeunderSec5on1915(b)authorityapprovedbytheCentersforMedicare&MedicaidServices(CMS)
• EachPASSEwillberequiredtohavecoverageofservicesfortheen5restate
• Tobecomelicensed,aPASSEapplicantmustmeet3requirements:1)demonstratetheabilitytoestablishnetworkadequacy;2)providea$250,000suretybond;and,3)meeta$6millioncapitalreserverequirement
• Anaddi5onalamountofreservesmayberequiredbyAIDbasedontheriskassumedandtheprojectedliabili5es
• PASSEswillberegulatedbyAIDasatypeofinsuranceandwillbeaccountabletoDHSthroughthePASSEagreementaswellasthePASSEprovidermanualandfederalMedicaidmanagedcarerules.
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WhichMedicaidEnrolleeswillbeservedbyaPASSE?• ARMedicaidbeneficiarieswho:
• Haveadevelopmental/intellectualdisability(DD/ID)andweredeterminedinneedofins5tu5onallevelofcare
• Haveabehavioralhealth(BH)condi5onandhavereceivedanindependentassessmentthatdeterminedtheneedforanintensivelevelofcommunity-basedorresiden5altreatmentservices
• Onlyindividualsrequiringintensivelevelsofcarewillbemandatorymembersofthisnewmodelofcoordinatedcare.
• Individualswillini5allybeaaributedintoaPASSEbasedontheirrela5onshipswithprovidersbutwillhaveachoicetoswitchtoadifferentPASSEwithin90days.AnindividualwillhavetheirchoiceofPASSEseachyear. 4
PurposeofModel• TheprimarypurposeofAIDandDHSregulatoryrolesistoprotecttheinterestsoftheconsumer/beneficiary
• ToimprovethehealthofArkansanswhoneedintensivelevelsofspecializedcareduetobehavioralhealthissuesordevelopmental/intellectualdisabili5es
• Tolinkprovidersofphysicalhealthcarewithspecialtyprovidersofbehavioralhealthanddevelopmental/intellectualdisabili5esservices
• Tocoordinatecareforallcommunity-basedservicesforindividualswithintensivelevelsofspecializedcareneeds
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PurposeoftheModel(continued)• Toreduceexcesscostofcareduetoover-u5liza5onandunder-u5liza5onofappropriatecare
• Toallowflexibilityinthearrayofservicesofferedtothepopula5onserved
• Willreducecostsbyorganizingcare,notjustbymanagingfinances
• Toincreasethenumberofserviceprovidersavailableinthecommunitytothepopula5oncovered
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PASSEPhases
• PhaseI--February1,2018-December31,2018• EachPASSEprovidescarecoordina5ononlyusingthePrimaryCareCaseManagement(PCCM)model
• PhaseII–BeginsJanuary1,2019• EachPASSEwillreceiveaglobalpayment,beresponsibleformemberstotalcostofcare,andacceptfullriskusingtheManagedCareOrganiza5on(MCO)model
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PhaseI
• CareCoordina5on–IstobeprovidedbythePASSEwhichwillberesponsibleforthecoordina5onofcareacrossmul5plesystems,includingBH,DD/IDandMedicaltreatment
• Allotherserviceswillcon5nuetobeprovidedonafeeforservicebasis
• Beneficiarieswillcon5nuetoaccesstreatmentservicesdirectlyfromcommunityprovidersandproviderswillcon5nuetheircurrentrela5onshipwithARMedicaid
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January1,2019,thePASSEwilltakeoverallabovefunc=ons.
ResponsibilitiesofPASSEinPhaseI• Ensuringeverymemberhasamedicalhome
• Ensuringeachmember’smul5pleplansofcarearebeingmet
• Organizingaformalnetworkofprovidersincludingindependentprimarycarephysicians,independentphysicianspecialists,BHproviders,Pa5entCenteredMedicalHomes(PCMH),FederallyQualifiedHealthCenters(FQHCs)RuralHealthCenters(RHCs),pharmacists,andDD/IDproviders
• Ensuringeverymemberreceivesthemedicallynecessaryservicesinhis/herplanofcare
• Providingcarecoordina5onforeverymember9
CareCoordina5onassistsadultsandchildrendeveloppersoncenteredplansandfacilitatesaccesstoneededservicesacrossmul5plesystems.ThePASSEwillberesponsibleforcoordina5ngthecareofaaributedbeneficiariesacrossthesemul5plesystems.
CareCoordination
CareCoordina=on
HealthEduca=on
SpecialtyServices
Medica=onmanagement
Preven=veServices
Medical-HealthServices
CareCoordinationIncludes
• Healtheduca5onandcoaching• Coordina5onwithotherhealthcareprovidersfordiagnos5cs,ambulatorycareandhospitalservices
• Assistancewithsocialdeterminantsofhealth,suchasaccesstohealthyfoodandexercise
• Promo5onofac5vi5esfocusedonthehealthofapa5entandtheircommunity,includingwithoutlimita5onoutreach,qualityimprovementandpa5entpanelmanagement
• Coordina5onofcommunity-basedmanagementofmedica5ontherapy
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PhaseII
• BeginningJanuary1,2019,eachPASSEwillreceivea“globalpayment”fromDHS.
• TheGlobalPaymentwillbeanactuariallysoundpaymenttocovertheen5recostofcareofallnon-excludedservicesprovidedtoallofthemembersofaPASSE.
• Thiscalcula5onwillincludethecostofprovidingallservices,includingbutnotlimitedto,DD/IDandBHspecialtyservices,primarycareofficevisits,hospitaliza5ons,personalcareservices,andpharmaceu5calservices.
• ItincludesanyservicesaPASSEoffersinaddi5ontothemandatoryandop5onalservicescoveredbyMedicaidstateplanandapplicablewaiverservices.
• Itwillincludepaymentforcaremanagementandcarecoordina5on.
• Itwillincludeareasonablecosttocoveradministra5veexpenses.12
ResponsibilitiesofPASSEPhaseII
• DevelopmentofacareplanbasedonresultsreceivedfromtheIndependentAssessment
• Developmentandimplementa5onofconflictfreecasemanagement
• Sharing5melyinforma5onanddatawithaffiliatedproviders,members,andfamilymembersasappropriate
• Repor5ngnecessarydatatoensureaccountabilityandmeasureperformance
• Centralizedadministra5vefunc5onssuchas:processclaims,networkadequacy,memberenrollmentandsupport,performancemeasurement,anddevelopmentofop5onalincen5vepaymentstonetworkmembers 13
QualityIncentivePool
• Inaddi5ontotheGlobalPayment,eachPASSEwillbeeligibletoreceiveincen5vepaymentsundertheQualityIncen5vePool.
• PaymentsfromthePoolwillbebasedonoutcomemeasures,notprocesses,forexamplemedica5onadherencera5osgreaterthanbaseline,reduc5onsinuseofemergencyroomcareforAmbulatorySensi5veCondi5ons,andreduc5onsininpa5entlengthsofstay.
• Willbedata-driven,therefore,mustbemeasurableandreportable.
• Mustbeassessedagainstbaselinedata.
• Specifictochildrenandadults,inTierIIandTierIIIBHandDD/ID
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WhatServicesareCovered?ArkansasMedicaidMandatoryServices• HospitalServices–Inpa5entandOutpa5ent
• PhysicianServices
• LaboratoryandX-Ray
• ChildHealthServicesEarlyandPeriodicScreening,DiagnosisandTreatment(Under21)
• RuralHealthClinic
• NursePrac55oner
• HomeHealthServices
• FederallyQualifiedHealthCenters
• FamilyPlanningServicesandSupplies
• Cer5fiedNurseMidwifeServices15
CoveredServicesContinuedOp=onalServicesThereare38op5onalservices
• Includingbehavioral,developmental,homeandcommunity-basedservicesforthecoveredpopula5on
Examplesinclude:DDTCS/CHMS,OT,PTorSpeechTherapy
• Includingspecifictypesofproviders,medicalsuppliesandequipment
Examplesinclude:podiatrists,chiropractors,prescrip5ondrugs,audiologists,privatedutynurses,ordurablemedicalequipment 16
WhichServicesareExcluded?• Nonemergencymedicaltransporta5on• Dentalbenefits• School-basedservicesprovidedbyschoolemployees
• Skillednursingfacilityservices• Assistedlivingfacilityservices• Humandevelopmentcenterservices
• Waiverservicesprovidedtoadultswithphysicaldisabili5esthroughtheARChoicesinHomecareprogramortheARIndependentChoicesprogram
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WhattypeofproviderswilljoinaPASSENetwork?• Alltypes.• ArkansasMedicaidhasmorethan47,000enrolledprovidersincluding:• Over9,600physicians• Nearly3,300occupa5onal,physical,andspeechtherapyserviceproviders
• Morethan1,300aaendantcareproviders
• Over900pharmacies
• Morethan450hospitals
• APASSEWILLNEEDALLOFTHESETYPESOFPROVIDERSANDMORE 18
Asaprovider,whataremyoptionsforparticipationinaPASSE?
1.Themajorityofproviderswill simply joinaPASSEasapar=cipa=ngprovider in thePASSEnetworkofproviders.Just as in becoming a par=cipa=ng provider for aninsurancecompany, theseproviderswill agree tobepaidto deliver a service to a client/pa=ent under the rulesestablishedbythePASSE.2.SomeprovidersmayjoinaPASSEunderasharedsavingsfinancial arrangement. This higher level of commitmentmightincludereceivingvalue-basedincen=vepaymentsorsharedsavingsbonusesaswellasbeingpaidtoprovideadirectservice.3. A small number of providerswill help form the PASSEitself as equityowners in thePASSE. APASSEmayofferdifferentclasses(shares)ofequity.
THEDECISIONASTOHOWYOUWILLPARTICIPATEISUPTOYOU 19
AmIlimitedtothenumberofPASSEnetworksinwhichIcanparticipate?
No.
Muchlikeinsurancecompaniesdevelopnetworks,eachPASSEwilldevelopitsnetworksofprovidersaswell.
AproviderwilllikelywanttobeanetworkproviderinallPASSEstoensurethatthereisacon5nuumofcoverageforthebeneficiariesthatitserves.
APASSEwillberequiredoperateonastatewidebasisandtomeetfederalandstatenetworkadequacystandards.ThereforeeachPASSEwillneedawideanddeeppoolofproviders.
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CanIbeexcludedasaNetworkProvider?• No.TheArkansasAnyWillingProviderprotec5onswillapplytothePASSE.
• IftheprovideriswillingtoacceptthetermsofthePASSE,andisaqualifiedlicensedorcer5fiedproviderofservices,theprovidercannotbeexcludedfrompar5cipa5oninthePASSEnetworkofproviders.
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ShouldIInvestinaPASSE?• Inves5nginaPASSEasanequityownerisen5relyyourdecision.
• APASSEisaprivatebusinessventure.Areturnoninvestmentisnotguaranteedbyanygovernmentagency.
• DHSdoesnotrequireyoutoinvestinaPASSEinordertojoinaPASSE’sprovidernetwork.
• IfaPASSErequiresyoutoinvestinordertojoinitsnetwork,youmaywishtoconsiderotherPASSEswhichdonot.Howmuchriskyouarewillingtotakeisuptoyou.
• TheequityinterestofaproviderinaPASSEisnotafactorintheDHSaaribu5onmethodology.
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AmIRequiredtoJoinaPASSEExclusively?• No.Nothinginthestatuteorregula5onsrequiresyoutoofferyourservicesexclusivelytoasinglePASSE.
• Exclusivityisabusinessdecisionforyoutomake.
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WheredoIsubmitmyclaimsforpayment?• Fortheremainderof2017andcalendaryear2018,youwillsubmitallclaimsthroughDHSjustasyoudotoday.
• In2019,asthePASSEassumesfullrisk,claimsforTierIIandTierIIIclientswillbesubmiaedtothePASSEforpayment.ForTierIbeneficiarieswhodonotopttojoinaPASSE,youwillcon5nuesubmiqngclaimstoDHS.
• Beginningin2019,thePASSEwillnolongerbe5edtotheFFSratesorservices;therefore,youwillnego5ateyourratesforservicesprovidedtotheTierIIandTierIIIbeneficiarieswiththePASSE.ThiswillofferanumberofbenefitstoproviderswhowillnolongerbeconfinedtoMedicaidFFSrules.
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StatusofPASSEApplicantsasof10/24/17• TobecomelicensedbyAID,anen5tymustmeetthefinancialrequirements
underAct775anddemonstratetheabilitytoestablishanadequatemedicalservicedeliverynetwork.
• Threeorganiza5onshavebeenlicensedbyAID:• ArkansasAdvancedCare• ArkansasTotalCare• Empower
• OtherPASSEapplicantshavetheopportunitytoupdatetheirprovidernetworkseverymonthinordertodemonstratenetworkadequacy.
• Upda5ngprovidernetworksserves2purposes—firsttodeterminenetworkadequacyinordertoobtainalicensefromAID.
• Second,onceaPASSEislicensed,theprovidernetworkwillbeusedtomatchaclienttohis/herproviderstodeterminewhetherthereisastrongrela5onshipbetweenaMedicaidbeneficiaryandproviders.DHSwillthen“aaribute”thememberstoeachlicensedPASSE.TheDHSaaribu5onmethodologyisweightedtowardDDandBHspecialtyproviders.
• IfaMedicaidbeneficiaryisnotsa5sfiedwiththePASSE,he/shemayswitchtoanotherPASSEwithin90days.
• EachPASSEmustcon5nuouslymaintainanadequatenetworkofalltypesofproviders.
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LicensedPASSEs• Contactinforma5on:• ArkansasAdvancedCare
• USABLEHMOInc.• [email protected]• 320WCapitolAve,Ste.211LialeRock,AR72201
• ArkansasTotalCare • ARHealthandWellnessHealthPlan• [email protected]• 1AlliedDrive,Ste.2520LialeRock,AR72202
• Empower• BeaconHealthOp5onsInc.• [email protected]• 400W.CapitolSuite1711LialeRock,AR72201
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PASSEApplicants• ArkansasProviderCoali5on
• AmerigroupPartnershipPlanLLC
• ShaneSpoas [email protected]
• 1010WThirdStreetLialeRock,AR72201
• ForevercARe• GatewayHealthplan• [email protected]
• 444LibertyAve,Ste.2100Piasburgh,PA15222-1222
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PASSEApplicantsLicensureTimeline• Thereisno“final”deadlineforaPASSEtobecomelicensedinstatefiscalyear2018.
• However,DHSwillaaributeMedicaidbeneficiariesonlytolicensedPASSEs.
• Approximatelyone-thirdofthecurrentbeneficiarieswillbeaaributedbasedonprovidernetworkssubmiaedbyJanuary15,2018.
• LicensedPASSEswillberesponsibleforcarecoordina5onofitsmembersbeginningFebruary1,2018.
• Approximately60percentofthecurrentbeneficiarieswillbeaaributedbasedonprovidernetworkssubmiaedbyMarch15,2018.
• BeginningApril1,2018eachPASSEmustbepreparedtodemonstrateitsreadiness“forprovisionofhealthcareservices…”whichwillbebasedonitsnetworkofproviderswhichareenrolledasMedicaidproviders.
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