Medicaid Managed Care Regulations

Silvia Rodriguez-Sánchez

Erika Cristo

Discussion Overview

• Background

• MMC Regulations Technical Areas

• DMH Implementation Process

• DMH Communication with CMS

• Beneficiary Problem Resolution Processes– Title 9, CCR, §1850.205– Title 42, CFR, §438, Subpart F

Background

• Medicaid is a joint Federal and State health care program

• States have flexibility in administering their Medicaid programs

• DHS administers California’s Medicaid program: Medi-Cal

• DMH administers California’s Medi-Cal Managed Mental Health Care Program

Background, Cont.

• The Balanced Budget Act (BBA) of 1997 allowed States greater flexibility in administering their Medicaid programs

• CMS published the MMC Final Rule on June 14, 2002 to implement the provisions of the BBA

• The MMC regulations compliance due date was August 13, 2003

Background, Cont.

• County Mental Health Plans (MHPs) are considered Prepaid Inpatient Health Plans (PIHPs)

• MHPs must comply with MMC regulations that apply to PIHPs

• DMH must comply with MMC regulations as the administrator of the Medi-Cal managed mental health care program for California

MMC Technical Areas

• Information Requirements

• Beneficiary Rights and Protections

• Emergency and Post-Stabilization

• Availability of Services

• Assurances of Adequate Capacity and Services

• Authorization of Services

MMC Technical Areas, Cont.

• Provider Selection• Practice Guidelines• Quality Assessment and Performance

Improvement Programs• External Quality Reviews• Health Information Systems• Grievance and Appeals Systems• Program Integrity

Regulations Text

The full text of the MMC regulations is available on the CMS website:

http://www.cms.gov/medicaid/managedcare/cms2104f.asp

DMH Implementation Process

• Detailed analysis of proposed regulations

• Participation in CMS’ public comment period

• Waiver Requests

• Internal Workgroup

DMH Implementation Process, Cont.

• California Mental Health Directors Association (CMHDA) Workgroup – Biweekly Meetings

• Client Family Member Task Force (CFMTF) Workgroup – Biweekly Meetings

• Joint CMHDA/CFMTF – Meetings as needed

DMH Implementation Process, Cont.

• Proposed contract language to stakeholders for review and comment

• DMH/MHP contract amendments in December 2003

• Information notices and letters as needed to provide clarification in implementing MMC regulations

DMH Communication with CMS

• California did not meet the 8/13/03 deadline primarily due to resource shortages

• DMH is making a good faith effort to comply as quickly as possible

• DMH is in frequent contact with CMS

Beneficiary Problem Resolution Processes

Grievances and Appeals

Title 9, CCR, Section 1850.205 (Problem Resolution Processes)

Beneficiary files complaint(may be oral or in writing)

with the MHP

MHP informs beneficiary ofright to use the grievance

process or request a SFH,before, during, or after the

complaint process has begun

MHP informallyinforms

beneficiary ofdecision

End of complaintprocess

Beneficiary filesgrievance (in

writing) with MHP

MHP logsgrievance withinone working day

of receipt

MHP conducts 1stlevel grievance

review

MHP decides on grievance andnotifies beneficiary of decisions andright to appeal to the 2nd level ofreview and to request a SFH if the

beneficiary disagrees with he decision,instead of, before, during, or after

filing the grievance at the 2nd level ofreview

Problem resolvedto beneficiary'ssatisfaction?

Beneficiaryrequests 2nd level

of review

MHP decides on grievanceand notifies beneficiary of

decision and right to requestSFH if the beneficiary

disagrees with the decision(decision-maker is at MHP

discretion)

Problem resolvedto beneficiary'ssatisfaction?

Beneficiary maypursue SFH

End of grievanceprocessNo

No

Yes

Yes

TIMEFRAMES

COMPLAINTS must be resolved as quickly as possible.

GRIEVANCES must be resolved within 30 calendar days at each level of review. A grievance resolution could take up to 60 calendar days if it went through both levels of review.

Title 42, CFR, Section 438, Subpart F (Grievances)

Beneficiary filesgrievance (orallyor in writing) withMHP. Grievance

can be anyexpression ofdissatisfactionabout anythingother than an

"action"

MHP logsgrievance withinone working day

of receipt andacknowledges

receipt in writingto the beneficiary

Is the grievanceabout a clinical

issue?

End of grievanceprocess

Yes

No

Decision makermust not have

been involved inany previous level

of review ordecision making

Decision maker must alsobe a health care

professional with theappropriate clinical

expertise in treating thebeneficiary's condition

MHP decides ongrievance

MHP notifies thebeneficiary inwriting andexplains the

beneficiary's rightto request a SFHif the beneficiary

disagrees with thedecision

TIMEFRAMES

New regulations specify that grievance dispositions cannot exceed 90 days from the day in which the MHP received the grievance.

DMH will retain a 60 calendar day limit for grievances to be resolved.

Timeframe may be extended by up to 14 days in certain circumstances.

Title 42, CFR, Section 438, Subpart F (Standard Appeals)

Beneficiaryfiles appeal(orally or inwriting) with

MHP toreview an"action"

MHP logs appealwithin one workingday of receipt and

acknowledgesreceipt in writingto the beneficiary

Is the appealabout a clinical

issue?

End of appealprocess

Yes

No

Decision makermust not have

been involved inany previous level

of review ordecision making

Decision maker must alsobe a health care

professional with theappropriate clinical

expertise in treating thebeneficiary's condition

MHP decides onappeal

MHP notifies thebeneficiary inwriting of theresults of the

appeal and thedate it wascompleted

If appeal is oral,beneficiary

follows up oralappeal with a

signed, writtenappeal. The

date of the oralappeal startsthe time clock

Beneficiary maypresent evidence

in person or inwriting

Beneficiary mayexamine his/hercase file and any

other recordspertaining to theappeal beforeand during theappeal process

Is the decisionwholly in favor ofthe beneficiary?

Yes

No

Written notice alsoinforms the

beneficiary that s/hehas the right to file aSFH, instructions on

how to file a SFH,his/her right to

request serviceswhile the hearing ispending and how tomake that request

TIMEFRAMES

APPEALS must be resolved within 45 calendar days of MHP receipt of appeal.

Timeframe may be extended by up to 14 days in certain circumstances.

Title 42, CFR, Section 438, Subpart F (Expedited Appeals)

Beneficiary files appeal(orally or in writing) with

MHP to review an "action"when using thestandard appeal

resolution processcould jeopardize the

beneficiary's life, health,or ability to attain,maintain, or regainmaximum function.

MHP logsappeal within

one working dayof receipt andacknowledges

receipt in writingto the

beneficiary

Is the appealabout a clinical

issue?

End of appealprocess

Decision makermust not have

been involved inany previous level

of review ordecision making

Decision maker must alsobe a health care

professional with theappropriate clinical

expertise in treating thebeneficiary's condition

MHP decides onappeal

MHP notifies thebeneficiary inwriting of theresults of the

appeal and thedate it wascompleted

Beneficiary maypresent evidence inperson or in writing

Beneficiary mayexamine his/her case

file and any otherrecords pertaining to

the appeal before andduring the appeal

process

Is the decisionwholly in favor ofthe beneficiary?

Yes

No

Written notice alsoinforms the

beneficiary that s/hehas the right to file aSFH, instructions on

how to file a SFH,his/her right to

request serviceswhile the hearing ispending, and how tomake that request

MHP makesreasonable effort

to provide thebeneficiary with

oral notice ofappeal resolution

decision

Does appealmeet the criteriafor an expedited

appeal?

No

Appeal followsstandard appeal

process

Yes

Yes

No

MHP providesbeneficiary with

prompt oral notice ofdenial of expedited

appeal process

MHP provides beneficiarywith written notice of denialof expedited appeal process

TIMEFRAMES

EXPEDITED APPEALS must be resolved and the affected parties must be notified orally and in writing no later than 3 working days after the MHP receives the expedited appeal.

Timeframe may be extended by up to 14 days in certain circumstances.

If the MHP denies the expedited appeal process and reverts the appeal to the standard appeal process, the MHP must make reasonable efforts to promptly notify the beneficiary orally and must notify him/her in writing within 2 calendar days.