NCDHHS Division of Health Benefits | MCT 112 LTSS and Ongoing Transition of Care | 8/15/2019 1

NC Department of Health and Human Services

Crossover to NC Medicaid Managed Care: Supporting the LTSS Community Through the Transition to Managed Care

Trish Farnham, Senior Health Policy Analyst

Garrick Prokos,Project ManagementQuality and Population Health

August 15, 2019

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• Summary Overview of NC’s Transition to Managed Care

• Transition of Care “Crossover” Concept

• Overview Activities Underway to Support Members and Providers through Crossover.

• Preview of Resources in Development

Today’s Session: The Last in a Series and the First in a Series

What’s Covered What’s Not Covered• Specific guidance on how to

enroll in PHP network • Specific guidance on PHP

benefits.• Please see resource links for

all items not covered.• Ongoing Transition of Care

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• FFS: Fee-for-Service−The service based reimbursement model NC Medicaid currently

operates.

• MCL: “Managed Care Launch:” −The date managed care goes “live” in a particular region. − Often referred to as member’s “Managed Care Effective Date.”

• PHP: Prepaid Health Plan−Five managed care organizations under NC Medicaid Managed Care:

• PA: Prior Authorization−A request submitted in advance of services starting for a provider to be

authorized to provide service

• UM Vendor: Utilization Management vendor−The entity that reviews and processes the PA request.

Terms Used in this Presentation

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OVERVIEW OF NC’S TRANSITION TO STANDARD PLANS UNDER NC MEDICAID MANAGED CARE

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IntroductionIn 2015, the NC General Assembly enacted Session Law 2015-245, directing the

transition of Medicaid and NC Health Choice from predominantly fee-for-service (FFS) to managed care.

• Since then, the North Carolina Department of Health and Human Services (DHHS) has collaborated extensively with clinicians, hospitals, beneficiaries, counties, health plans, elected officials, advocates, and other stakeholders to shape the program, and is committed to ensuring Medicaid managed care plans:

• Deliver whole-person care through coordinated physical health, behavioral health, intellectual/developmental disability and pharmacy products and care models

• Address the full set of factors that impact health, uniting communities and health care systems

• Perform localized care management at the site of care, in the home or community

• Maintain broad provider participation by mitigating provider administrative burden

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Medicaid Transformation Vision

“To improve the health of North Carolinians through an innovative, whole-person centered, and well-coordinated system of care which addresses both medical and non-medical drivers of health.”

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What do some of those terms mean?

• New name for our current Medicaid program.• Fee-for-service + LME-MCOs (or PACE)• What everyone on Medicaid has now

NC Medicaid Direct

• The term used reference the five “prepaid health plans” or “PHPs” or “health plan”

• Also called “Standard Plan” or “Standard Plan Option.”

NC Medicaid Managed Care

• Specialized plans for members with significant behavioral health needs and intellectual/developmental disabilities

• What the LME-MCOs will become in a few years• NOT the focus of today’s webinar

Tailored Plan

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PHPs for NC Medicaid Managed Care

Statewide Contracts• AmeriHealth Caritas North Carolina, Inc.• Blue Cross and Blue Shield of North Carolina, Inc.• UnitedHealthcare of North Carolina, Inc.• WellCare of North Carolina, Inc.

Regional Contract – Regions 3 & 5• Carolina Complete Health, Inc.

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NC Medicaid Managed Care Regions

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Phase 1: Region 2 & 4 Counties Launch Date: November 1, 2019

REGION 1

REGION 2 REGION 4 REGION 6

REGION 3

REGION 5

Region 2 Region 4Alleghany

Ashe Davidson

Davie Forsyth Guilford

RandolphRockingham

Stokes Surry

Watauga Wilkes Yadkin

Alamance Caswell

Chatham DurhamFranklin Granville Johnston

Nash Orange Person Vance Wake

Warren Wilson

Serving beneficiaries living in one of these counties?

Launch Date: November 1, 2019

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Phase 2: Regions 1, 3, 5, 6 Launch Date: February 1, 2020

Serving beneficiaries living in one of these counties?

Launch Date: February 1, 2020

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Phase 1 Timing – Regions 2 and 4

Note: LTSS members may select different

PHP without cause at any time.

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DHHS Vision for Transition of Care

As beneficiaries move between delivery systems, the Department intends to maintain

continuity of care for each beneficiary and minimize the burden on providers during the

transition. -NC Department of Health and

Human Services (NC DHHS)

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Transition of Care: Two Distinct Phases

Crossover to MCL Transition

of Care

One time crossover of beneficiaries eligible for NC Medicaid Managed Care on November 1, 2019 or February, 1 2020 (“Managed Care Implementation” or “MCL”)

OngoingTransition of

Care

Ongoing transition of care for beneficiaries moving between PHPs, between PHPs and FFS, between FFS/LME-MCOs and PHPs

NOTE: TRANSITIONS BETWEEN SETTINGS ARE RELATED BUT IDENTIFIED IN SEPARATE PROTOCOLS AND NOT FOCUS OF THIS PRESENTATION

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NC’s TRANSITION TO MANAGED CARE: THE CROSSOVER DESIGN

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Our Crossover Policy Direction

PHPs have the necessary data to ensure effective service continuity for transitioning beneficiaries..

As beneficiaries move between delivery systems, the Department intends to maintain continuity of care for each beneficiary and minimize the burden on

providers during the transition.

High-need beneficiaries have additional “high touch” support to ensure service continuity and reassurance through the transition.

PHPs maintain service continuity by implementing DHHS requirements related to prior authorizations, non-participating providers, appeal rights and identified services.

PHPs, LME-MCOs and FFS vendors establish mechanisms that facilitate the effective data and knowledge transfer.

The Department ensures effective oversight through quality communication, reporting and other oversight mechanisms.

Providers facilitate service continuity by being effectively informed on Crossover-specific requirements, such as PA submissions.

The Department’s Crossover direction is enhanced by the insight and contribution of stakeholders.

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Key Components of NC DHHS Crossover Design

Supporting Continuity of Care Through Data Transfer

Establishing Additional Safeguards for High Need Members

Member and Provider Education

Clear and Organized Communication Between Entities

Facilitating Uninterrupted Service Coverage

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• 24 months of paid and denied claims/encounter history for all services

• Full file to begin 9/21/2019, weekly updates• Transferred via GDIT Move It site

Claims and Encounter

• Open and recently closed PAs (60 days)• Full file to begin 10/1/2019, daily updates.• Transferred via GDIT Move It and state ftp site.

Open and Recently

Closed Prior Authorizations

(PAs)

• Care Plans from CCNC and identified LME-MCO members receiving care coordination.

• PCS Care Plans/Assessments from PCS Vendor.• All begin approximately 3 weeks prior to MCL• All via state ftp site.• All other treatment plans accessed from providers as

needed.

Identified Care Plans

Data Transfer at Crossover: Key Data

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• Provider Impact: None anticipated. • Data will be transferred by NC TRACKS

Claims and Encounter

• Provider Impact: Minimal. PHPs may seek clarification on a detail on PA .

Open and Recently

Closed Prior Authorizations

(PAs)

• Provider Impact: PHPs may seek care/service plans for transitioning members if not otherwise included in the file transfer.

Identified Care Plans

Data Transfer at Crossover: Provider Impact

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• GDIT and Other UM Vendors will continue to process Prior Authorization requests*

• Open and recently closed Prior Authorizations will be transferred to Member’s PHP to help ensure continuity of care.

• PHPs are required to honor open PAs up to 90 days after launch.

• If PHP ends open PA after 90 days, it must provide appeal rights.

* Final timelines to be shared in September.

Prior Authorization Requests for DOS Prior to Managed Care Date

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Member’s Managed Care Date (or Managed Care Launch=MCL)

Member Covered by FFS (Medicaid Direct) Member Covered by PHP

Scenario A: Provider submits PA request prior to MCL for member transitioning to PHP. UM Vendor authorizes services as clinically indicated. Authorization will be transferred to PHPs as part of incremental PA transfer file.

Scenario A. PHP honors open FFS PA authorization for first 90 days. If Authorization extends beyond 90 days and the PHP ends, it must issue appeal rights.

.

Scenario B: Provider submits retroactive PA request for preMCL DOS for a member formerly enrolled in Medicaid Direct, now enrolled in PHP. Vendor may only authorize for pre MCL DOS

Scenario B

Scenario A: FFS UM Vendor generated PA received prior to MCL

Scenario B: Provider may submit separate PA request directly to PHP.

Prior Authorization Requests for DOS Prior to Managed Care Date

Retroactive PA

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• Ensure providers know about PA submission requirements.

• Ensure providers have information needed to resubmit PA request to proper PHP

Intensive Provider

Education

• If a provider attempts to enter member who is now enrolled in Managed Care, it will see banner message instructing where to get additional information.

Notification: Auto-

Information Message

• UM call center staff will be informed on how to guide both members and providers.

Informed Call Center Staff

Stop Lights for Attempted PA Request Submissions after Managed Care Effective Date

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• If a provider attempts to enter member who is now enrolled in Managed Care, it will see banner message instructing where to get additional information.

Notification: Auto-

Information Message

Stop Lights for Attempted PA Request Submissions after Managed Care Effective Date

SAMPLE

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PA Requests at Crossover: Guidance in Development

• Vendor-specific guidance on submission and timelines.

• Guidance on identifying member’s managed care status and selected PHP in NCTracks Provider Portal.

• Web-resource, providing PHP specific PA submission contact information and instruction.

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Know Member’s MCL Dates: For members transitioning to Standard Plan, this is the key date to know where to submit the PA request.

Be Clear on DOS:PA Requests for DOS on or after MCL will need to be submitted to the member’s PHP.

Identify Member’s Managed Care Status and Selected ProviderEvidence will be available in both Provider Portal and GEF.

To submit PA Request for DOS on or after MCL• Follow instructions provided directly by the PHP• To find all PHP instruction in one place, go to upcoming DHHS

Crossover Resource page.

PA Requests at Crossover: What Providers Need to Know

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Transition-Related Safeguards for High-Need Members

Data File Transfer at CrossoverClaims/Encounter Data

PA ExtractCare Plans (As Applicable)

Targeted Follow Up For High-Need MembersPHPs perform time-sensitive follow up to High Need

Members

Warm HandoffIndividualized knowledge transfer sessions

for members identified by DHHS, LME-MCOs, CCNC. PHPs may also initiate.

Applies to All Transitioning Beneficiaries

See High Need Member Definition

Complex Treatment/Service Circumstances

NCDHHS Division of Health Benefits | MCT 112 LTSS and Ongoing Transition of Care | 8/15/2019 27

“High Need” Members include:• High need subset of members receiving in-home long-

term services and supports/

• High need subset of members receiving behavioral health services

• Exempt members who elect to enroll in PHP.

• Members identified by CCNC, an LME-MCO or the Department who have complex treatment circumstances or multiple service interventions and necessitate a “warm handoff.”

• NEMT users with repeated or multiple appointments.

• Members with Inborn Errors of Metabolism

Managed Care

Launch Date

Pre MCL, PHP identify and prioritize “High Need” members based on criteria and information provided.

Follow Up (reported weekly to DHHS):• Direct contact between PHP

and member (in-person or phone)

• Are services in place?• Any confusion about

processes?• Ongoing status of pre-MCL

authorized services.

Member PHP representative

Targeted Follow Up For High-Need MembersPHPs perform time-sensitive follow up to High Need Members

Provider Note: Providers may be invited to

participate in Follow Up sessions

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• https://files.nc.gov/ncdma/How--Does-Medicaid-Managed-Care-Affect-Me-Enrollment-Guide-for-LTSS-Final-for-Web-Posting.pdf

Member Education

Member Guide to explaining enrollment pathways for beneficiaries with disabilities and older adults.

NCDHHS Division of Health Benefits | MCT 112 LTSS and Ongoing Transition of Care | 8/15/2019 29

Member Education: Non Emergency Medical Transportation

Provider Note: Providers can help educate members

about this option.

• Enrolled Members will be able to reserve post MCL appointments 31 days PRIOR to their effective date.

• Jan is in Phase 1 County and selects ABC Health Plan on August 15th. Her managed care effective date will be November 1, 2019.

• Jan has an appointment on November 2, 2019.

• Jan can reserve her appointment directly from ABC starting October 1, 2019.

In Development: Additional Educational

Materials to Help Members Understand this

Option

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Number to call if I have issues getting care after my start date.

My health plan is:

Number to call if I have questions about my supplies.

Number to call if I need to schedule a ride to an appointment after I start getting

care through my health plan.

My primary care provider is:When I will start getting care through my

health plan:

We want to ensure Members have simple, clear, “pocket reference” answers to these questions.

Member Education

PHASE I AUTO ASSIGNMENT 9/16/2017

PHASE I OPEN ENROLLMENT CONTINUES

NC Medicaid Transformation: Key Phase I Crossover Activities

August, 2019

September, 2019

October, 2019

November, 2019

December, 2019

MANAGED CARE LAUNCH (MCL) Phase I: 11/1/2019 Enrolled Member May Change PHP through February 1 (90 days)LTSS Members May Change Any Time

Crossover Education and Communication

PHPS begin receiving information on enrollees

Crossover Education and Communication

10/1/2019: Phase I enrollees may reserve post MCL NEMT appointments through their PHP

Last PA Requests for FFS submitted

PHPs conduct follow along to high need members. LTSS members receive care managers and newly enrolled ABD members receive expedited screening

PHP responsible for NEMT services for Enrolled Members

New PAs submitted to Member’s PHP

PHP must honor open FFS PAs for no less than 90 days.

Non participating provider requirements in effect.

Crossover-Education and Communication Begins

NOVEMBER 1, 2019: PHASE I LAUNCH

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RESOURCES

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General Overview of Provider Transition to Managed Care

MCT 101 Provider Transition to Managed Care https://medicaid.ncdhhs.gov/nc-medicaid-managed-care-training-courses

Information on Benefits under Managed Care

MCT 108 Clinical Policies under Managed Care https://files.nc.gov/ncdma/documents/Clinical-Policies-Webinar-FINAL20190613.pdf

To Contact the PHPs about Contracting

Information about Provider Network Adequacy

Requirements, Grievances and Appeals and Other Policies

MCT 104 Key Policies for Providers in Managed Care https://files.nc.gov/ncdma/Provider-Policies-Webinar-5.9.19-Final.pdf

Information about Provider Rates and Contracting

MCT 102 Provider Payment and Contractshttps://files.nc.gov/ncdma/documents/Providers/Revised-6.26.19-Provider-Payments-and-Contracting-Webinar-4-11-19-FINAL.pdf

https://medicaid.ncdhhs.gov/providers

Please visit the NC DHHS Medicaid Provider webpage

Information about Standard Plan and Tailored Plans

MCT 106 Behavioral Health Services: Standard Plan and Transition Periodhttps://files.nc.gov/ncdma/MCT106-BH-Transition-Final.pdf

Provider Education: General Resources

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• Crossover Specific Medicaid Bulletin Articles beginning with August’s Bulletin.

• General Crossover Trainings (starting in September)− Through Provider Education Series (see announcements at the

end).− Through LME-MCOs

• DHHS Crossover Resource Page

Provider Education: Crossover

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DHHS Crossover Resource Page

Crossover Guidance to be Provided• Finding Members’ Managed Care Status• Resources to Support Members through Transition through Managed Care• Guidance on Submitting Prior Authorizations• Contacting the PHPs• Overview of PHP Crossover Requirements• Additional Crossover Information

https://medicaid.ncdhhs.gov/providers

Crossover-Specific Information Coming

Soon

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Need More Information?• To submit a question to the Medicaid

Team: − MedicaidSWAT@dhhs.nc.gov

• If member has a question about enrollment and PHP selection: − Contact the NC Medicaid Enrollment

Broker − 833-870-5500 (free call)− www.ncmedicaidplans.gov

• Want to review earlier MCT Trainings?− https://medicaid.ncdhhs.gov/providers

• Want to review Medicaid Bulletins?− https://medicaid.ncdhhs.gov/documen

ts/2019-medicaid-bulletins

In Development:Guidance if Member or Provider has issue at

Crossover.

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Upcoming DHHS-Sponsored Webinars

• For September 5, 2019: MCT 113− NC’s Transition to Managed Care: The Crossover Series− This session provides general crossover guidance, with a focus on identifying

beneficiary managed care detail and guidance on submitting prior authorization requests during the crossover period.

• For September 19, 2019: MCT 114− NC’s Transition to Managed Care: The Crossover Series (Continued)− This session is a continuation of the session on Sept. 5, 2019, providing a brief

review of topics previously covered and additional guidance for supporting beneficiaries through the transition to Medicaid Managed Care.