Medicaid Reform in Colorado The Final Plan Summary The biggest change is the following: CCHAP --affiliated practices will continue to receive their higher reimbursement for preventive care visits (the “bump”) through June 30, 2012, whether or not they participate in the initial phase of the Accountable Care Collaborative (described below). The CCHAP – affiliated practices will not receive the $4 PMPM (per-member-per-month) as mentioned in the last version. [We don’t know why they changed this.] You could wind up with patients that are in the initial phase (pilot program) and other patients that are not in the initial phase; but for all patients you will receive the same higher reimbursement you are receiving now. Then, starting in July, 2012, if their region has achieved budget neutrality (see below), the practices will start receiving $3PMPM for children on Medicaid and each practice will have an opportunity to earn another $1 PMPM in incentives for meeting certain objectives (see below). There will be an additional chance to receive more incentives if cost savings for the state are high enough (and most analysts agree the likelihood of this is low in the early years). The Summary Colorado Medicaid is overseen by the Colorado Department of Health Care Policy and Financing (HCPF). HCPF has been planning for a couple of years to reform Colorado Medicaid by creating a new approach, The Accountable Care Collaborative (ACC). HCPF (Colorado Medicaid) has divided the state up into 7 regions (map attached) and will contract with one organization in each region to be a Regional Care Coordination Organization (RCCO). The RCCOs will be accountable for controlling costs and improving the health of Medicaid clients in their region. The RCCOs will be a hybrid model, adding characteristics of a regional Accountable Care Organization to the Primary Care Case Management system. HCPF will also contract with a data management company to collect health information on Medicaid patients and make it available to Primary Medical Care Providers (PMCPs) and the RCCOs. The two central goals of the ACC Program are to improve health outcomes of Medicaid Clients through a coordinated, Client/family-centered system that proactively addresses Clients’ health needs, whether simple or complex, and to control costs by reducing avoidable, duplicative, variable and inappropriate use of health care resources. To reach these goals, the Department will contract with the RCCOs to: Expand access to comprehensive primary care. Provide a focal point of care/Medical Home for all Members (Medicaid clients enrolled with a particular RCCO) including coordinated and integrated access to other services. Ensure a positive Member and Provider experience and promote Member and Provider engagement. Effectively apply an unprecedented level of statewide data and analytics functionality to support transparent, secure data-sharing and enable the near-real-time monitoring and measurement of health care costs and outcomes. The RCCOs will For the Medicaid client: educate clients on how an RCCO can help them market Medicaid and RCCOs help them find providers help them understand available services help keep clients content with their health services help with CARE COORDINATION help patients find and obtain ancillary services help patients and families with socio-economic issues For the providers: recruit Medicaid providers develop a cohesive provider network contract with providers to participate in the program, provide support services for PCMPs ASSIST WITH CARE COORDINATION help providers improve health outcomes and reduce costs of care by developing goals and expectations for providers (with provider input) help providers meet those expectations help practices meet all of the needs of Medicaid patients and keep providers content hold PCMPs accountable for meeting the expectations required to receive PMPM and incentive payments. make sure that the PCMP Network is adequate in size and has: 1. extended hours in evenings and on weekends (the network will have this, not necessarily the individual PCMP); 2. alternatives for members to visiting the emergency room for after-hours urgent care; 3. systems to track access at the individual PCMP provider-level including day-of- the-week call volume, requests for same-day care, requests for routine care and time frames in which appointments can be scheduled; 4. ability to comply with access standards; specifically, appointments with PCMPs shall be available to all Members: o within 48 hours of a Member’s request for urgent care; o within 10 calendar days of a Member’s request for non-urgent symptomatic care; and o within 45 calendar days of the Member’s request for non-symptomatic care, unless an appointment is required more quickly to ensure the provision of screenings in accordance with accepted EPSDT schedules. ensure that Members have adequate access to specialists and other Medicaid providers promptly with a referral, and without compromise to quality of care or health. highlight and promote those providers who demonstrate exemplary access capacity. Educate providers about: Colorado Medicaid programs, policies and processes, including benefit packages and coverage policies, prior authorization and referral requirements, claims and billing procedures, eligibility and enrollment processes other operational components of service delivery the roles other Department contractors and partners play in the Colorado Medicaid system (including but not limited to the SDAC, the Enrollment Broker, the Medicaid fiscal agent, the utilization management contractor, the managed care ombudsman, the county departments of human and social services, and the Community-Centered Boards and Single Entry Point agencies) Serve as a link and liaison between these contractors and partners and assist providers in navigating these administrative systems when barriers or problems are encountered in administrative processes like: Medicaid provider enrollment; prior authorization and referral issues; Member eligibility and coverage policies and benefit packages; PCMP designation problems; and PCMP PMPM payment issues Educate PCMPs, specialists and other Medicaid providers; assist with the completion and submission of referral documents, as needed Help PCMPs promote member empowerment, healthy life style choices and informed decision-making *RCCOs will provide practice support tools like: Clinical Tools Client Materials . Clinical care guidelines and best practices. . Client reminders. . Clinical screening tools . Self-management tools. (e.g. depression screening tools, substance use . Educational materials about specific screening tools). conditions. . Health and functioning questionnaires. . Client action plans. . Chronic care templates. . Behavioral health surveys and other self- . Registries. screening tools. Operational Practice Support Data, Reports and Other Resources . Guidance and education on the principles of . Expanded provider network directory. Medical Home. . Comprehensive directory of community . Training on providing culturally competent care. resources. . Training to enhance the health care skills and . Directory of other Department-sponsored knowledge of supporting staff. resources such as the managed care ombudsman and . Guidelines for motivational interviewing. nurse advice line. . Tools and resources for phone call and . Link from main ACC Program website to the appointment tracking. RCCO-specific website where all tools and resources . Tools and resources for tracking labs, referrals, are centrally located and easily accessible. . Referral and transitions of care checklists. . Visit agendas or templates. . Standing pharmacy order templates. *The complete list of responsibilities of the RCCOs can be found in Section V. of the complete RFP. The Initial Phase (pilot program) The RCCOs will be selected by early 2011. There will be one RCCO in each region. An RCCO could be selected to cover more than one region. There will be a 12 month initial phase (pilot program) lasting from the RCCOs start date (any where from April to June, 2011) through June, 2012. See the attached map for a look at the regions. Regions 1, 2 and 4 (non-metro, non-CO Springs) will start in April, 2011. The other (metro and Colorado Springs) regions will start in June, 2011. Each RCCO will have roughly 8,600 Medicaid members in their initial RCCO panel, of which one-third will be children. So, each RCCO will have roughly 2,900 Medicaid children from their region during the initial phase (June, 2011 through June, 2012). These children for the initial phase will be in practices or community clinics that are part of the “Medical Homes for Children Program” (MHCP) through HCPF, the program that all CCHAP- affiliated practices are part of, and the one that pays the higher reimbursement (the “bump”) all CCHAP- affiliated practices receive. These patients don’t have to be from CCHAP-affiliated practices; some or all may be from Federally Qualified Health Care Centers or other community clinics that are part of the “Medical Homes for Children Program.” The RCCO will select practices or clinics to work with in the initial phase and the children in those practices/clinics will make up the 2,900. Practices may volunteer to participate in the initial phase, but can also opt not to participate in the initial phase. Ultimately the RCCO will choose and HCPF can participate in that choice. HCPF, the data management company (SDAC) and the RCCOs will try to keep patients in their medical home (see below). It is recommended that RCCOs do their initial phase (pilot program) in one “focus” community rather than spread out throughout their region. Who qualifies to be a PCMP in the ACC program and what are the expectations? In order to enter into a written agreement as a Primary Care Medical Provider (PCMP) in the Accountable Care Collaborative (ACC) Program, the Regional Care Collaborative Organization (RCCO) shall ensure that the following criteria are met: A PCMP Practice shall: Be an enrolled Colorado Medicaid provider. Be either: Certified by the Department as a provider in the Medicaid and CHP+ Medical Homes for Children program (as all CCHAP-affiliated practices are), or An FQHC, RHC, clinic, or other group practice with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology. Act as the dedicated source of primary care for Members and be capable of delivering the majority of the Members’ comprehensive primary, preventive, and sick medical care. Be committed to the following principles of the Medical Home model: The care provided is: Member/family-centered; Whole-person oriented and comprehensive; Coordinated and integrated; Provided in partnership with the Member and promotes Member self- management; Outcomes-focused; Care consistently provided by the same provider as often as possible so a trusting relationship can develop; and Provided in a culturally competent and linguistically sensitive manner. The PCMP Practice will be: Accessible, aiming to meet high access-to-care standards such as: 24/7 phone coverage with access to a clinician that can triage; Extended daytime and weekend hours; Appointment scheduling within 48 hours for urgent care, 10 days for symptomatic, non-urgent care and 45 days for non-symptomatic routine care; and Short waiting times in reception area. Committed to operational and fiscal efficiency. Able and willing to coordinate with the RCCO on medical management, care coordination, and case management of Members. Committed to initiating and tracking continuous performance and process improvement activities, such as improving tracking and follow-up on diagnostic tests, improving care transitions, and improving care coordination with specialists and other Medicaid providers, etc. Willing to use proven practice and process improvement tools (assessments, visit agendas, screenings, Member self-management tools and plans, etc.). Willing to spend the time to teach Members about their health conditions and the appropriate use of the health care system as well as inspire confidence and empowerment in Members’ health care ownership. Focused on fostering a culture of constant improvement and continuous learning. Willing to accept accountability for outcomes and the Member/family experience. Able to give Members and designated family members easy access to their medical records when requested. Committed to working as a partner with the RCCO in providing the highest level of care to Members. This commitment includes data-sharing, access to medical records when requested, cooperation on referrals, participation in performance improvement activities and initiatives, willingness to give feedback and potentially participate on committees and provide clinical expertise, and use the data available to the practice to better manage Members and their health needs. Each individual PCMP or Pod of providers shall: Be an enrolled Colorado Medicaid provider. Be either: o Certified by the Department as a provider in the Medicaid and CHP+ Medical Homes for Children program, or o An individual physician, advanced practice nurse or physician assistant with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology. Act as the dedicated primary care provider for Members and be capable of delivering the majority of the Members’ comprehensive primary, preventive, and sick medical care. Be committed to the principles of the Medical Home model described in Item #4 above. RCCOs will establish Performance Improvement Advisory Committees that will have providers, members, community organizations, advocates, mental health organizations, etc represented. HCPF will have a medical management committee to guide policy, with representation from the RCCOs, providers and experts. HCPF will also have a Performance Improvement Advisory Committee. Extended Hours The RCCO must ensure that there is adequate access to services within their region, including extended hours. The term “extended hours” refers to hours of operation beyond typical Monday through Friday, 8:00 a.m. to 5:00 p.m. schedules. The RCCO has the responsibility to ensure that its network has this capacity for its Members. However, it is not expected that every PCMP within the RCCO network will have to have an “extended hours” capacity. Extended hours may be an additional one hour or more, and may vary among PCMPs within a region so long as Members have access to adequate services within a region. Referrals to specialists required The PCMP provides the majority of the Member’s care and also serves as the coordinator and integrator for the Member to access other services as needed, including specialty care. The goal is for the Member to get the right services, at the right time and in the right setting and provide a new level of accountability to improve Member health and control costs. The requirement to obtain a referral was carefully considered in light of feedback from many stakeholders and current Medicaid providers. The referral process consists of the PCMP discussing the referral with the Member, the PCMP locating/identifying the Medicaid provider that the Member is being referred to and informing the client of the physician’s identity, providing that physician with the needed Member health information, and providing the administrative information needed for the physician to submit the claim (the referring physician’s identification #), and arranging for the results of that visit to be communicated back to the referring physician. The following services do not require a PCMP referral: (1) Emergency care (2) EPSDT screening examinations (3) Emergency and non-emergent medical transportation (4) Anesthesiology services (5) Dental and vision services (6) Family planning services (7) Behavioral health services (8) Home and Community-Based Waiver services (9) Obstetrical care Limiting the number of children on Medicaid in the practice Providers will still be able to limit their Medicaid enrollment (panel size) in the ACC Program Reimbursement HCPF (Colorado Medicaid) will continue to pay Fee-For-Service just as they have in the past. In addition, HCPF (Colorado Medicaid) will continue to pay CCHAP-affiliated practices (certified medical homes for children) the higher reimbursement that these practices has been receiving through June, 2012, whether or not the practice participates in the ACC initial phase (pilot program). The expansion phase for each region will begin in July, 2012 or when that region (and RCCO) reach budget neutrality, which ever come later. When the expansion pahse begins, all practices will be required to participate in the ACC and their reimbursement will include: Providers will receive customary fee-for-service reimbursement for visits as they do now, plus Providers will receive $3 PMPM in addition to the fee-for-service reimbursement And $1 PMPM for the expansion phase will be held by HCPF to use to provide incentive payments for performance in meeting certain outcome measures. How does this compare to the current higher reimbursement received by CCHAP-affiliated practices? The higher reimbursement (the “bump”) for well child visits for children on Medicaid, received through the Medical Homes for Children Program from HCPF by CCHAP- affiliated practices, roughly works out to $3.33 PMPM. When the expansion occurs in their region, they would receive $3 PMPM and may receive additional incentive payments that year, too, up to $1PMPM. Incentives There will be no incentives paid during the initial (pilot) phase, the first year. The focus in the initial phase will be getting the RCCOs and the whole ACC program to budget neutrality. Data will be collected to help set targets for the next year, the expansion phase. In later years, incentives will be paid out to RCCOs and providers based on specific utilization and outcomes targets, with Medicaid client and PCMP input. In the first year of the Expansion Phase, the RCCOs and PCMPs will be responsible for meeting certain specific cost-containment targets in order to receive any incentive payments from the $1PMPM set aside. The types of performance targets have been determined, but the actual target numbers will be determined based on data collected during the initial phase. The performance measures for the determining any incentives during the first year of expansion will be: (1) Emergency Room Visits per 1,000 full time enrollees (FTEs); (2) Hospital Re-admissions per 1,000 FTEs; and (3) Outpatient Service Utilization per 1,000 FTEs and MRI, CT scans, and X-ray tests per 1,000 FTEs. The actual targets and method of providing incentives will be determined during the initial phase. In subsequent years, incentives will depend on meeting new annual “aggressive” health improvement goals selected from sources like HEDIS, CAHPS and Healthy People 2020. Shared savings Additional incentives in later years may also come from shared savings. If an RCCO is successful in exceeding a 7% cost savings, then the savings above the 7% may be divided among the RCCO and the PCMPs. Details are not determined yet. Again, nationally Medicare ACCs have not been able to experience these shared savings in the early years and many have not reached that point, yet. Opting out A practice will have the ability to “opt out” of participating in the ACC Program. However, it is the intent of the Department to make the ACC Program the primary Medicaid program in the future. In the expansion phase the Department will be enrolling all eligible Medicaid Clients into the ACC Program. If a provider decides to “opt out”, their Members will be reassigned to other practices and new Members will be redirected to current ACC Program providers. Current Managed Care Organizations (MCO) will continue to have Clients. Electronic medical record The Department has no Electronic Health Record (EHR) requirements at this time. Please note the requirements of Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009. We expect the RCCO to support its providers in the adoption of EHR technology and other components of practice redesign. Medicaid Client Enrollment in the RCCO: Enrollment in the ACC Program will be on a voluntary basis only. Clients will have the choice to participate in the ACC Program or to “opt out” of participating in the program. During the Initial Phase, all Members will be enrolled utilizing the voluntary process called Passive Enrollment. The RCCOs will not be allowed to perform Marketing activities to increase their enrollments during the Start-Up Initial Phases. Passive Enrollment This is the way things will be during the initial phase. Modifications to the enrollment process can also be brought forth and implemented through the Advisory Committees Passive Enrollment is the process of voluntarily enrolling Clients into a specific program and includes the selection of Clients appropriate for enrollment, notification of Clients selected for enrollment, and Choice Counseling to assist Clients in making a decision regarding enrollment. Selection of Clients appropriate for enrollment into a RCCO will be performed by the Department through the SDAC (Statewide Data and Analytics Contractor). The SDAC will identify Clients appropriate for enrollment from two Client populations: Clients who are newly eligible for Medicaid and existing Medicaid Clients that have an established relationship with a PCMP participating in the RCCO’s network and Focus Community. The SDAC will be given a list of participating PCMPs, and use an Attribution Method to determine whether a PCMP-Client relationship already exists. The SDAC will mine historical claims data to identify the primary care provider the Client has seen most often during the past 12 months. Clients will be selected and notices mailed two months prior to the date of actual enrollment, during the Start-Up Phase. Critical to the Passive Enrollment process is that all Clients receive advance notice and have the opportunity to make an informed choice. The Enrollment Broker will be responsible for sending notices to all Clients identified for enrollment by the Department through the SDAC. The notice informs Clients of the Department’s intent to enroll them in the ACC Program, provides them with information about their Colorado Medicaid enrollment choices, provides contact information for the Enrollment Broker’s Choice Counseling services and allows 30 days for the Client to make an active choice or be enrolled in the ACC Program. A Client that chooses not to participate in the ACC Program must contact the Enrollment Broker. The Client may choose to enroll in another Colorado Medicaid managed care organization, if available, or to remain in the FFS program or PCPP. Clients that do not opt out of participation in the ACC Program will be enrolled with the RCCO responsible for the region in which they live. The enrollment will be effective the first day of the month following the Client’s 30-day choice period. For each region, during the initial phase, a list of contracted PCMPs within Focus Communities will be provided by the RCCOs. Using the Focus Communities as bases, all Members within those Communities appropriate for selection will be put in a pool of potential enrollees. This pool will include all of the children and adults from the appropriate Medicaid eligibility categories. The SDAC will generate a random selection of Members to be enrolled, consisting of one-third (approximately 2,900) children from the Medicaid and CHP+ Medical Homes for Children Program and two-thirds (approximately 5,700) adults from the remaining Medicaid eligible categories. The Department expects all children enrolled into the RCCO during the Initial Phase to be existing Clients in the Medicaid and CHP + Medical Homes for Children Program. Additional information: RCCOs will not be required to have agreements with PCMPs from other regions. PCMPs may serve Members who live in any region. Members will be assigned to a RCCO based on their residence address, may select a PCMP in another region and obtain care in other regions if they choose. RCCOs will assist their Members in selecting a PCMP who will deliver the majority of the Member’s care. To support the ACC Program, the Department will contract with an organization that has the requisite health information technology expertise. This organization (SDAC) will support ACC Program operations and work closely with RCCOs, providers, and the Department by organizing and distributing data. The SDAC will be responsible for bringing a new level of information and data analytics to the Medicaid program, providing insight into variations within and across RCCOs, benchmarking across key performance indicators, and serving as conduit for health information exchange between the Department and the RCCO. To support these reform measures and improve health information technology in Colorado, the Department is working with stakeholders to support communities and individual health care providers interested in participating in the Colorado Regional Health Information Organization (CORHIO) health information exchange. This will help providers become better equipped to use technology to facilitate the exchange of health information. Under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, eligible health care professionals can qualify for Medicare and Medicaid incentive payments when they adopt certified electronic health record technology and meaningfully use it to improve the quality and safety of care, improve care coordination, engage Clients and families, promote public health, and promote the security of private health information. The ACC Program will work with CORHIO’s regional extension centers to encourage providers in each region to participate in the HITECH program and improve their health information technology.
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