aiver in hand, Maryland joins small group of states enrolling disabled in managed care
MD Disabled Managed Care
November 30, 1996
Maryland will soon join a small group of states in enrolling its disabled population into mandatory statewide Medicaid managed care along with its Aid to Families With Dependent Children (AFDC) population.
Maryland won Health Care Financing Administration (HCFA) approval Oct. 30 to enroll about 280,000 people, some 80% of its current Medicaid population, into managed care. The state plans to begin enrollment Feb. 1 and complete the process in only six months. The institutionalized, dual eligibles, those in "spend-down" status, and those in other waiver programs are excluded from the Medicaid managed care waiver.
The state has made many special provisions for its special needs and disabled
populations, in some cases carving out services. Among these provisions:
• the state will risk-adjust capitation rates for those with medical conditions using a program developed at the Johns Hopkins University School of Public Health;
• specialty mental health services are being carved out and will be provided on a fee-for-service basis;
• recipients with rare and expensive conditions, about 1-2% of the Medicaid population, will be placed in an intensive case management program, and services will be rendered on a fee-for-service basis;
• managed care organizations (MCOs) will have to detail what resources they have to care for special needs populations such as pregnant women, HIV/AIDS patients , the homeless and children with special needs among others. Plans will have to show that they are offering outreach, qualified specialists, special needs coordinators and other services. The MCO also will be required to perform focus studies as part of the quality review.
Barbara Shipnuck, deputy secretary for health at the Maryland Department of Health and Mental Hygiene, estimated that about one-quarter of current Medicaid recipients—and eventually one-third of the waiver eligibles—will have capitation rates risk-adjusted for diagnoses, age and gender under the Johns Hopkins’ Ambulatory Care Group (ACG) Case-Mix System. Capitation rates will be adjusted only for those Medicaid recipients who have a "good medical history," said Ms. Shipnuck. At least six months of ICD-9 data from claims or encounter data will be needed, according to Johns Hopkins.
The ACGs were used to develop nine rate cells for Maryland Medicaid. There are separate cells for families (e.g. AFDC) and the disabled (e.g. SSI). The cells vary by a factor of 20, with payment ranging from a low of $40 a month to a high of $1100 a month. Currently, Ms. Shipnuck said, Maryland Medicaid uses about 50 rate cells that account for differences in age, gender, eligibility category and geography.
AIDS patients included
AIDS patients in Maryland also will be included in managed care, but they will have their own capitation rate. The state has set the rate for AIDS patients at $1,812 to $2,161 depending on geography. Based on the state’s experience with AIDS patients, those rates do not include the new class of protease inhibitor drugs, which will be paid for on a fee-for-service basis.
Plans will not receive AIDS rates for HIV-infected patients, however, Ms. Shipnuck said. That could mean an enrollee’s capitation rate might increase from "$130 month to $1800 per month if the T-cell count jumped five points," said Jerry Gott- hainer, president and chief operating officer of Johns Hopkins HealthCare, an integrated health care system which hopes to participate in Medicaid managed care. But, Ms. Shipnuck said capitation rates for HIV-infected individuals will be risk-adjusted based on how they are classed under ACGs.
Pediatric AIDS patients under the age of 14 will not be placed in managed care, but will be put in an intensive case management program for "rare and expensive" conditions. Only about 300 patients in the state, who have one of about 20-30 diagnoses, will be included in this intensive case management program, Ms. Shipnuck said.
Mental health
Specialty mental health services have been carved out and will be provided on a fee-for-service basis in a separate system overseen by the Mental Health Administration, although the state is considering capitation. The state will contract with a behavioral health managed care firm to administer the system, serve as a gatekeeper and to closely monitor utilization, referrals and pre-authorizations. Counties will form Core Service Agencies (CSA) to serve administrative and planning functions.
Ms. Shipnuck said managed care plans will provide some mental health services through primary care providers—i.e. ob/gyns can treat their patients suffering from post-partum depression, pediatricians will treat hyperactive children, family practitioners can treat depression. But, when those providers do not feel qualified to provide mental health services to their patients, they will be referred out. Prescription drugs will be covered by the MCO when its providers have written the prescriptions. The Mental Hygiene Administration will specify when care will be delivered by primary care providers and when it will be delivered by specialty mental health providers, county officials said.
"A beneficiary is entitled to access specialty mental health services either through a referral by an MCO or by directly contacting an Administrative Services Organization, CSA or participating provider," states HCFA’s terms and conditions for the Medicaid waiver.
Debbie Goeller, health officer for Worcester County Health Department, said her county had been resisting forming a CSA in the past because of a concern over spending dollars for administration rather than services. There is "not enough to be wasting a dime," she said. One issue is what administrative functions will be performed by ASOs and by CSAs.
The county mental health system will now be a fee-based system, rather than one dependent on grants from the state. Ms. Goeller said she is concerned about covering services for the "gray area population" previously covered under those grants.
Pegeen Townsend, vice-president for legislative policy for the Maryland Hospital Association, applauded the state for allowing provider sponsored networks to participate in the Medicaid managed care program. She said this will help traditional providers—often the only safety net for the uninsured—to remain viable in the Medicaid program. A dozen community health centers were expected to announce formation of a network with Johns Hopkins by mid-November.
Provider-sponsored networks will have to meet the same reserve requirements as other managed care organizations ($1.5 million at start-up), but the state will have the option of putting up $250,000 to meet the reserve requirement, Ms. Townsend said. Also helpful to these networks, she said, is that participating Medicaid plans will have to purchase group stop-loss insurance rather than making their own individual arrangements. While experienced MCOs have objected to this, Ms. Townsend said it is beneficial for start-ups.
However, the tight implementation schedule—capitation rates were announced in October and enrollment is due to begin in January—will make it difficult for newly formed provider networks to become operational, according to Ms. Townsend, who was hopeful the state would delay enrollment for a few months.
Scheduled to begin enrollment Jan. 1, the state recently decided to delay enrollment for 30 days. An enrollment broker is to be selected in November. Managed care plans will be restricted from marketing except for advertising and mailings to entire zip codes. (They will not be able to select out names.) Local health departments will be reimbursed for educating clients about Medicaid managed care. To avoid problems with adverse selection, Ms. Shipnuck said the state will only do a risk-assessment after the Medicaid recipient has selected an MCO.
Contact Ms. Shipnuck at 410-767-4664, Ms. Townsend at 410-321-6200 or Ms. Goeller at 410-632-1100.
aiver in hand, Maryland joins small group of states enrolling disabled in managed care
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