1. health and fitness

Medicaid Network Adequacy
Standards and Value Options
Maryland Carve Out
MHBE Network Adequacy and ECP Workgroup
Shannon M. McMahon
Deputy Secretary, Health Care Financing
Maryland Department of Health and Mental Hygiene
May 20, 2015
Elements of Discussion
• Provide an overview Medicaid Network Adequacy
requirements;
• Introduce role of Value Options (VO) Maryland in
Medicaid;
• Describe elements of VO’s provider directory;
• Discuss data available concerning its providers and
network;
• Discuss possibility of using VO provider network data
as a proxy for understanding the denominator of BH
providers participating in MD QHP networks.
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Federal Medicaid Network
Adequacy Requirements
• 42 CFR 206 requires the single state Medicaid agency
to assure availability of services covered under the State
plan (e.g. FFS) are available and accessible to enrollees
of MCOs, PIHPs, and PAHPs.
• This requirement applies to Maryland’s 8 MCOs as
well as to the state’s contracts with Value Options for
behavioral health and substance use services, and
DentaQuest for dental services.
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Federal Medicaid Network
Adequacy Requirements continued
• The MCOs/VO are required to establish and maintain a
network that considers:
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(i) The anticipated Medicaid enrollment;
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(ii) The expected utilization of services;
(iii) The numbers and types (in terms of training, experience,
and specialization) of providers required to furnish the contracted
Medicaid services including those who are not accepting new
Medicaid patients;
(iv) The geographic location of providers and Medicaid enrollees,
considering distance, travel time, the means of transportation
ordinarily used by Medicaid enrollees, and whether the location
provides physical access for Medicaid enrollees with disabilities.
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Maryland Medicaid Network
Standards
• In addition to the federal network adequacy
standards, Maryland regulations require MCOs to:
• provide a complete network of adult and pediatric
primary care, specialty care, ancillary service, vision,
pharmacy, and home health;
• establish mechanisms to ensure that network
providers comply with access requirements, monitor
regularly to determine compliance, and take
corrective action if there is failure to comply.
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Maryland Medicaid Network
Standards continued
• Medicaid requires an enrollee-to-PCP ratio of 200:1
– However, Medicaid may approve a ratio of up to 2,000:1 for adults, and
1,500:1 for children under the age of 21
• An MCO must have a provider network that ensures enrollees
have access to primary care, pharmacy, OB/GYN, diagnostic
laboratory, and X-ray.
• An MCO must provide services in:
– Urban areas, within 10 miles
– Rural areas, within 30 miles
– Suburban areas, within 20 miles
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Maryland Medicaid Network
Standards continued
• DHMH requires MCOs to provide all medically necessary
specialty care.
– If MCO doesn’t have the appropriate in-network specialist needed to
meet the enrollee’s medical needs, MCO must arrange for care with an
out-of network specialist and compensate the provider.
• Regulations for specialty care access require that each
MCO have an in-network contract with at least one provider
statewide in the following medical specialties:
Allergy
Dermatology
Endocrinology
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Infectious disease
Nephrology
Pulmonology
Maryland Medicaid Network
Standards continued
• Additionally, each MCO must include at least one innetwork specialist in each of the 10 regions throughout
the State for the following eight core specialties:
Cardiology
Otolaryngology
Gastroenterology
Neurology
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Ophthalmology
Orthopedics
Surgery
Urology
Coming Down the Pike…New Federal
Network Adequacy Standards for
Medicaid?
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The Centers for Medicare and Medicaid Services has been
working on what has been reported to be a “substantial rewrite” of the Medicaid managed care regulations.
The regulations have not been substantially changed in over 13
years.
CMS has been working on the new regulations for more than a
year.
Anticipate that they will include new standards for long term
care services offered though Medicaid MCOs as well as:
– more robust data collection;
– stronger anti-fraud policies, and
– new requirements for provider networks.
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Value Options Maryland
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Medicaid and the Behavioral Health Administration (BHA)
is jointly working with ValueOptions to serve as the state’s
Administrative Services Organization (ASO) to manage the
carve out behavioral health services from its managed care
program, with added performance risk.
Specifically, the State carved out all SUD services, which
were previously provided by the managed care organizations
(MCOs) and are now delivered fee-for-service through an
Administrative Services Organization (ASO).
Specialty mental health services, which were already carvedout of MCOs are included in the ASO contract which is now
overseen by Medicaid.
Provider File Layout Process
• ValueOptions currently receives a weekly
electronic provider file from MMIS.
• VO and DHMH have worked together to
develop a provider file layout which specifies
format/frequency.
• VO has also developed a crosswalk needed
to define behavioral health provider types.
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ValueOptions Provider
Directory
• Includes physicians, non-physicians,
hospitals and Outpatient Mental Health
Clinics (OMHC).
• Provider search is available through our
website and is searchable for anyone
(HealthChoice MCOs, Members, Providers
etc.).
• ValueOptions also has the capability to
generate specific reports based on any
number of specifications.
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VO Provider Data Capabilities
• VO can provide counts of its provider network by:
– Clinician type: Our data contains a licensure type field
– Location (County, City, Zip Code)
– Jurisdiction
– Accepting new patients (Not available at this time due
to credentialing issues. Is available through our QHOP
partnership with Evergreen.)
– Can provide counts based on OMHC (Outpatient
Mental Health Center)
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ValueOptions
ReferralConnect®
• On June 29th ReferralConnect® will
launch on the VO website: http://
maryland.valueoptions.com/
• ReferralConnect® is an innovative Webbased provider referral system which
offers real time information on our provider
network.
• Users can search for providers, view
specialties and other helpful demographic
information.
• Mobile Referral Application is also available.14
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Questions?
• Contact:
Shannon M. McMahon
Deputy Secretary, Health Care Financing
Department of Health and Mental Hygiene
[email protected]
Zereana Jess-Huff, Ph.D.
Chief Executive Officer
ValueOptions Maryland
[email protected]
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