Town Hall Presentation
Provider Town Hall Presentation Managed Medical Assistance (MMA) & Child Welfare (CW) 2014 1 Agenda • Sunshine Health & Managed Medical Assistance (MMA) Overview • Child Welfare (CW) Program Overview • Continuity of Care for Transitioning Members • Cenpatico Behavioral Health • Contracting • Covered Services & Expanded Benefits • Q&A 2 Sunshine Health & Managed Medical Assistance (MMA) Overview Mark Barrett VP, Network Development & Contracting MMA & CW 2014 3 Sunshine Health Overview Sunshine Health is a wholly-owned subsidiary of Centene Corporation and has provided Medicaid Managed Care services in Florida since 2009. • Products: Medicaid; Long Term Care; HealthyKids; Medicare SNP; and Health Insurance Exchange • Number of Florida employees: 1,200+ • Number of Florida physicians: 18,500+ 4 Centene Overview “Better Health Outcomes, Lower Cost” History and Scope of Centene • Established in 1984 in Milwaukee, WI • Headquartered in St. Louis, MO Medicaid (19 States) ~2.6M • Fortune 500 company (#303) Members • Employs approximately 8,700 individuals • Serves government sponsored healthcare programs in 21 states Exchanges (9 States) MA D-SNP (6 States) Correctional (3 States) • Provider network includes over 190,000 physicians and 1,900 hospitals 5 Bringing Medicaid Leadership Experience to New Markets 1984 1995 1999 2004 2006 2006 2007 2009 2009 2010 2011 2011 2012 2012 Partnering with 19 State Medicaid Agencies* 2012 2013 2013 2013 Starting Q4 2014* * Fidelis SecureCare is subject to certain acquisition closing conditions including regulatory approvals 6 Specialty Company Resources and Expertise Total Solution Integration physical health, behavioral health, pharmacy services, and ancillary services Behavioral Health & Specialty Therapies Case Management Software Integrated Approach HCBS for I/DD Populations Centurion is a correctional healthcare joint venture between Centene and MHM Services Inc. Currently has contracts in MA, MN, and TN. Provider of In-Home Services Life, Health & Wellness Pharmacy & Specialty Pharmacy Benefits Vision Benefits Telehealth Services 7 Managed Medical Assistance (MMA) Sunshine Health was selected to provide managed care services for Medicaid recipients in Regions 3 through 11 for a five year period. 2014 Rollout of MMA • • • • Regions 2, 3, 4 Regions 5, 6, 8 Regions 10, 11 Regions 1, 7, 9 - May 1 June 1 July 1 August 1 8 Managed Medical Assistance (MMA) & Managed Care The goals of Florida MMA are to provide: • Coordinated health care across different health care settings • A choice of the best managed care plans to meet recipients’ needs • The ability for health care plans to offer different, or more, services • The opportunity for recipients to become more involved in their health care 9 Medicaid Managed Care There are two different components that make up the Statewide Medicaid Managed Care (SMMC) program: • Long Term Care (LTC) • Managed Medical Assistance (MMA) Medicaid recipients who qualify and become enrolled in the Florida LTC managed care program will receive LTC services through a LTC managed care plan. Medicaid recipients who qualify and become enrolled in the Florida MMA program will receive all health care services other than LTC through a managed care plan. 10 AHCA’s List of Statewide Comprehensive Plans Region Comprehensive Plans Available 1 2 3 4 5 6 7 8 9 10 11 None available None available Sunshine, United Sunshine, United Sunshine Sunshine Molina, Sunshine, United Sunshine Sunshine Humana, Sunshine Amerigroup, Coventry, Humana, Molina, Sunshine, United 11 Child Welfare (CW) Overview Cathy Sharp Manager, Provider Partnership MMA & CW 2014 12 Child Welfare (CW) Through a competitive bid process, the Agency for Health Care Administration (AHCA) selected Sunshine Health as the only specialty managed care plan to provide managed care services for children in the CW system for a five year period. 2014 Rollout of CW • • • • Regions 2, 3, 4 Regions 5, 6, 8 Regions 10, 11 Regions 1, 7, 9 - May 1 June 1 July 1 August 1 13 Child Welfare (CW) Sunshine Health is the sole specialty plan in Florida for the child welfare population, serving approximately 30,000 children statewide. CW includes three primary partners: • Sunshine Health • Cenpatico Behavioral Health • Community Based Care Integrated Health (CBC-IH) 14 Community Based Care (CBC) Sunshine Health is contracted with Community Based Care – Integrated Health (CBC-IH) to provide support and care coordination for all Sunshine Health CW Members statewide. Sunshine Health’s contract with CBC-IH is an innovative partnership designed to ensure that all behavioral or physical health care related services are coordinated with the CBC agencies. Our staff provide care and utilization management through an integrated team of professionals focused on meeting the overall needs of each child. 15 Child Welfare (CW) CBC-IH is assisting Sunshine Health in gathering information for the new CW members’ Health Risk Screenings (HRS). The HRS includes questions regarding physical health, behavioral health, dental, and pharmacy authorizations or appointments during the 90 day CW continuity of care period. CBC-IH will identify a PCP for each child in the Sunshine Health CW Plan, and at go-live, it is anticipated that Sunshine Health will have the designated PCP on its provider list. This will greatly reduce the need for auto-assignment and ensure uninterrupted transition of care. 16 Continuity of Care Cathy Sharp Manager, Provider Partnership MMA & CW 2014 17 New Members Sunshine Health ensures continuous care for new members receiving an active course of treatment through their previous health plan or Medicaid Fee-For-Service (FFS), provided the services were prior authorized before enrollment with Sunshine Health. These services include: • Prior existing orders • Provider appointments (dental appointments, surgeries, etc.) • Prescriptions (including those at non participating pharmacies) • Behavioral health services 18 Continuity of Care Period Sunshine Health provides continuity of care for all new members for the following time periods following the enrollment date or until the member’s new PCP or behavioral health provider reviews the member’s treatment plan: • MMA members up to 60 calendar days • CW members up to 90 calendar days Sunshine Health ensures new members who are pregnant and have initiated a course of prenatal care, regardless of the trimester, continuity of care with their current OB/GYN until the completion of postpartum care Sunshine Health also ensures, in conjunction with Medicaid eligibility, continuity of care for active orthodontia until the completion of care and reimbursement to providers, regardless of provider network 19 Authorization & Payment In the event a new enrollee is receiving a prior authorized treatment with an out-of-network provider, Sunshine Health will: • Continue to pay for the course of treatment through the continuity of care timeframes, regardless of whether the services are provided by participating or non-participating providers • Adjudicate claims submitted by out-of-network providers between the date of service and the date of the clean claim submission, unless that period exceeds 365 days 20 Pharmacy Management • Sunshine Health adopted AHCA’s Preferred Drug List (PDL) formulary for the first year of MMA and CW. • Sunshine Health’s Pharmacy Benefit Manager (PBM), US Script, will continue to manage the pharmacy network and process PA or step edit requests • Sunshine Health’s specialty drug company, Acaria will continue to process requests for specialty drugs • Age, gender, and quantity limits along with the drugs that require a PA will mirror those on AHCA’s PDL. This information can be accessed through a link on Sunshine Health’s website to the AHCA website • PA forms and criteria can be accessed through US Script or Sunshine Health’s website • Any changes made by AHCA will be adopted to the PDL by Sunshine Health 21 Case Management Support A Sunshine Health case manager is assigned to all members needing continuity of care services. Case managers and other team members will follow these members and facilitate the care coordination process by: • Contacting the member/caregiver to obtain information on the member’s providers, dates of appointments, and provided services • Providing additional clinical information to utilization management • Helping the member make appointments with their Sunshine Health PCP or behavioral health provider • Helping the member transition to a participating provider, if needed 22 Contact Us We encourage providers who have new Sunshine Health patients transitioning from Medicaid FFS or another heath plan with approved authorizations, or in ongoing treatment plans, to contact Sunshine Health’s Utilization Management staff as soon as possible by calling: 1-866-796-0530 23 Cenpatico Behavioral Health Kristie Cavins Provider Relations Cenpatico Behavioral Health MMA & CW 2014 24 Service Area and Provider Types Cenpatico contracts with an extensive provider network that contracts with the following: • Community Mental Health Centers (CMHCs) • Independent Practitioners (MDs, PhDs, LPC, LCSW, and LMFTs) • Institutes for Mental Disorders (IMD) • General Hospitals offering psychiatric and/or substance use services • Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Primary Care Clinics (PCCs) • Statewide Inpatient Psychiatric Programs (SIPP) 25 Provider Participation Responsibilities Cenpatico emphasizes its commitment to quality of care for Sunshine Health members by ensuring our providers adhere to the following: • Provide members with a professional level of care and efficiency that is consistent with community standards • Prepare and maintain complete medical records and other required documents for all member care • Participate in quality improvement activities, utilization review activities, orientations, continuing education, and other medical management components • Abide by ethical principles of their profession Cenpatico will communicate with providers to inform them of their participation responsibilities, credentialing and application status, and network requirements. 26 Provider Training Program Cenpatico will offer a series of trainings for providers specific to behavioral management services for members including: • Motivation interviewing • Trauma informed care • Privacy/HIPAA • Behavioral health screening tools • Integration of Care • IMPACT – depression model – PCP focused A schedule of upcoming training events will be available at: SunshineHealth.com 27 Network Participation Agreements Cenpatico wants to extend an agreement to your organization if you are not already contracted with us. For those existing network providers, an amendment to your existing contract to incorporate the expanded behavioral health outpatient benefits and applicable modifiers for MMA and CW may be necessary. For additional information, contact Dawn Kinkead at: [email protected] or 727-434-4139 28 Contracting Bridget Jones Contract Negotiator MMA & CW 2014 29 Sunshine Health Network Snapshot Medical 168 5,500+ 13,000+ Hospitals Primary Care Physicians Specialist Physicians Behavioral 100+ Psychiatric Community Hospitals & Crisis Stabilization Units 650+ Psychiatrists 3,100+ Behavioral Health Providers Dental 1,000+ Dentists 100+ Oral Surgeons Pharmacy 4,300+ Retail Pharmacies 30 Participating Hospitals in Region 5 Morton Plant Northbay Hospital 6600 Madison St New Port Richey 34652 727-842-8468 Pasco 5 Community Hospital/Medical Center of Trinity 9330 State Road 54 Trinity 34655 727-834-4000 Pasco 5 Regional Medical Center Bayonet Point Hudson 34667 727-819-2929 Pasco 5 Florida Hospital Wesley Chapel 14000 Fivay Road 2600 Bruce B Downs Blvd Wesley Chapel 33543 813-929-5000 Pasco 5 Florida Hospital Zephyrhills 7050 Gall Blvd Zephyrhills 33541 813-788-0411 Pasco 5 Bayfront Health Dade City 13100 Fort King Rd Dade City 33525 352-521-1100 Pasco 5 Mease Countryside Hospital 3231 Mcmullen Booth Rd Safety Harbor 34695 727-725-6111 Pinellas 5 Mease Dunedin Hospital 601 Main St Dunedin 34698 727-733-1111 Pinellas 5 Morton Plant Hospital 300 Pinellas St Clearwater 33756 727-462-7000 Pinellas 5 St. Anthony's Hospital 1200 7th Ave N St Petersburg 33705 727-825-1100 Pinellas 5 Bayfront Medical Center St. Petersburg 33701 727-823-1234 Pinellas 5 Florida Hospital North Pinellas 701 6th St 1395 South Pinellas Avenue Tarpon Springs 34689 727-942-5000 Pinellas 5 Edward White Hospital 2323 9th Avenue North St. Petersburg 33713 727-323-1111 Pinellas 5 Largo Medical Center 201 14th Street SW Largo 33770 727-588-5200 Pinellas 5 Northside Hospital 6000 49th Street North St. Petersburg 33709 727-521-4411 Pinellas 5 St. Petersburg General Hospital 6500 38th Avenue North St. Petersburg 33710 727-384-1414 Pinellas 5 All Children's Hospital 501 6th Ave S St. Petersburg 33701 727-898-7451 Pinellas 5 Largo Medical Center - Indian Rocks 2025 Indian Rocks Rd Largo 33774 727-581-9474 Pinellas 5 31 Participating Hospitals in Region 6 Florida Hospital Wauchula 533 West Carlton Street Wauchula 33873 863-773-3101 Hardee 6 Florida Hospital Lake Placid 1210 US Hwy 27 North Lake Placid 33852 863-465-3777 Highlands 6 Florida Hospital Heartland Medical Center 4200 Sun n' Lake Blvd Sebring 33872 863-314-4466 Highlands 6 Highlands Regional Medical Center 3600 S Highlands Ave Sebring 33870 863-385-6101 Highlands 6 Brandon Regional Hospital 119 Oakfield Dr Brandon 33511 813-681-5551 Hillsborough 6 St. Joseph's North Hospital 4211 Van Dyke Road Lutz 33558 813-443-7000 Hillsborough 6 South Florida Baptist Hospital 301 N Alexander St 33563 813-757-1200 Hillsborough 6 South Bay Hospital 4016 Sun City Center Blvd Plant City Sun City Center 33573 813-634-3301 Hillsborough 6 Florida Hospital Carrollwood 7171 N. Dale Mabry Highway Tampa 33614 813-932-2222 Hillsborough 6 Florida Hospital Tampa 3100 E. Fletcher Ave. Tampa 33613 813-971-6000 Hillsborough 6 Shriners Hospitals for Children- Tampa Tampa 33612 813-972-2250 Hillsborough 6 Tampa 33607 813-870-4000 Hillsborough 6 St. Joseph's Women's Hospital 12502 USF Pine Dr 3001 W Dr Martin Luther King Jr Blvd 3030 W Dr Martin Luther King Jr Blvd Tampa 33607 813-879-4730 Hillsborough 6 Tampa General Hospital 1 Tampa General Cir Tampa 33606 813-844-7000 Hillsborough 6 Blake Medical Center 2020 59th St W Bradenton 34209 941-792-6611 Manatee 6 Lakewood Ranch Medical Center 8330 Lakewood Ranch Blvd Bradenton 34202 941-782-2100 Manatee 6 Manatee Memorial Hospital 206 Second Street East Bradenton 34208 941-746-5111 Manatee 6 Bartow Regional Medical Center 2200 Osprey Blvd Bartow 33830 863-533-8111 Polk 6 Heart of Florida Regional Medical Center 40100 U.S. 27 Davenport 33837 863-422-4971 Polk 6 Lakes Wales Medical Center 410 S 11th St Lake Wales 33853 863-676-1433 Polk 6 Lakeland Regional Medical Center 1324 Lakeland Hills Blvd Lakeland 33805 863-687-1100 Polk 6 Winter Haven 33881 863-293-1121 Polk 6 St. Joseph's Hospital *Letter of Intent Completed & Agreement Pending Winter Haven Hospital 200 Avenue F NE 32 Contracting Overview Contractual agreements must be in compliance with the terms of the Managed Care Plan’s AHCA contract. • 55 required contract checklist provisions • Template agreements must be approved by AHCA • Providers must be eligible for participation in the Medicaid Program • Fully completed application, including updated CAQH credentials, will expedite the credentialing process Who do I contact about an agreement? • Contracting Representatives are on site today 33 Covered Services, Expanded Benefits & Program Incentives Cathy Sharp Manager, Provider Partnership MMA & CW 2014 34 MMA Covered Services • • • • • • • • • • • • • Advanced registered nurse practitioner services Ambulatory surgical treatment center services Chiropractic services Dental services Early periodic screening & treatment services Emergency services Family planning services Healthy start services Hearing services Home health agencies services Hospice services Hospital inpatient services Hospital outpatient services • • • • • • • • • • • • • • Laboratory & imaging services Medical equipment & prostheses Mental Health services Nursing care Optical services Optometrist services Physical, occupational, respiratory, and speech therapy Podiatric services Physician services, including physician assistant services Prescription drugs Renal analysis services Respiratory equipment & supplies Substance abuse treatment Transportation to access covered services 35 Sunshine Health Expanded Benefits (Limitations and Authorizations may apply) Benefit Description MMA CW • Two (2) exams a year and two (2) cleanings a year. • Routine and diagnostic x-rays every two (2) years. • Targeted dental outreach to non-compliant members. • Postcard referrals for dental check ups provided to PCPs for distribution to members. Yes Part of standard benefits Expanded Vision An additional dollar allowance towards glasses, lenses, or frames. Yes Yes Expanded Hearing Adult members will receive one (1) hearing exam per year and one hearing aid every two (2) years. Yes Part of standard benefits Over-the-Counter/ Mail Order A $25 per family per month benefit to purchase health related items such as vitamins, aspirin, and first aid supplies. Yes Yes Expanded Adult Dental 36 Sunshine Health Expanded Benefits (Limitations and Authorizations may apply) Benefit Description MMA CW Unlimited Primary Care Visits Unlimited office visits for general services such as family practice or pediatric when medically necessary. Yes Yes Home Health Visits Up to four (4) intermittent visits per day for non‐pregnant adults age 21 and older (additional home health visits are already covered for children and pregnant adults). The visits can be any combination of licensed nurse and home health aide visits when medically necessary. Yes Yes Home Visits Two (2) home visits per month by a physician or physician extender for supervision of chronic conditions. Yes Yes 37 Sunshine Health Expanded Benefits (Limitations and Authorizations may apply) Benefit Description MMA CW Expanded Perinatal Visits Unlimited office visits with participating maternity providers for prenatal and postpartum care. Yes Yes Expanded Outpatient Hospital Visits Outpatient hospital services covered up to $1,500 per year for members over the age of 21; excluding Region 3 which covers up to $1,800. Yes Part of standard benefits Waived Co-payments No co-payments. Yes Yes Adult Pneumonia, Influenza, and Shingle Vaccines No charge for certain vaccines for members age 21 and older. Yes Part of standard benefits Post-Discharge Meals Up to ten (10) home-delivered meals for members who are discharged from the hospital and participating in Sunshine Health’s Transitional Care Program. Yes Yes Nutritional Counseling Up to 3 outpatient visits per year with a participating dietician for nutritional counseling. Yes Yes 38 Sunshine Health Expanded Benefits (Some limitations and authorizations may apply) Benefit MMA CW Yes Yes Medically Related Up to $100 per day for up to 21 days to cover lodging and up Lodging and Food to two (2) meals per day for family members when a member’s approved specialized hospital stay is 150 miles or more from home. Yes Yes Circumcision Yes Yes Art Therapy Description Delivered in an outpatient setting in conjunction with other behavioral health services. Circumcision is covered for newborn males during the initial hospitalization. 39 Sunshine Health Program Incentives Benefit Description MMA CW NurseWise A 24/7 nurse advice line to answer healthcare questions. Assistance is offered in English, Spanish, and other languages per request. Yes Yes Peer Support Services Peer Support Services for members with mental health conditions provided by Certified Peer Support Specialists in mental health recovery who are trained in delivering effective peer support. Yes Yes Care Grants Care Grants up to $150 a year to cover expenses not covered by Medicaid. Examples include athletic uniforms, athletic equipment, school trips, and college application fees. Requests for Care Grants can be made through a referral from a Provider, CBC Dependency Care Manager, or a Sunshine Health staff member. Children under age 21 who have a follow-up outpatient appointment within seven (7) days of discharge from a Behavioral Health inpatient hospitalization will receive an incentive to increase compliance with discharge plans. Provides educational materials along with a $10 gift card following confirmation that they attended their appointment. N/A Yes Yes Yes Children’s Follow-Up Incentive Program 40 Questions 41
© Copyright 2024