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