The governor signed into law all of the managed care oversight provisions that were put into the House’s health and human services budget bill. A summary of the new oversight language is below:
The DHS is required to submit to the chairs and ranking members of the human resources committees of the House and Senate and to the chairs and ranking members of the HHS budget subcommittee quarterly reports and an annual report regarding consumer protection, outcome achievement, and program integrity in the Medicaid program.
The HHS budget sub is required to dedicate one meeting per year to review this data.
Consumer protection — The consumer protection report to the legislature shall be based on the following reports on provider and member services:
• Member enrollment and disenrollment
• Member grievances and appeals
• Member call center performance
Outcome achievement — The focus of the Legislature in moving to managed care is to improve the quality of care and outcomes for Medicaid members. The outcome achievement reports to the legislature have to include the following reports related to health outcomes and contract management:
• Percentage of claims paid and denied
• Managed care organization capitation payments
• The medical loss ration
• Managed care savings
Program integrity — Under managed care, federal, state and contractual safeguards will continue to be incorporated to prevent and eliminate fraud, waste abuse in the Medicaid program. The program integrity report given to the legislature will include information on the following:
• The level of fraud, waste, and abuse identified by the MCOs
• A summary report by the insurance division related to the MCO licensure status and audit.
Other oversight entities — The DHS council, Medical Assistance Advisory council, Hawk-I board, MHDS commission and Office of Long-Term Care Ombudsman shall regularly review managed care and how it impacts their groups and submit summaries of pertinent information to DHS to be included in the legislative report.
The DHS council, MAAC, and Hawk-I board are required to submit to the chairs and ranking members the minutes of their meetings related to managed care.
The DHS director shall submit the compilation of recommendations from stakeholders and Medicaid members to the chairs and ranking members of the House and Senate human resources committee and the HHS budget sub.
DHS shall ensure that MCOs comply with all the following:
• Continue a member’s benefits during an appeals process
• MCOS shall allow providers to appeal on a member’s behalf
MCOs shall, at the request of a member, attempt to negotiate in good faith a single-case agreement with a recipient’s out-of-network provider, including a provider outside of the state.
The health policy oversight committee will meet at least two times a year during the interim to provide continuing oversight for managed care and to ensure effective and efficient administration of the program, address stakeholder concerns, monitor program costs and expenditures and make recommendations.
This bill expands the authority of the office of the long-term care ombudsman and appropriates an additional $100,000 for one new ombudsman position.
The bill adds 10 public members to the MAAC. It also adds a member of the Hawk-I board to the MAAC and the Long-Term Care Ombudsman’s office. It also adds a member of the public as a co-chairperson of the council.
The DHS director shall make recommendations to the governor for appointment of public representatives to the MAAC and fill them no later than June 30, 2016. The MAAC executive committee will continue to meet across the state with stakeholders and get feedback. They will meet six times in 2017.
The bill includes occupational therapy as a covered service under the Hawk-I program. The Hawk-I Board shall monitor the capacity of the MCOs to specifically and appropriately address the unique needs to children and children’s health delivery.