CMS Approves KanCare Carve-In of ID/DD Population
February 7, 2014 02:33 PM
On January 29, the Centers for Medicare and Medicaid Services (CMS) approved Kansas’ inclusion of the Intellectually Disabled/Developmentally Disabled (ID/DD) population into its Medicaid managed care program KanCare, effective February 1. In a letter to the Medical Director of the Kansas Department of Health and Environment (KDHE), Cindy Mann, the Director of the Center for Medicaid and CHIP Services (CMCS) of the Centers for Medicare and Medicaid Services (CMS), attached a 106-page document highlighting the Special Terms and Conditions (STCs) stipulating the details. The Council reports on some of the key STCs as they apply to the ID/DD population.
Scope of the Carve-In
Services. Services in the carve-in include targeted case management and HCBS services, including: assistive services, financial management services, medical-alert rental, overnight respite, personal assistance services, residential and day supports, sleep-cycle supports, specialized medical care, supportive employment, supportive home care and wellness monitoring. For details, clickhere.
Transition period. During the transition period from fee-for-service (FFS) to managed care, ID/DD enrollees can see their old long-term services and supports (LTSS) providers for 180 days from February 1, or until a service plan is in place. Those with residential LTSS providers can continue to see them for as long as oneyear, at full FFS rates. After the transition, out-of-network qualified providers are reimbursed at 90% of in-network providers. For details, see page 27 and 36, here.
Obligations of the Plans
Network adequacy. Each MCO must contract with at least two ID/DD LTSS providers in every county where at least two providers are available, licensed and certified. Each MCO must extend three contract offers to each provider serving the ID/DD enrollees for at least the FFS rate.
Obligations of the State
Protections from improper institutionalization. The State must review and approve all recommendations of placements into ICF/IID or nursing facilities, in order to prevent any improper institutionalizations.
Elimination of the underserved waitlist. In January, the State had expressly declared that it will seek to eliminate the so-called “underserved waitlist” “over the next several months.” The waitlist includes approximately 1,400 developmentally disabled Kansans who are only receiving some of the Medicaid services they need. The state plans to soon publish a more detailed strategy of how it will achieve this objective.
For now, the savings generated from the transition away from FFS to KanCare will be used to increase the number of slots available for HCBS waiver services. The State must meticulously report to CMS on rebalancing efforts vis-a-vis the waiting lists, including:
the total number of individuals in nursing facilities, and public ICF/IDs, the total number of people on each of the 1915(c) waiting lists; the number of people that have moved off the waiting list and the reason; the number of people that are new to the waiting list; and the number of people that are on the waiting list, but [are] receiving community-based services through the managed care delivery system.
Ride-alongs. The State will conduct a “ride along” with the MCO care coordinators within the first 180 days of the carve-in for the State to observe the MCOs performing needs assessments and service plan developments.
Call center and review of complaints and grievances. The State will also operate a call center that will field complaint calls from beneficiaries. This provides an independent mechanism for beneficiaries to complain about the MCOs. The State must review call center response statistics daily for the first 30 days of the carve-in, and at least weekly thereafter up to 180 days of the carve-in. Additionally, the State must review the MCOs’ complaint logs.
State-MCO implementation calls. The State must hold calls with the MCOs twice a week for the first 30 days of the carve-in, and at least weekly for the first 90 days thereafter and bi-weekly for the next 90 days thereafter. These calls will mostly serve to troubleshoot problems and devise prompt solutions.
Quality review. The State or its External Quality Review Organization (EQRO) shall review the MCOs’ performances, in an annual review, on metrics relating to: level of care determinations, person-centered plans, MCO credentialing and/or verification policies, and health and welfare of enrollees. To see a previous Council brief on CMS’ recent guidance for EQRO review of managed long term services and supports (MLTSS), click here.
Co-payments. Currently, no enrollees are required to make co-payments. However, the State reserves the right to charge co-payments as stipulated in its state plan given that it provides CMS with notice at least 60 days prior to implementation. For details, see page 23, here.
Timely payments. As the National Council on Medicaid Home Care has discussed in its previous brief on KanCare, one of the primary provider concerns with the program has been late payments and denial of services. The Council believes that the STCs provide insufficient assurances of timely payments based on medical necessity. The STCs stipulate merely that “to provide for a smooth transition for beneficiaries, the state has assured CMS, through the submission of pre-implementation reports, that â€¦a timely and efficient billing process will be established.” Additionally, one of the jobs of the ombudsman is to “[h]elp consumers understand and resolve billing issues, or notices of non-coverage.”
Jane Kelly, Executive Director of the Kansas Home Care Association (KHCA), stated that problems with pre-authorizations and proper payments persist with KanCare notwithstanding the recent carve-in. She recognizes that all three of the MCOs have held conference calls with home care providers every few weeks, which helps somewhat with billing concerns. However, she remains skeptical, stating “I don’t see where adding another huge group [i.e., the ID/DD population] on top of the current KanCare population, without first solving existing problems, will help.” For a more complete list of KHCA member grievances, see Ms. Kelly’s article in a previous Medicaid Council Report, here.
The Council advocates that states integrating MLTSS should institute ample training for providers to come up to speed on MCO billing systems. This can be accomplished by creating and leveraging existing stakeholder workgroups as forums where state plans can properly educate providers in how to properly submit requests for payments. Wherever possible, the Council also suggests that states implement uniform billing systems amongst all MCOs involved in MLTSS, in order to improve provider compliance and efficiency.
Underserved waitlist. The Council commends the State and CMS for instituting concrete steps for eliminating the HCBS waitlists, and awaits the State’s forthcoming detailed plan.
Transitioning to MLTSS. The Council is seeing an increasing trend towards transitioning LTSS from fee for service into managed care. The carve-in of the ID/DD population into KanCare is one of the latest developments in this trend. However, home care providers should be aware that beneficiaries and interest groups alike are voicing legitimate concerns regarding the move to managed care in Medicaid. Providers are also not powerless or voiceless in the matter. To see a recent Council brief on recommendations to providers of LTSS faced with the transition to MLTSS, click here.
Stakeholders can be very useful in improving a state’s transition to managed care in Medicaid. Likewise, if these stakeholders have outright opposition to using managed care in Medicaid, the forums are there to voice those opinions. Any state’s consideration or movement to Medicaid managed care is neither automatic nor a decision made in a vacuum.
Home care providers are encouraged to keep abreast of managed care transitions in their states, advocate on a state level, and to contact the Council with any questions or concerns.