Combined Report on Medicaid Managed Care Provider Network Adequacy, Monitoring, and ...

79 Pages·2017·1.37 MB·English

by  Allaway Shirley

Combined Report on Medicaid Managed
Care Provider Network Adequacy,
Monitoring, and Violations

As Required By
S. B. 760, 84th Legislature, Regular Session, 2015, and
2016-17 General Appropriations Act, H.B. 1, 84th Legislature,
Regular Session, 2015
(Article II, Health and Human Services Commission,
Rider 81 and Rider 82)

Health and Human Services Commission
January 2017
Contents
1. Executive Summary ...................................................................................................................1
2. Introduction ................................................................................................................................3
S.B. 760 ........................................................................................................................................3
Riders 81 and 82 ...........................................................................................................................4
3. Background ................................................................................................................................4
Medicaid Managed Care Network Requirements ........................................................................4
Single Case Agreements ...............................................................................................................8
4. Current Network Adequacy Initiatives ...................................................................................9
Stakeholder Engagement ..............................................................................................................9
Access to Care: Distance, Travel Time, and Appointment Availability ......................................9
Expedited Credentialing .............................................................................................................12
Provider Directories and Appointment Assistance ....................................................................13
5. MCO Network Adequacy Oversight ......................................................................................14
Direct Monitoring .......................................................................................................................14
Prior Authorization Wait Times .................................................................................................15
Provider Ratios / Benchmarks ....................................................................................................16
MCO Compliance Data ..............................................................................................................20
MCO Compliance Actions .........................................................................................................24
6. Conclusion ................................................................................................................................25
List of Acronyms ..........................................................................................................................25
Appendix [A]: STAR+PLUS Geo-mapping (2nd Quarter, FY 2016) ................................... A-1
Appendix [B]: STAR (Children) Geo-mapping (2nd Quarter, FY 2016) ..............................B-1
Appendix [C]: STAR (Adult) Geo-mapping (2nd Quarter, FY 2016)................................... C-1
Appendix [D]: Remedies Assessed for MCO Non-compliance of Medicaid OON Standards
(FY 2011 through FY 2015) ..................................................................................................... D-1
Appendix [E]: Remedies Assessed for MCO Non-compliance of Geo-access Standards
(3rd Quarter, FY 2015 through 2nd Quarter, FY 2016) ...........................................................E-1
Appendix [F]: Overview by Year (SCAs by Reason and SCAs by MCO) .......................... F-1
Appendix [G]: SCAs by Reason and MCO ........................................................................... G-1
Appendix [H]: SCAs by Provider Category and Reason ..................................................... H-1
Appendix [I]: SCAs by Provider Category and SCAs by Reason, Descending Order ........ I-1
Appendix [J]: DME SCAs by Provider Category and Type of DME .................................. J-1
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Appendix [K]: SCAs by MCO, Provider Type Category, Service Provided, SCA Reason,
by Fiscal Year ............................................................................................................................ K-1
Appendix [L]: Texas MCOs FY 2011 through FY 2015 (By Fiscal Year and MCO) ........L-1

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1. Executive Summary

The Texas Medicaid program serves more than four million individuals, the vast majority of
whom receive services through managed care.1 Under the managed care model, the Health and
Human Services Commission (HHSC) contracts with managed care organizations (MCOs), also
known as health plans. HHSC pays the MCOs a monthly amount per enrolled individual (known
as a member) to coordinate and reimburse providers for health services for Medicaid members
enrolled in their health plan. Services are provided to individuals in Medicaid through an MCO's
network of providers, which includes primary care physicians, specialty care, and behavioral
health providers. MCOs are required to maintain networks of providers so individuals have
timely access to care, within specific distances, as well as a choice of providers. HHSC similarly
contracts with dental maintenance organizations (DMOs), also known as dental plans, to
coordinate and provide dental services for members under Children's Medicaid Dental Services
and the Children's Health Insurance Program (CHIP). For purposes of this report, the term MCO
is used to refer to both health and dental plans.

In Texas, the Medicaid managed care contracts include provider network requirements for
MCOs designed to ensure all members have access to, and a choice from, a network of
providers. To determine whether MCOs have adequate provider networks, HHSC tracks
timeliness of care through annual surveys, monitors member and provider complaints2, monitors
geo-mapping3 results to track the distance between providers' geographic locations and members'
residences, monitors member utilization of out-of-network (OON) providers, and examines the
number of single case agreements (SCAs) made by MCOs with non-contracted providers. While
none of these indicators alone can provide a full and accurate measure of network adequacy,
combined they help HHSC assess the adequacy of an MCO's provider network and performance
in meeting contractual obligations.

S.B. 760, 84th Legislature, Regular Session, 2015, requires HHSC to establish additional
minimum provider access standards for MCO provider networks. While Texas currently has a
range of provider network requirements and contractual remedies for MCO non-compliance with
these requirements, S.B. 760 specifically requires MCOs to:

• Pay liquidated damages for failing to comply with minimum network access standards;
• Establish an expedited credentialing process for provider types identified by HHSC;
• Regularly update and publish provider directories on their websites; and
• Send paper copies of provider directories to all STAR+PLUS and STAR Kids members,
unless these members opt-out, and to members of other Medicaid managed care programs
only upon request.4

1 Texas Health and Human Services Commission, Medicaid Enrollment by Managed Care Plan (March 2016)
https://hhs.texas.gov/about-hhs/records-and-statistics/research-and-statistics.
2 HHSC operates a complaint process for management of complaints or inquiries received from Medicaid providers,
members, state agencies, or government officials. Information received provides direct insight of current events or
trends in Medicaid managed care programs which, if not resolved in a timely manner, can result in corrective action
against an MCO.
3 Geo-mapping can be used to measure distance between member residence and providers.
4 Members in STAR Health receive paper directories as part of initial enrollment into that program.
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S.B. 760 also requires HHSC to submit a biennial report to the Legislature providing information
on access to providers in the MCOs’ provider networks, and MCO compliance with contractual
obligations related to provider access standards specified in S.B. 760. The report is required to
include:

• Information on provider-to-recipient ratios in an MCO's provider network, including
benchmark ratios to indicate whether there are deficiencies in a given network;
• A description and analysis of results from HHSC’s process for monitoring MCOs; and
• A compilation and analysis of information reported by MCOs to HHSC on MCO compliance
with Medicaid managed care network adequacy requirements.

In response to the requirements of S.B. 760, HHSC is working with stakeholders, including
member advocates, provider groups, and MCOs, to implement several key initiatives, including:

• Updated requirements for MCO provider directories, including a requirement all directories
be available online, updated regularly, and searchable;
• New time and distance standards for certain provider types, taking into account geographic
area;
• Updated expedited credentialing standards to decrease the time before a provider may begin
billing for services, and to allow MCOs to more quickly address gaps in network coverage;
and
• Enhanced MCO reporting methodologies and HHSC oversight processes to ensure
compliance with all network adequacy standards.

In addition to S.B. 760, the 2016-17 General Appropriations Act, H.B. 1, 84th Legislature, 2015
(Article II, HHSC, Rider 81 and Rider 82), requires HHSC to report data related to MCO
provider networks. Per Rider 81, HHSC is required to report on the number of disciplinary
orders or corrective action plans (CAPs) imposed on MCOs over the last five years based on
non-compliance with Medicaid managed care program network adequacy requirements. Rider 82
requires HHSC to report on the number of SCAs between Medicaid and CHIP MCOs and
providers over the last five years.

As required by Rider 81, reported data includes contractual remedies associated with MCO non-
compliance of OON utilization and distance standards. Key findings from HHSC's review of the
Rider 81 data included:

• The highest number of MCO OON utilization remedy assessments (31) occurred in fiscal
year 2012, the year the STAR managed care program expanded statewide and the
STAR+PLUS managed care program expanded to all areas of the state, except the Medicaid
rural service areas (MRSAs).
• The highest frequencies of distance standard violations occur in rural areas as do the highest
number of special exception requests from MCOs. A lack of specialty providers in rural areas
and a lack of provider interest in managed care, both commercial and government programs,
contribute to these findings.

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As required by Rider 82, the report includes data regarding SCAs between Medicaid and CHIP
MCOs and providers. HHSC's review of the Rider 82 data revealed the number of SCAs vary
widely by the area of the state and by provider type. Key findings included:

• The highest volume of SCAs are due to Medicaid-enrolled hospitals choosing not to contract
with Texas MCOs, even at or above fee-for-service (FFS) reimbursement rates.
• A high number of SCAs are with durable medical equipment (DME) suppliers due to certain
DME supplies only being available through a single DME provider who has declined to
contract with MCOs.
• Other common reasons for SCAs included transplants and transplant-related medical
services, pregnancy complications while a member is traveling, and a member's provider
requesting care at a hospital with specialists located out of the MCO's service area or not
contracted with the MCO.
• SCAs are also often required for emergency surgery while members are away from their city
of residence.
• There is a high number of SCAs between MCOs and behavioral health providers.

This combined report addresses the requirements of S.B. 760, Rider 81, and Rider 82, and
provides a comprehensive report on HHSC's efforts to enhance provider network standards and
ensure Medicaid members have timely access to services and supports in managed care.

2. Introduction

This report is intended to provide details on HHSC's efforts to enhance managed care provider
network standards in fulfillment of the requirements of S.B. 760, and provide data and analysis
regarding MCO violations of managed care network adequacy requirements, as required by
Rider 81, and SCAs by Medicaid and CHIP MCOs, as required by Rider 82.

S.B. 760

S.B. 760 included a number of provisions intended to improve access to care for Texans in
Medicaid managed care programs. Specifically, S.B. 760 directed HHSC to undertake several
initiatives to improve network adequacy, including requiring:

• HHSC to establish minimum access standards for MCO provider networks for specific
provider types;
• MCOs to submit a plan on how their provider networks comply with provider access
standards;
• HHSC to monitor MCO compliance with provider access standards and to seek liquidated
damages against MCOs that fail to comply with those standards;
• HHSC to submit a publicly available report to the Legislature on MCO compliance with the
established provider access standards;
• MCOs to create an expedited credentialing process for specific provider types identified by
HHSC;
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• MCOs to regularly update and publish provider directories on their website and to implement
member appointment scheduling assistance process through email or phone contact with the
MCO; and
• HHSC to amend rules as necessary to implement these network adequacy initiatives.

HHSC is engaged in several activities to implement the requirements of S.B. 760 and further
strengthen Medicaid managed care access standards to ensure Medicaid members' access to care.
These activities are described in detail in Section 4 (Current Network Adequacy Initiatives).

Riders 81 and 82

Both Riders 81 and 82 require HHSC to report Medicaid MCO data from the last five years
related to MCO provider networks. As directed by Rider 81, the report includes the number of
disciplinary actions imposed on MCOs over the last five years for non-compliance with
Medicaid managed care program network adequacy requirements.

Additionally, data regarding SCAs between Medicaid and CHIP MCOs and providers over the
last five years is reported as required by Rider 82. SCAs are initiated when a member requires
care that is not available from an MCO's network provider and the MCO arranges for these
services to be provided by an OON provider. When this occurs, the MCO may negotiate a SCA
with the OON provider to provide the care necessary to address the member's specific needs until
a qualified in-network provider is available.

3. Background

Medicaid Managed Care Network Requirements

In Texas, Medicaid managed care network adequacy requirements are based on both federal and
state statutes and regulations, which set minimum standards for MCOs participating in managed
care.

Federal Requirements

At the federal level, the Social Security Act5 and Code of Federal Regulations6 require each
MCO to provide adequate assurances to the state it has the capacity to serve expected enrollment
in its service area7. This includes an appropriate "range of services and access to preventive and
primary care services," with a "sufficient number, mix, and geographic distribution of providers
of services." Generally, each state is given latitude in determining how these requirements are
met.

In May 2016, the Centers for Medicare & Medicaid Services (CMS) published its final rule
related to Medicaid managed care, which included specific MCO network adequacy provisions.

5 SSA §1932(b) (5), Demonstration of Adequate Capacity and Services.
6 42 CFR §438.206 Availability of Services, §438.207 Assurances of Adequate Capacity and Services.
7Service area means all the counties, as applicable to each managed care program, for which an MCO has been
selected to provide MCO services.
4
Additional discussion regarding the implications of the new CMS managed care rule on S.B. 760
implementation can be found in Section 4 (Current Network Adequacy Initiatives).

State Requirements

At the state level, managed care requirements are established in accordance with Texas
Department of Insurance (TDI) requirements and Texas Medicaid rules and contract standards
established by HHSC. Requirements adopted by HHSC are generally consistent with, or more
stringent than, federal or TDI requirements.

TDI establishes standards for the maximum distance an individual must travel from their
residence to a provider. These standards vary by provider type and geographic location. For
example, the maximum travel distance for individuals in a health plan are as follows:

• 30 miles for primary care
• 30 miles for general hospital care
• 60 miles for primary care and general hospital care in rural areas
• 75 miles for specialists and specialty hospitals

HHSC must take TDI and federal requirements into consideration when developing Texas
Medicaid managed care access standards.

Texas Medicaid Network Requirements (Prior to S.B. 760 Implementation)

HHSC's current Medicaid managed care contracts include expectations for distance from
member residence to provider location, appointment availability, and OON utilization for a
number of provider types.

MCOs are expected to offer enrolled individuals a network of providers within a maximum
number of miles from the individual's residence (Table A). The distance requirements vary based
on provider types. For example, members must have a primary care provider within 30 miles and
specialists within 75 miles of their residence. There may also be variances based on geographic
area of the state. For example, the distance requirement for behavioral health providers is within
30 miles in urban areas and 75 miles in rural areas. All Medicaid MCOs are required to provide
quarterly geo-mapping data to HHSC for select provider types by program and service area.

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Table A: HHSC Distance Requirements for Medicaid MCOs
Percent of
Distance
Geographic Members
Category Provider Type Requirement
Designation8 with Access

(Benchmark)
Primary Care Provider9 30 miles
Acute Care Hospital 30 miles
Specialists, Including Statewide
Medical
Obstetrics/Gynecology 75 miles
Providers 90%
(OB/GYN)10

30 miles Urban
Outpatient Behavioral Health11
75 miles Rural
All Other Provider Types 75 miles Statewide
2 miles Urban 80%
Non-MRSA 5 miles Suburban 75%
15 miles Rural 90%
Pharmacy
2 miles Urban 75%

MRSA 5 miles Suburban 55%
5 miles Rural 90%
24 Hour Pharmacy 75 miles Statewide 90%
30 miles Urban 95%
Main Dentist
Dental 75 miles Rural 95%
Specialty Providers12 75 miles Statewide 90%

MCOs are also expected to offer a network of providers that can accommodate appointments for
persons enrolled in the plan within specified timeframes for emergent and urgent needs, routine
primary care, outpatient behavioral health, prenatal care, and preventive care (Table B).

8 Rural means any county with fewer than 50,000 residents and Urban means any county with 50,000 or more
residents as reported by the Texas Association of Counties.
9 Additional Frew requirement for Medicaid: 90 percent of child members must have access to at least two primary
care providers.
10 HHSC has access requirements for all specialties, but only monitors the most common specialists for adults,
including general surgery, cardiology, orthopedists, urology, and ophthalmology. Child specialties monitored
include: orthopedics, otolaryngology, ophthalmology/therapeutic optometry.
11 Outpatient behavioral health providers include Masters and Doctorate-level trained practitioners practicing
independently or at community mental health centers, other clinics, or at outpatient hospital departments.
12 Dental specialty providers are defined as endodontist, oral surgeon, orthodontist, pediatric dentists, periodontist,
and prosthodontist. DMOs must ensure access to at least one dental specialty provider within 75 miles of the
member.
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Table B: Appointment Wait Time Standards

Service Type Wait Times
Emergency Services Upon member presentation at service
delivery site
Urgent Care Within 24 hours
Routine Primary Care Within 14 days
Initial Outpatient Behavioral Health Within 14 days
Primary Care Provider Referrals to Specialty No later than 30 days
Prenatal Care Within 14 days
Prenatal Care for High Risk Pregnancy or Within 5 days
New Members in 3rd Trimester
Preventive Health Services – Adults Within 90 days
Preventive Health Services – Children According to Texas Health Steps periodicity
schedule13
Vision Care (Ophthalmology, Therapeutic None indicated (access without primary
Optometry) care physician referral)

Additionally, HHSC monitors MCOs' use of OON services for the following provider network
standards. In each service area, OON utilization should not exceed the following thresholds each
quarter:

• 15 percent of inpatient hospital admissions (health plans);
• 20 percent of emergency room visits (health plans); and
• 20 percent of total dollars billed for "other outpatient services" (health and dental plans).

Medicaid utilization is reviewed quarterly for contract compliance with these OON utilization
standards. Every MCO must submit quarterly OON utilization reports for each Medicaid
program type (e.g., STAR, STAR+PLUS, Children's Medicaid Dental Services, STAR Health)
and service area in which the MCO is contracted to provide Medicaid services.

An MCO may request a special consideration when it exceeds the OON utilization threshold if
efforts to contract with an OON provider are demonstrated. If an MCO satisfies the requirements
for special consideration, the MCO submits a second report for HHSC review excluding the non-
contracted provider from calculations used to assess compliance.

13 In Texas, federally required Early and Periodic Screening, Diagnostic and Treatment services are referred to as
Texas Health Steps. A schedule recommending when periodic preventive checkups should be conducted is referred
to as a periodicity schedule. The current medical periodicity schedule includes preventive checkups for newborns;
within 5 days of newborn discharge; at 2 weeks; at 2, 4, 6, 9, 12, 15, 18, 24, and 30 months; and annually for
children and young adults 3 through 20 years of age. The dental periodicity schedule includes preventive dental
checkups every 6 months for ages 6 months through 20 years of age.
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