Washington, DC (December 16, 2013) – On Tuesday, December 17, the National Academy for State Health Policy (NASHP) and the Urban Institute will co-host a briefing, Maximizing Enrollment Under the ACA, during which state officials and national experts will examine the building blocks of successful state enrollment strategies. The discussion will offer lessons for state and federal policymakers from the Robert Wood Johnson Foundation’s Maximizing Enrollment program and prior coverage expansions.
As January 1 approaches, policymakers and the public are increasingly focused on state and federal agency work to enroll the uninsured under the Affordable Care Act. Over the past four years, the Maximizing Enrollment program, directed by NASHP, has worked with eight states to transform their enrollment systems, policies and procedures for Medicaid and the Children’s Health Insurance Program and to prepare for the ACA’s enrollment requirements.
The briefing will be held from 12:30 to 2:00 p.m. at the Urban Institute, 2100 M Street, NW, 5th Floor, Washington, DC. Panelists will spotlight state innovations that make enrollment faster, more efficient, and more effective, and will talk about expectations for participation levels under the ACA. The event will also be webcast and viewers can watch the event here.
Susan Dentzer, Senior Policy Adviser, Robert Wood Johnson Foundation, will moderate a panel that will include:
- Lori Grubstein, Program Officer, Coverage Team, Robert Wood Johnson Foundation
- Stan Dorn, Senior Fellow, Health Policy Center, Urban Institute
- Alice Weiss, Co-Director, Maximizing Enrollment; Program Director, NASHP
- Gretel Felton, Director, Technical Support Division, Alabama Medicaid Agency
- Rebecca Mendoza, CHIP Director & Director of Maternal and Child Health Division, Virginia Department of Medical Assistance Services
Registration is required to attend the event in person. No registration is needed to view the webcast. Follow the conversation on Twitter at: #ACA and @nashphealth.
The National Academy for State Health Policy (NASHP) is an independent academy of state health policymakers who are dedicated to helping states achieve excellence in health policy and practice. A non-profit and non-partisan organization, NASHP provides a forum for constructive work across branches and agencies of state government on critical health policy issues. For more information visit www.nashp.org.
The Urban Institute (www.urban.org) is a nonprofit, nonpartisan policy research and educational organization that examines the social, economic, and governance challenges facing the nation. It provides information, analyses, and perspectives to public and private decisionmakers to help them address these problems and strives to deepen citizens’ understanding of the issues and trade-offs that policymakers face.
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to health and health care, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, measurable, and timely change. For more than 40 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime.
- As of July 1, 2011, there were 930,736 beneficiaries enrolled in the state’s Medicaid program, 568,332 of whom were enrolled in the primary care case management program known as Patient 1st.
- Physical, behavioral, and oral health services are provided through Patient 1st and reimbursed on a fee-for-service basis. Certain Medicaid populations are excluded from this program, including dual eligibles, recipients residing in a residential or institutional facility, and recipients with developmental delays or impaired mental conditions.
- Medicaid eligible individuals ages 3 and older who would otherwise require the level of care available in an intermediate care facility for Individuals with Intellectual Disabilities (ICF/IID) can apply to receive services through two state waivers:
- Home- and Community-Based Waiver for Persons with Intellectual Disabilities, which provides residential habilitation services, including day habilitation, physical therapy, personal care, skilled nursing, and behavior management; and
- Living at Home (LAH) Waiver for Persons with Intellectual Disabilities, which includes in-home residential rehabilitation, personal care, and personal care transportation.
The Alabama Medicaid Agency uses the federal statutory definition for medical necessity. The state requires that medical necessity be documented in a beneficiary’s medical record with supporting documentation such as: Laboratory test results, diagnostic test results, history (past attempts of management if applicable), signs and symptoms, etc. All Medicaid services are subject to retrospective review for medical necessity.
|Initiatives to Improve Access
|Reporting & Data Collection|
The Alabama ABCD Screening Academy Project worked to spread structured developmental and social emotional screening in primary health care practices. Through this project, the state expanded Medicaid reimbursement for standardized screening, and sustained and spread the use of validated, objective screening tools. More information regarding the state’s ABCD efforts can be found here.
Alabama Medicaid allows qualified providers to bill for Intensive Developmental Diagnostic Assessments (using the 96110 and 96111 CPT codes) for children under age two. These assessments are performed by multidisciplinary teams and may include both developmental screening tests and early language milestone screens (as well as interpretation and reporting of results).
|Support to Providers and Families||
Support for Providers:
The Alabama Medicaid Agency operates an EPSDT website which contains information for providers, including billing information, administrative code, provider agreement forms, a provider manual, and a reference sheet on periodic screenings.
The Alabama EPSDT provider manual includes information on the state’s patient education method, known as PT+3, developed to assist providers who work with illiterate or marginally literate patients and families. The method’s standardized protocol is meant to give providers the skills needed to help young or marginally literate patients remember points from a health care visit and increase knowledge and compliance. EPSDT, Patient 1st, and Medicaid family planning providers who receive training in PT+3 are eligible to receive free low literacy materials for children, teens, and adults.
Support for Families:
Alabama’s EPSDT website also contains resources for parents and families, including contact information for care coordinators, education materials, and other facts sheets.
The Alabama Medicaid Agency operates the Patient 1st program, which creates a medical home for Medicaid recipients by linking them with a primary medical provider (PMP). Participating PMPs receive a monthly care management PMPM for coordinating care for Medicaid recipients in their practices. Each PMP provides and arranges for each recipient’s health care needs, and is required to provide EPSDT preventive care screenings to Medicaid eligible children. PMPs serving this population who do not provide EPSDT services are required to sign an agreement with another provider to provide EPSDT services.
Patient Care Networks
Alabama has enhanced the Patient 1st primary care case management program by creating regional Patient Care Networks. These nonprofit organizations supplement provider capacity for care coordination by assuming responsibility for “implementing a plan of care … for each [Medicaid] participant that includes coordination of care through collaboration with the member, family, primary care physicians, specialists, community resources, and pharmacists.”
A Section 2703 Health Homes state plan amendment approved in 2013 allowed Alabama to incorporate additional comprehensive care management services into the Patient Care Networks for Medicaid beneficiaries with two or more of the following conditions: asthma, diabetes, heart disease, cardiovascular disease, chronic obstructive pulmonary disease, cancer, HIV, mental health conditions, substance abuse disorder, sickle cell anemia, or organ transplant.
Alabama is currently building off of the Patient Care Network concept by planning the launch of Regional Care Organizations (RCOs). RCOs will be risk-bearing organizations that are responsible not only for providing comprehensive Medicaid benefits (including EPSDT services) and securing medical homes for all enrolled Medicaid beneficiaries in a region, but also for coordinating care across settings.
The Alabama Medicaid Agency partnered with the Department of Public Health to initiate an EPSDT care coordination service for private and public providers. The program assists provider offices with identifying, contacting, coordinating, and providing follow up for children who are behind on EPSDT screenings and immunizations. Care coordinators are also available to assist with transportation services using Alabama’s Medicaid Non-Emergency Transportation (NET) program.
In partnership with the Alabama Chapter of the American Academy of Pediatrics, the Alabama Academy of Pediatric Dentistry, and the Alabama Dental Association, the Alabama Medicaid Agency operates the 1st Look Program. The collaborative program is designed to reduce early childhood caries by “encouraging primary care physicians to perform dental risk assessments, provide anticipatory guidance, apply fluoride varnish when indicated, and refer children to a dental home by age one.” Children who have already seen by a dentist do not qualify for this program.
Mary G. McIntyre, MD, MPH, Acting State Epidemiologist and Assistant State Health Officer for Disease Control and Prevention, Alabama Department of Health (ADPH) is working to ensure the quality of health in Alabama. With responsibility for the bureaus of Communicable Disease and Clinical Laboratories, she addresses emerging infectious disease issues such as the new Avian Influenza A (H7N9). She also assists in other areas at ADPH including the Chronic Disease and Health Promotion area and supports the state’s priority focus on Medicaid funding and programs related to diabetes prevention, smoking cessation, increasing smoke free policies, and reducing infant mortality rates. Mary engages with other NASHP Academy members to learn what is working in their states as they face similar challenges. “As a result of engaging with other NASHP members and participation in meetings, I have tried to take lessons learned from other states to implement changes in disease control efforts in Alabama.” Mary is also working to institute pilot programs that will provide capacity to offset reductions in public health staffing due to cuts in federal and state budgets, and train individuals who specialize in one area, assist in other areas. Making health care accessible and affordable to Alabama residents is critical to Mary and having access to NASHP makes a difference. “NASHP provides me with a network and resources I would not have otherwise,” she said. To learn more about Mary McIntyre and her work in Alabama, click here.
- October 1, 2013: RCO regions established
- October 1, 2014: RCO governing boards approved by Medicaid
- April 1, 2015: RCO provider networks in place
- October 1, 2015: RCOs must meet solvency requirements
October 1, 2016: RCO accepts capitation payments from Medicaid
Last updated: November 2013.
Eligible Patient Population: Alabama Medicaid plans to directly contract with regional care organizations (RCOs) for the majority of the Medicaid population (approximately 800,000 beneficiaries). The state would continue and/or expand the existing enhanced primary care case management program (the Patient Care Networks of Alabama program) while the RCOs are under development. Most Medicaid beneficiaries would be included while dual eligibles, those in long term care facilities or utilizing home and community-based waiver services, and the developmentally disabled would be excluded from the initiative.
Scope of services: Community-led RCOs would manage and coordinate care for the majority of the non-dually eligible Medicaid population. Through a capitated payment, RCOs would manage the full scope of Medicaid benefits, including physical, behavioral, pharmacy and long-term care services.
The state’s 1115 Waiver Concept Paper envisions building the RCOs over time, potentially by phasing them in as pilots across the state. Regions may first opt to develop a PCNA program to serve as the foundation for a future RCO. RCOs would initially manage and be at risk for primary, acute and post-acute care services. As they build capacity, they would be expected to integrate and fully manage behavioral health services for the population served. RCOs will be required to design care coordination programs to ensure these beneficiaries have access to adequate physical and behavioral health care in addition to connecting them with social services.
Provider Population A RCO may contract with any willing hospital, doctor or provider to provide services in a Medicaid region if the provider is willing to accept the payments and terms offered to comparable providers. Providers should meet licensing requirements set by law and have a Medicaid provider number. As stated in the initiative’s Planning Principles, any willing provider who chooses to apply does so not only within his or her region, but also across regional lines. Mental health and substance abuse providers currently certified by the Alabama Department of Mental Health (ADMH) and functioning as approved Medicaid providers are expected to be critical participants in RCO and PCNA networks.
Federally Qualified Health Centers (FQHCs) are also expected to play a role in the development of both the RCOs and PCNAs as critical primary care providers.
Attribution In June 2013, Alabama’s Medicaid agency divided the state into 5 RCO regions. All affected beneficiaries would be required to enroll in an RCO or PCNA based on geographic location. To the extent there is more than one RCO in a region, beneficiaries would retain the right to choose between RCOs; beneficiaries who do not choose will be auto-assigned. Beneficiaries will also retain their choice of medical provider and medical/health home within network.
Act 2013-261 became law in June 2013. This legislation calls for Alabama to be divided into regions and that a community-led network coordinates the health care of Medicaid patients in each region, with networks ultimately bearing the risks of contracting with the state of Alabama.
Alabama’s Medicaid agency is seeking an 1115 Waiver from CMS to allow for the implementation of the Regional Care Organizations.
The Alabama Medicaid Agency is responsible for the development and oversight of the Regional Care Organization (RCO) program. RCOs would be largely governed by provider organizations that agree to share in the risk in a particular region of the state. Because they are provider-based organizations, the state would establish criteria and oversight procedures that will be managed within the Medicaid Agency (separate and apart from traditional insurers). The state will have the power to approve governing board members and to approve the selection process for RCO advisory committees.
Act 2013-261 requires that RCOs have a governing board of directors which includes 12 members will represent risk-bearing participants in the RCO (i.e. via contributing cash, capital, or other assets to the RCO) and 8 members representing other stakeholders. Of these eight members there will be:
Each RCO will have a Citizens’ Advisory Committee (at least 20% of members must be Medicaid beneficiaries).
|Criteria for Participation||
Act 2013-261 requires the Medicaid agency to establish by rule the criteria for certification of Regional Care Organizations (RCOs).
Since RCOs will provide Medicaid services to Medicaid enrollees directly or by contract with other providers, the certification standards will include service delivery network requirements: each RCO will be required to establish an adequate medical service delivery network as determined by the Medicaid agency. An alternate care provider contracting with Medicaid shall also establish such a network.
As described in the 1115 Waiver Concept Paper, this initiative would utilize a payment model that includes capitation with care management payments (the transition period could include fee-for-service).
The state will reform its payment methodologies to implement value-based purchasing strategies (the state offers the example of transitioning hospitals from per diem payments to All Patient Refined Diagnosis Related Groups). RCOs would be expected to use this methodology in establishing contracts with providers.
The state also proposes to enhance coverage or modify reimbursement for a number of services to encourage capacity development, potentially including care coordination fees to providers to cover necessary care coordination services that are not directly reimbursable under the current benefit structure.
As stated in the initiative’s Planning Principles, Medicaid will establish a floor for applicable provider payments for all regions, including out-of-region contracts.
|Support for Infrastructure||
Regional Care Organizations (RCOs) and Alabama’s Patient Care Networks would be required to leverage the health information exchange (HIE) infrastructure under development in Alabama, One Health Record™. To ensure better integration of the Medicaid providers into the larger health care marketplace, the health information exchange (HIE) would be the primary vehicle through which Medicaid providers share and access clinical information.
Providers affiliated with RCOs would be expected to use the standardized continuity of care record (CCD), which is currently under development and will be a component of the providers’ electronic health records. HIE will provide real-time access to data that will support providers in predicting, planning for, and intervening when necessary in a beneficiary’s care management plan. In the interim, the state has approved other web-based tools to facilitate the efficient exchange of medical information between physician offices and health care facilities.
In the state’s 1115 Waiver Concept paper, it proposes that RCOs would be eligible to receive reimbursement for certain upfront development and implementation costs, such as:
|Measurement and Evaluation||
The Medicaid Agency will create a quality assurance committee appointed by the Medicaid commissioner. Members of the committee will serve two year terms. At least 60 percent of the committee must be physicians who provide care to Medicaid beneficiaries served by Regional Care Organizations (RCOs).
In accordance with Act 2013-261, the committee will identify objective outcome and quality measures for ambulatory care, inpatient care, chemical dependency and mental health treatment, oral health care and all other services provided by RCOs. The quality measures must be consistent with existing state/national measures. The Medicaid Commission will incorporate these measures into RCO contracts. The committee will adopt outcome and quality measures annually and adjust measures to reflect:
The Medicaid Agency will evaluate the outcome/quality measures adopted by committee and will publish information by RCO on quality, cost, outcome and as well as other relevant information.
The Medicaid agency will publish aggregate-level public reports by RCO on:
No HIE Strategic Plan available yet.
The Alabama ABCD Screening Academy Project worked to spread structured developmental and social emotional screening in primary health care practices. The ABCD Screening Academy Project work plan will be incorporated into Alabama’s Blueprint for School Readiness (Zero to Five) plan.
Specifically, the ABCD Screening Academy project in Alabama improved developmental screening by:
- Expanding Medicaid and All Kids reimbursement for standardized screening and modifying policy and billing manuals to inform providers of the changes. In addition, S-CHIP is now paying for up to 4 standardized screenings tied into a well-child visit during the first 4 years – which so far has led to a 600 percent increase in claims for the 96110 procedure code.
- Sustaining and spreading the use of validated, objective screening tools as part of well child care through partnerships with The Alabama Partnership for Children (APC), the Alabama AAP chapter and The National Governors Association Center for Best Practices (NGA Center) as well as pursuing grant funding to bolster coordination of early childhood services and streamline resources to improve outcomes for young children and their families.
|Alabama’s ECCS Organization||(Alabama ABCD Screening Academy Project) Two PowerPoint slides for Alabama’s Early Childhood Comprehensive Systems Initiative (ECCS), the first is an organizational chart for ECCS, the second is a flow chart of their progress from 2002 to 2008.||December 2008||Improving Policy|
|Alabama’s Early Intervention System: Dear Doctor letter||(Alabama ABCD Project) Alabama Early Intervention System’s ‘Dear Doctor’ letter, a check-off form letter used by Alabama’s Early Intervention System (AIES) service coordinators to communicate back with physicians and other members of the multidisciplinary service team about their patients’ Individualized Service Plan (ISP).||December 2008||Improving Policy|
|Community Resource Data Form||(Alabama ABCD Project) The purpose of this tool is to provide a structured approach to collecting information about services in the community that might benefit patients.||December 2007||Addressing Needs|
|Community Resources Inventory||(Paula Duncan) The purpose of this tool is to structure an approach to identifying community resources that might enhance a practice’s ability to serve their patients. This tool allows practitioners to evaluate which organizations they would like to develop or improve links with.||December 2007||Addressing Needs|
|Locating Community-Based Services for Children and Families||(Alabama ABCD Project) PowerPoint presentation created to provide stakeholders with information about Alabama’s participation in the ABCD Screening Academy. Presentation provides information on identifying generic and specialized community resources for families and children, birth to five years, and identifying roles for participant involvement in the local ABCD Demonstration Project.||September 2007||Addressing Needs|
|Agenda for meeting: Locating Community-Based Services to Support Children (Birth to Five) and Families||(Alabama ABCD Project) Agenda for meeting held September 26, 2007 to introduce stakeholders to the Alabama ABCD project.||September 2007||Addressing Needs|