Medicaid Managed Care Contracting.
The Health Care Authority (HCA) provides medical care services to eligible low-income state residents and their families, primarily through the Medicaid program. While some clients receive services through the HCA on a fee-for-service basis, the large majority receive coverage for medical services through managed care systems. Integrated managed care is a prepaid, comprehensive system for delivering a complete medical benefits package that is available for eligible families, children under age 19, low-income adults, certain disabled individuals, and pregnant women. Since January 1, 2020, all physical health, mental health, and substance use disorder services have been fully integrated in a 10 regional service area integrated managed care health system for most Medicaid clients, called Apple Health. The HCA contracts with managed care organizations (MCOs) under a comprehensive risk contract to provide prepaid health care services to persons enrolled in a managed care Apple Health plan. The MCOs must have a sufficient network of providers to provide adequate access to behavioral health services for the residents of their regional areas.
The HCA selects plans through a competitive procurement process and establishes standards for MCOs that seek to contract to provide services. Several factors must be given significant weight in a procurement process including:
While most Medicaid clients receive behavioral health services through an MCO, behavioral health administrative service organizations (BHASOs) administer certain behavioral health services that are not covered by the MCO within a specific regional service area. The services provided by a BHASO include maintaining continuously available crisis response services, administering services related to the involuntary commitment of adults and minors, coordinating planning for persons transitioning from long-term commitments, maintaining an adequate network of evaluation and treatment services, and providing services to non-Medicaid clients in accordance with contract criteria. An MCO must contract with the BHASO within the regional service area for the administration of crisis services and the MCO must reimburse the BHASO for behavioral health crisis services provided to the MCO's enrollees.
Behavioral Health System Coordination Subcommittee.
The Behavioral Health System Coordination Subcommittee was established in 2019 as an avenue for state agencies, counties, and the BHASOs to address systemic issues within the behavioral health system.
At least six months prior to releasing a Medicaid-integrated managed care procurement and no later than January 1, 2025, the Health Care Authority (HCA) is required to adopt regional standards for behavioral health networks managed by managed care organizations (MCOs). Standards must ensure access to appropriate and timely behavioral health services for MCO enrollees within the regional service area and must include a process for at least one annual update; county and behavioral health provider participation in initial development and updates; an accounting of regional needs; a structure for monitoring compliance with provider network standards; and a consideration of how statewide services are utilized cross-regionally and how the standards would impact requirements for behavioral health administrative service organizations.
Service types covered by the standard must, at a minimum, include outpatient, inpatient, and residential levels of care for adults and youth with a mental health disorder; outpatient, inpatient, and residential levels of care for adults and youth with a substance use disorder; crisis and stabilization services; providers of medication for opioid use disorders; specialty care; facility-based services; and other providers as determined by the HCA.
Before releasing a Medicaid-integrated managed care procurement, the HCA must identify options that minimize provider administrative burden, including the potential to limit the number of MCOs that operate in a regional service area.
During the procurement process, additional factors are to be weighed, including:
The HCA is authorized to use existing cross-system outcomes data to determine that value-based purchasing efforts or payments that secure enough capacity regardless of fluctuating utilization have advanced community-based behavioral health outcomes more effectively than a fee-for-service model.
The HCA must expand the types of behavioral health crisis services funded with Medicaid to the extent allowable by federal law.
The HCA is required to develop contracting methods that increase MCO accountability in the long-term involuntary treatment system and must explore opportunities to maximize Medicaid funding as appropriate.
The HCA is required to include county and behavioral health provider representatives in the development of any procurement process. At minimum, involvement should include two representatives chosen by the Association of County Human Services and two representatives chosen by the Washington Council for Behavioral Health.
An issue the Behavioral Health System Coordination Subcommittee must address is the data-sharing needs of behavioral health system partners.
The substitute bill adjusts the timeframe in which the Health Care Authority (HCA) must adopt network adequacy standards from July 1, 2024, to January 1, 2025. The list of covered services the standards must address is modified to reflect updated references to service types. Additional considerations to be incorporated in the standards are added, including how statewide services are utilized cross-regionally and how standards would impact requirements for behavioral health administrative service organizations. The requirement that HCA evaluate whether provider administrative burden would be reduced by limiting the number of managed care organizations (MCOs) operating in a region is modified by instead requiring the HCA to identify options that would limit provider administrative burden, including the potential to limit the number of MCOs in a region. Comprehensive population-based payment arrangements is added to the types of value-based purchasing option payment structures. The HCA requirement to seek approval from the Centers for Medicare and Medicaid services for amendments to expand Medicaid for long-term involuntary inpatient treatment is removed and instead HCA is authorized to explore opportunities to maximize Medicaid funding as appropriate. County and behavioral health provider representation from the scoring phase of a procurement is removed. Provisions related to the Behavioral Health System Coordination Committee are amended by highlighting that the group address data sharing needs of behavioral health system partners.
(In support) The shift to an integrated managed care model for physical and behavioral health has fundamentally changed the way the system is funded and how services are delivered and accessed. There has been a collaborative effort by those with a vested interest in evolving the system.
This bill is timely because the Health Care Authority (HCA) is looking to initiate a procurement process. It is a good time to see where there is room for improvement as we continue to build a more robust behavioral health system. Robust standards need to be in place before procurement is finalized. It is important to embed values in the contract so that the HCA can hold managed care organizations (MCOs) accountable.
The current system lacks sufficient network adequacy standards which results in gaps in the provision of critical services which then leads to difficulty in getting into treatment. It is important that a region have sufficient network providers in both number and type so that services are available to all clients without unreasonable delay. Each county has unique demographic and geographic challenges that need to be addressed. Redefining and tightening up standards is a meaningful path to address access issues, especially in rural communities.
Reducing the number of MCOs in a region will help reduce reporting requirements which hinders a provider's ability to provide direct services. Each provider has individual contracts with a number of MCOs and no contract is the same. A provider had 11 audits occurring in the same time period.
Managed care organizations should be required to adopt a more sustainable payment structure for crisis services.
(Opposed) None.
(Other) Including county and behavioral health providers raises potential conflict of interest issues. Contracting with more providers does not add capacity to the system; part of access is having a sufficient workforce to work with vulnerable populations.
Before addressing network adequacy, it is important to do a continuum-based system assessment to determine what each region needs.