EXHIBIT A-4-d SPECIALTY SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA
RESPONDENT NAME: Florida MHS, Inc., dba Magellan Complete Care
A. RESPONDENT BACKGROUND/EXPERIENCE
SPECIALTY SRC#1 – Specialty Experience (Statewide):
The respondent, including respondent’s parent, affiliate(s) or subsidiary(ies), shall provide a list of all current and/or recent (within five (5) years of the issue date of this solicitation [since July 14, 2012]) contracts for managed care for the proposed specialty population. If the respondent does not have experience with the provision of managed care to the proposed specialty population, the respondent shall not submit a response to this SRC. The respondent shall provide the following information for each identified contract:
a. The specialty population served; b. The name and address of the client; c. The name of the Contract; d. The specific start and end dates of the Contract; e. A brief narrative describing the role of the respondent and scope of the work performed, including covered populations and covered services; f. The use of administrative and/or delegated subcontractor(s), their scope of work; g. The annual contract amount (payment to the respondent) and annual claims payment amount; h. The scheduled and actual completion dates for contract implementation; i. The barriers encountered that hindered implementation (if applicable) and the resolutions; j. Accomplishments and achievements; k. Number of enrollees, by health plan type (e.g., commercial, Medicare, Medicaid); and l. Whether the contract was capitated, fee-for-service or other payment method.
For this SRC the respondent shall not include subcontractor experience.
Response:
OVERVIEW A detailed list of Magellan managed care contracts covering the past five years, and providing all of the data elements requested in items a. through l. is included in [Specialty SRC #01, Attachment 1: Magellan Complete Care Contract Listing].
As requested, the attachment covers five years of Medicaid contracts. However, Magellan’s commitment to public sector healthcare in Florida goes back almost 20 years to the time we started providing fee-for-service pharmacy and utilization management services to Medicaid enrollees in the state.
As the state started to roll out managed care, Magellan participated, first as administrator of several regional Prepaid Mental Health Plans (PMHPs) and then as MCO in AHCA Area 10. Most recently, we have served as AHCA’s Statewide Medicaid Managed Care (SMMC) serious mental illness (SMI) specialty plan since 2014, providing integrated behavioral health, and pharmacy services to more than 50,000 adults and youth with complex health care needs – in other words,
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exactly the membership we propose to serve statewide through this procurement. At Magellan, the SMMC program represents an opportunity to continue to evolve and transform health care delivery within a managed care model, keeping Florida at the forefront of public sector innovation, and bringing continuity and stability at a time of transition and uncertainty for the Medicaid program at a federal level.
While our fully integrated specialty plan has only been operating since 2014, our work, and the partnership with AHCA it represents, is the culmination of decades of specialized experience. The best practices embedded in our Florida operation evolved as the result of numerous lessons learned in the field, working directly with enrollees, and addressing their often complex and challenging needs. Working closely with the State over the past four years, Magellan has implemented a person-centered, evidence-based system of care for individuals with multiple behavioral and physical challenges. In the process, we have addressed significant access barriers, and personally reached out to, and successfully engaged, individuals who in many cases have spent most of their lives outside the healthcare system. Our mission is to build upon what we have accomplished to date with AHCA and our enrollees, and to truly lead more Floridians to healthy and vibrant lives, our company mission.
We are proud of our legacy of tackling some of the most costly and complex specialty health areas, and developing concrete, replicable solutions that improve outcomes for our enrollees, while managing public program costs. Nationally, other states are very interested in the work that ACHA is doing to create a specialized view of how we manage the care and costs for the “super utilizers” in the Medicaid program. People with SMI are a subset of the most complex of Medicaid enrollees. ACHA’s leadership on this issue, and in creating this specialty plan has placed Florida at the forefront of Medicaid managed care. Magellan is honored to be part of this work.
On the following pages, we specifically address each of the four evaluation criteria included in this question.
CRITERIA 1: THE EXTENT THE MEDICAID POPULATION SERVED… Each of the contracts summarized in [Specialty SRC #01, Attachment 1: Magellan Complete Care Contract Listing] includes a description of the membership served in column “a” and the scope of services provided in column “e”.
As the information in the contract table illustrates, Magellan’s roots lie in behavioral health – one of the most challenging health care specialties – and as we have grown, our experience in complex niche areas of health care has likewise expanded. Today, we are differentiated by our broad and deep capabilities in critical specialties, including not only mental health and substance use, but also radiology, oncology, physical medicine, pain management, pharmacy management, and medical pharmacy. In contracts that cover a broad range of products (Medicaid, commercial and federal programs) and reflect flexibility in both capitated and administrative financial arrangements, Magellan today covers a total of more than 50 million individuals, or nearly 1 in 6 Americans nationwide. This total does not include the millions of people who receive services through our fee-based pharmacy programs. Our commercial division provides services to more than 100 health plans and provider organizations. Our government division provides general healthcare and integrated complex population management through more than 70 direct contracts with counties, states and federal agencies, including Medicaid, Medicare, and the Department of
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Defense. Our pharmacy division provides pharmacy services to the state government agencies of 27 states and the District of Columbia; processed approximately 17 million claims every month in 2016; and had oversight of nearly $17 billion in annual Medicaid drug spend.
With specific regard to our public sector membership, Magellan provides behavioral health and/or specialty health – imaging, cardiac management, pain management, PT/OT and similar services – to over 11 million Medicaid and dual Medicaid/Medicare members, and approximately 1.7 million Medicare-only members on behalf of nearly 50 health plan customers. Of these members, we estimate that approximately 60 percent are aged 18 or younger, and a substantial sub-set have a diagnosis of serious emotional disability (SED).
Further, an estimated 20 percent of our public markets membership is eligible for ABD benefits (this figure excludes individuals served through our Medicaid PBM contracts, which are not reimbursed on a capitated basis). To serve these members effectively, Magellan has prioritized building teams that have a significant percentage of clinicians working directly with members. We are proud that more than 40 percent of Magellan employees and staff are clinicians or other individuals who require a professional credential to fulfil their daily work requirements. We believe our commitment to excellence in the workforce translates to superior interactions with, and outcomes for, our members.
The Magellan Complete Care specialty program is the culmination of more than four decades of overall managed care experience, and more than two decades of experience working directly and specifically with state Medicaid agencies to improve the behavioral and physical health of members.
Specifically, as a pioneer in Medicaid managed care, Magellan implemented one of the first behavioral health carve-out contracts in Iowa in 1996. A hallmark of that program was the community reinvestment program we spearheaded, working with both traditional and non- traditional providers, to expand community-based resources for people with mental illness. Later, in Iowa and Arizona, Magellan took our coordinated care model to the next level by implementing two innovative Integrated Health Home (IHH) programs, through which Magellan provided fully coordinated services to more than 45,000 individuals. In Pennsylvania, where Magellan has delivered county-based behavioral health services since 1997, we have operated an integrated health care portal for more than a decade. Lessons learned from all of these initiatives informed our proposed design for the Specialty HMO in Florida. In AHCA, we found an ideal State partner and leader to help us refine the model, a vision of better public sector healthcare delivery that is increasingly shared by other states as they implement their own integrated service models for complex populations.
Four years later, Magellan Complete Care is a progressive, innovative health plan whose staff, without exception, remain firmly committed to our shared mission of better health for all Floridians, regardless of their healthcare challenges. Our experience has convinced us of the importance of a focused specialty plan, for individuals living with SMI, SED, and substance use disorder (SUD), which includes customized benefits and processes, increased access to quality services, prevention in the escalation of health conditions, and better utilization of community supports, while at the same time assisting enrollees to achieve personal life and health goals.
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For ease of review, we have listed Magellan’s experience working directly with Medicaid enrollees in Florida in a number of specialty programs over many years. In addition, we provide a listing of Magellan programs in other states, held within the last five years, that cover complex behavioral health conditions, and/or individuals in vulnerable age groups (children and older adults), who by extension face similar challenges to enrollees of the Florida specialty SMI program:
Contracts Serving Florida Medicaid >Magellan Complete Care Medicaid Specialty Plan for Persons with Serious Mental Illness > Magellan Complete Care Integrated Medicaid Program, AHCA Area 10
Contracts Serving Individuals with Complex Behavioral Conditions >Arizona Regional Behavioral Health Authority >Prepaid Mental Health Program (PMHP) – AHCA Areas 2, 4, 9, 11, and child welfare >Iowa Plan for Behavioral Health >Nebraska Comprehensive Medicaid Managed Behavioral Health Program >Pennsylvania HealthChoices Program >Commonwealth of Virginia MLTSS Program >Commonwealth of Virginia Medicaid Behavioral Health Program
Other Managed Care Contracts Serving Medicaid Members, including Children and Youth > AHCA Medicaid Qualified Evaluator Network (QEN) Contract >Louisiana Behavioral Health Partnership >Florida Department of Children and Families Care Coordination program for youth > AHCA Utilization Management Program for Adults >Nevada Health Care Utilization and Program Management >Montana Utilization Management Program >Louisiana Coordinated System of Care for Children (CSoC) >Wyoming Care Management Entity Program
Medicaid Long Term Care and/or Programs for Dual Medicaid/Medicare-eligible Members >New York AlphaCare MLTSS Program >New York AlphaCare D-SNP Program >Wisconsin “Include, Respect, I Self-Direct” (IRIS) Program
We are excited about the opportunity to build on positive accomplishments in Florida to date, by contracting with AHCA for the next generation of managed care across Florida. The programmatic building blocks in place today, created by partnering with AHCA to meet significant challenges associated with an SMI plan, are the foundation for ongoing, continuous improvement in services and outcomes. We look forward to having the opportunity to continue our contract with AHCA and hope that our work to date will continue to evolve and mature across an expanded service area.
CRITERIA 2: THE NUMBER AND SIZE OF MANAGED CARE CONTRACTS ACTIVE… [Specialty SRC #01, Attachment 1: Magellan Complete Care Contract Listing] provides a complete listing of Magellan programs implemented in the last five years that delivered Medicaid specialty health services as either a prime contractor or as a collaborating partner with the Medicaid MCOs in a particular state. For each contract, we have included the size, in terms of revenue (column G) and number of members (column “k”); population served (column “a”), term
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(column “d”), scope (column “e”) and accomplishments (column “j”), together with implementation barriers and timelines (columns “h” and “i”).
Counting programs where Magellan was the behavioral health partner in a state or local government Medicaid program, we have implemented more than 30 programs in 11 states on behalf of 4.3 million Medicaid, Medicare, and CHIP members.
CRITERIA 3: THE EXTENT TO WHICH MANAGED CARE CONTRACTS, OR… Magellan has a strong track record of continuous growth in public sector healthcare. In the past five years, we have managed a cumulative total of 31 Medicaid contracts held directly with state and local government customers in 11 states, and covering approximately 4.3 million members. We have successfully renewed our Medicaid contracts, in some cases, multiple times. In Pennsylvania, for example, we recently celebrated the 20th anniversary of our Delaware County Medicaid Behavioral Health Program with a series of events attended by our county customer, members of our program, and other community members. Accordingly, the experience (columns “d” and “e”) and accomplishments (column “j”) listed for each Magellan Public Sector Program in [Specialty SRC #01, Attachment 1: Magellan Complete Care Contract Listing] have been selected because they impact members similar to those in the FL ITN, reflect AHCA’s priorities for the program, and/or demonstrate program solutions that informed our approach to implementation of our Specialty Plan in Florida.
3.1 Our Deep Experience with Specialty Health Plans Allows Us to Replicate Best Practices Our work with Medicaid members in many states has provided insights into the particular challenges that these individuals face. Many people entering our programs have largely been neglected by the traditional health care system and would not get care if we did not adopt the following overall approach, which we pioneered in Florida and have since incorporated into our standard model of care:
>We cannot help enrollees if we cannot communicate and stay in touch with them. Magellan devotes significant resources to finding enrollees, many of whom have transient living environments and are difficult to reach.
>It is important to engage a new enrollee through a meaningful relationship, based on mutual respect.
>This relationship often starts with helping the enrollee meet his or her most basic needs, such as food, shelter and basic hygiene. Until these needs are met, many individuals will not be able to engage in a productive way in the assessment and care coordination process.
>Once basic needs are met, we can begin addressing healthcare needs.
>A critical component in enrollee engagement is a thorough assessment that incorporates medical, clinical and social dimensions of the enrollee’s well being, followed by development of a comprehensive biopsychosocial plan.
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>Once the plan is in place and a positive relationship has been developed with the enrollee’s Care Coordination team and providers, he or she can begin the journey towards community stabilization and recovery.
As a result of our experience implementing programs for Medicaid-eligible individuals with complex needs and delivering specialty health services for close to 40 years, Magellan has learned valuable lessons that have directly informed our specialty program model in Florida today, as well as the next generation of innovations and enhancements proposed throughout our response to this ITN.
CRITERIA 4: THE EXTENT TO WHICH LISTED ACCOMPLISHMENTS… Accomplishments and achievements for each Medicaid program are summarized in column “j” of [Specialty SRC #01, Attachment 1: Magellan Complete Care Contract Listing]. Below, we summarize highlights of our accomplishments in several program areas relevant to this solicitation, specifically our approach to enrollees with SMI, and our experience meeting the special needs of children and adolescents in the Medicaid program.
4.1 Increasing Access, Improving Outcomes for Enrollees in the General Medicaid Population While the focus of our Magellan Complete Care program is individuals with SMI, the majority of enrollees in our Medicaid programs do not have complex multi-system needs. For these individuals, the most important services are access to good primary care, prevention, and wellness services, accessible pharmacy options, and availability of specialized services when they need it. Four other examples are summarized below.
1. Integrated Medical, Behavioral and Pharmacy Services: Through our in-house PBM, Magellan offers an integrated Medicaid program that leverages the benefits of fully-coordinated care coordination, network management, and medication adherence initiatives. In Florida, this synergistic partnership between Magellan Complete Care and our MRx PBM is exemplified by our WholeHealthRx initiative, which focuses on prescriber outreach and education as a tool in facilitating best practice medication management for complex cases. During the most recent annual outcomes reporting period in 2016, the WholeHealthRx team conducted an average of 125 face-to-face prescriber visits per quarter, impacting 877 enrollees, and resulting in positive outcomes in several key areas: Utilization of antipsychotic medications decreased by 10.6 percent and 26.7 percent of eligible enrollees were no longer receiving two or more antipsychotic medications; medication persistence for antipsychotic medications increased by 32.8 percent; and there was a 25.3 percent increase in the number of enrollees who received one or more of the recommended lab tests for second generation antipsychotic medications.
2. Peer Support: All of Magellan’s Medicaid programs feature peer support resources in Florida. For example, Magellan helped 14 CMHCs implement peer support as a billable service; a total of 355 enrollees participated in peer support in 2016, with an overall decrease in inpatient readmissions for peer support enrollees.
Our commitment to peer support goes well beyond our enrollees. We are national experts and host empowerment initiatives across the country to promote the concepts of independence, advocacy, and skill-building. We also introduced the MY LIFE youth empowerment initiative in Tallahassee at an event that has since become an annual fixture for Florida youth. The most
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recent MY Fest Florida took place in Tallahassee on October 7, 2017 and drew more than 700 young attendees. Also, there were 27 exhibitors and entertainers, including state agencies such as the Florida Departments of Juvenile Justice, Children Youth and Families, and Vocational Rehabilitation, local businesses such as Primer Meridian Bank, advocacy organizations such as Stop the Violence Against our Youth and entertainers including Two 24 Entertainment.
3. Addressing the Opioid crisis: In 2015, Magellan implemented an innovative Medication Assisted Treatment (MAT) initiative across six Pennsylvania counties in the eastern part of the state. Ours is a multi-pronged approach that increases access to MAT services for members with Alcohol and/or Opioid Use Disorder. As part of the initiative, we sponsored an addictions conference in June 2016 attended by more than 300 people. Through the MAT initiative, we collaborated with local providers to add approximately 70 withdrawal beds, 120 rehabilitation beds, and increased methadone maintenance capacity for 240 individuals across our Pennsylvania programs. We are also in discussions to contract with a new, 10-bed halfway house. The variety of services this initiative brings to our members is critical to our prevention efforts and addressing active opioid addiction.
4. Reducing administrative burdens for providers: In our Virginia Medicaid program, Magellan implemented an innovative Total Web Solution, an “Authorization Request Tool” for providers. Beginning in 2013, while we were contracted as the BHSA, we transitioned utilization management (UM) services from an incumbent and have worked with the Commonwealth since that time on service expansions while containing cost for nearly 900,000 members. The Authorization Request Tool has significantly reduced the amount of time that providers have to spend on the administrative tasks associated with the BHSA program, allowing them to allocate additional timeslots to members.
4.2 Supporting Enrollees with SMI Analysis of utilization data in the Magellan Complete Care program indicates that approximately five percent of super high-utilizing enrollees generate more than 50 percent of cost of care expenditures. As a result of this medical complexity, individuals living with SMI require support from a team with significant clinical expertise, combined with a comprehensive, tailored model of care, to reduce short- and long-term costs and health risks, and to provide the best chance for our enrollees to lead a healthy and vibrant life.
Magellan also understands that an effective approach to improving the lives of individuals living with SMI requires connecting behavioral, physical, pharmacy, and social needs—including permanent supportive housing (PSH), supported employment services, and peer support services—into a plan of care that is individualized, coordinated, and cost effective. We recognize the value and effectiveness of peer support services and incorporate evidence-based practices in all of our peer support programs, including in Florida and Virginia.
A key challenge in serving enrollees living with SMI is addressing their housing needs. In January 2016, one in five people experiencing homelessness was living with SMI and a similar percentage had a chronic SUD. These issues are particularly acute among veterans. In Florida, Pennsylvania, and Virginia where we support the local behavioral healthcare systems (or, in the case of Maricopa County, Arizona, and Louisiana have supported these systems in the past), Magellan has spearheaded efforts to ensure support services for individuals experiencing or at high-risk of
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homelessness in conformance with the Housing First approach and the SAMHSA’s PSH evidence-based practice.
As a result of these efforts, we have secured permanent housing for many previously homeless veterans and other individuals. In Florida, in particular, we have successfully implemented the Housing First approach under the leadership of the Magellan Complete Care Housing Specialist. Through his efforts, and those of the local Community Outreach Specialists (COS) with whom he coordinates in local communities across Florida to develop regional community housing resource guides, Magellan Complete Care has successfully placed more than 100 individuals in supportive housing since December 2015.
To accomplish this, the COS developed regional housing work flows that outlined each region’s homeless housing access process. They coordinated with the regional lead agencies designated by HUD to administer homeless housing funds and at monthly regional housing meetings, discussed available housing opportunities with Magellan Complete Care Coordination Clinicians. Further, Magellan Complete Care developed relationships with housing agencies such as the Florida Housing Finance Corp and Goodwill Industries to fast track placements into permanent supported housing; and contracted with Integra Service Connect in the Tampa and Miami areas to help locate and build relationships with our hardest-to-find, hardest-to-engage enrollees.
4.3 Providing Services to Children and Youth, Including Those with SED Magellan understands the unique issues that affect the daily lives of children in the Medicaid program. Because these young people are also affected by issues associated with living in poverty, they often have less robust support systems and a less stable home environment. Compared with children who do not face these challenges, they disproportionately experience complex behavioral health and medical issues that, if not addressed quickly, can escalate and cause significant stress to the young person and his or her family. Our success in other states shows Magellan’s commitment to improving the quality of life for the children, youth, and families within the communities we serve. For example:
>Magellan’s PMHP for Child Welfare in Florida, which we administered between 2007 and 2015, increased adoptions and reunifications of children with their families through integrating psychiatric and medical care, expanding specialized therapeutic foster care, unifying concurrent review and child welfare teams, and ensuring that a child’s mental health services were integrated into the child’s permanency plan.
>In Arizona, we developed the Child and Family Teams (CFT) initiative, which has since become an integral component in all Magellan programs for youth and families. The Arizona CFT program, included family members, natural supports, providers, and system partners involved with the family. The CFT works to establish and maintain a coordinated network of support around the family. The CFT identifies a coordinated network of support around the family. All activities are consistent with Systems of Care principles and child welfare best practices. Meetings are family- driven, youth-guided, family-centered, strength-based and solution-focused. Crisis planning is an integral component of the program, allowing us to anticipate potential obstacles, and manage them before a crisis occurs.
>In Louisiana, in 2012, Magellan implemented a Coordinated System of Care (CSoC) for youth in imminent danger of out-of-home placement. The CSoC was governed by two CMS Medicaid
AHCA ITN 009-17/18, Attachment A, Exhibit A-4-d, Page 8 of 100 EXHIBIT A-4-d SPECIALTY SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA waivers, through which eligible youth had access to five supplementary wraparound services: Parent Support and Training, Youth Support and Training, Crisis Stabilization, Short-term Respite, and Independent Living/Skills Building. After two years of managing youth, we experienced very positive outcomes, including a 50 percent decline in in-patient readmission rates for youth engaged in CSoC, a reduction in inpatient admissions once enrolled in CSoC by an average of 82 percent, and in number of total days spent in an inpatient hospital once enrolled by an average reduction of 79 percent. We continue to manage this program today, and have seen an extraordinary amount of success, so much so, that the state continues to have Magellan manage these services outside of their traditional managed care model.
>In Wyoming, Magellan has served since 2015 as the Care Management Entity (CME), implementing a High-Fidelity Wraparound Program on behalf of children and their families eligible for the state’s Children’s Mental Health Waiver. Through the program, we offer access to flex funds, respite services, family care coordinator support, youth support, parent support, and youth and family training. Partnering with service providers and organizations across the state, Magellan implemented a streamlined application process, shortened the length of time it took for children to be fully-enrolled and active in the program, and increased the total number of families served by the program.
>In our HealthChoices county-based programs in Pennsylvania, we identified a need for transition age youth (TAY) ‐focused services for youth who experienced difficulty transitioning from the child behavioral health system to the adult behavioral health system. In an average year, Magellan serves about 150,000 TAY members across our six PA counties. In 2013, we implemented the Transition to Independence (TIP) model in Bucks County. TIP engages and supports youth in their own future planning process across five transition domains: educational opportunities; living situation; employment and career; community life functioning; and personal effectiveness and well‐being. TIP assists youth as they transition from a Residential Treatment Facility (RTF) or behavioral health rehabilitation services (BHRS). This program has been instrumental in assisting youth with long-standing behavioral health issues in transitioning into education, stable housing, and employment. We are truly assisting our members in learning to live independent lives. To that end, we implemented TIP in the remaining four counties we serve in 2015.
In summary, Magellan Complete Care is an expert with established and demonstrated experience in effectively and efficiently serving Medicaid Managed Care enrollees, and in particular, the highly specialized and complex group of people with SMI. The examples above highlight our accomplishments on behalf of some of the most notable sub-groups in our overall Medicaid membership.
Evaluation Criteria:
1. The extent the Medicaid population served by the managed care contracts is similar to the specialty population proposed.
2. The number and size of managed care contracts active in the last five (5) years.
3. The extent to which managed care contracts, or other contracts, active in the last five (5) years, provided relevant experience.
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4. The extent to which listed accomplishments and achievements are significant and relevant to the specialty population proposed.
Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each.
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B. AGENCY GOALS
Specialty SRC#2 - Care Coordination and/or Case Management (Statewide):
The respondent shall propose care coordination and/or case management activities to meet the unique needs of the specialty population being proposed for this solicitation, including specific disease management interventions or special condition management relevant to the specialty population. The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in providing care coordination/case management for populations similar to the specialty population being proposed, including experience with disease management or other special condition management. The respondent shall describe proposed interventions, evidence-based risk assessment tools, self-management practices, practice guidelines, etc., relevant to the specialty population proposed. The respondent shall identify specific staff qualifications, training and/or experience for case management personnel related to the specialty population proposed. The respondent shall describe any other care coordination/case management activities the respondent proposes to meet the needs of the specialty population proposed.
Response:
OVERVIEW The State of Florida’s decision to establish amanaged Medicaid Specialty Plan for individuals with serious mental illness (SMI) was a national first, a bold experiment aimed at delivering on the promise of integrated behavioral health-physical health care delivery and management for this highly complex population. Although smaller efforts had been directed at coordinating the broad scope of services necessary to support the goals of stability, recovery, and resiliency, this was the first to target such a large, diverse population.
Magellan Health, Inc. embraced that challenge with the formation of Magellan Complete Care SMI Specialty Health Plan (Florida MHS, Inc. d/b/a Magellan Complete Care) in July 2014. We recognized the opportunity it presented to build an integrated model to address the full scope of capabilities necessary to achieve improved outcomes for a population to which the Magellan family of companies have been dedicated for more than 40 years.
Since its inception, Magellan Complete Care has worked continually with AHCA, our provider partners, enrollees, community organizations, and public stakeholders to craft and continuously refine an integrated health plan model that supports individuals with SMI in achieving their potential. We are committed to continuing that partnership through expansion to other regions, continuing to refine programs and approaches to manage and deliver care, developing provider capabilities and community partnerships to support system transformation, and demonstrating the value of an integrated Model of Care (MOC) to achieve outcomes that meet and exceed those for other populations served by Medicaid.
The programs and approaches presented in this section reflect that experience and the data- driven refinement of the MOC around solutions with demonstrated value for our enrollees and AHCA. We successfully launched our clinical programs and have continued to review, enhance,
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CRITERIA 1 - THE EXTENT OF EXPERIENCE…IN PROVIDING CARE COORDINATION/CASE MANAGEMENT… 1.1 Experience Providing Care Coordination / Case Management 1.1.a Magellan Health, Inc. For more than 40 years, Magellan Health, Inc. (Magellan), has provided comprehensive, evidence-based medical, behavioral health, utilization management, integrated care management, pharmacy management, and employee assistance programs to improve healthcare outcomes. We have experience serving SMI and Medicaid populations across the country, are consistently recognized for introducing innovative clinical programs that meet the unique needs of these enrollees, and make a significant impact on the daily lives of the individuals we serve. Our approach combines clinically-driven whole health with a collaborative care model to address the needs of the complete person and improve overall health and wellness.
As a leading specialty health care management organization, Magellan Health, Inc. was founded in 1969, with expertise in assessing, managing, and ensuring access to appropriate, high quality health services that promote acute and chronic condition management, recovery, and wellness. Magellan Health, Inc. provides healthcare management services to enrollees through health plans, state and local governments, the Federal government, employers, and the military.
Magellan Health, Inc. serves approximately 53.5 million members in all 50 states (including 3.95 million in Florida) with more than 7,200 employees nationally, including over 930 individuals currently employed or contracted with Magellan in Florida, representing all Magellan lines of business and numerous locations in every part of the State. Of these more than 930 people, the largest concentration of staff, approximately 260 individuals, are in the Magellan Complete Care Medicaid Center of Excellence in Miami.
A second Florida office, our pharmacy office in Orlando, houses more than 190 employees and contractors, while our pharmacy satellite office in Tallahassee has over 30 employees today working on the State Medicaid pharmacy contract. The remaining employees are counseling staff co-located at federal and military sites across Florida, or work from home in the communities that we serve.
Magellan provides behavioral health, radiology, pharmacy, and Medicaid Managed Care Services to enrollees with SMI across a broad set of Medicaid eligible groups including Temporary Aid for Needy Families (TANF), Aged Blind & Disabled (ABD), and waiver eligible populations, as well as dual eligible and Medicare Advantage populations. Magellan Health, Inc. provides care management and administrative/managed care services for a broad set of medical benefits including: physical, behavioral, and integrated health; complex areas of specialty healthcare; pharmacy; and, long-term care services and supports (LTSS).
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Within Magellan, we operate several corporate units that deliver various services to SMI populations similar to the target population for this response. These include:
1.1.b Magellan Rx Management Magellan Rx Management (Magellan Rx), which is part of Magellan Health, Inc., provides a smarter approach to pharmacy benefits. Magellan Rx serves SMI populations throughout the country, as well as general Medicaid populations, commercial populations, and others. Our integrated solution combines our pharmacy benefit and specialty pharmacy expertise into an organization that allows us to leverage our collective scale and experience in managing total drug spend, while ensuring a clear focus on the specific needs of each of our individual customers. Magellan Rx provides customers with easy-to-use tools and insightful cost-saving solutions that improve enrollee health and help customers make more informed decisions.
1.1.c Magellan Healthcare, Inc. Magellan Healthcare, Inc. (Magellan Healthcare), which is part of Magellan Health, Inc. (Magellan), has a strong focus on managing fully integrated healthcare benefits and programs for special populations with complex health issues and significant co-morbid conditions through care management. These programs begin with a health risk assessment and risk stratification and include utilization management of all healthcare services (medical and behavioral); integrated (medical and behavioral) care coordination and complex case management; management of transitions of care; and management of Medicare Advantage and Special Needs Plans.
1.1.d Magellan Complete Care Magellan Complete Care of Florida (Florida MHS, Inc. d/b/a Magellan Complete Care), which is part of Magellan Healthcare, Inc., is an innovative specialty healthcare plan focused on fully- integrated physical health (PH) and behavioral health (BH) care and care management for individuals with SMI. Magellan Complete Care is the nation’s first Medicaid plan specifically created for individuals with SMI. Our mission is to help our enrollees find their way through the health care system by integrating all care in a single solution, and managing that care through integrated PH-BH program design, interventions and care management. With collaboration across all types of providers, enrollees, and their caregivers, the plan holistically manages all physical, behavioral, and specialty healthcare services to deliver better care and improved outcomes for individuals with SMI.
1.1.e AlphaCare AlphaCare, a Magellan Complete Care owned health plan, operates a Managed Long-Term Care (MLTC) plan, serving the boroughs in and around New York City, as well as a Medicare Advantage Plan (MAPD), a Dual Special Needs Plan (D-SNP) and an Institutional Special Needs Plan (I-SNP). These populations are extremely complex and vulnerable, similar to those served by Magellan Complete Care of Florida.
In addition, given AlphaCare’s combined Medicaid and Medicare health plan capabilities, it has been selected as a Medicare-Medicaid Plan to participate in New York’s duals demonstration, the Fully Integrated Duals Advantage (FIDA) program, which began on January 1, 2015.
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1.2 Experience Providing CC/CM Similar Target Populations, Including Disease or Special Condition Management Magellan Complete Care is the first fully-integrated physical and behavioral health plan in the U.S., dedicated to improving health outcomes for SMI enrollees, who are some of the most complex, non-compliant, and vulnerable populations managed under the Medicaid program. This specialty health plan is a bold statement of commitment to demonstrate that improvement in the overall health outcomes for this population is possible by building physical health plan capabilities around a strong core of behavioral health management. Magellan has the capabilities and experience in managing multiple populations and programs across the country that is required to demonstrate success in this innovative model.
Magellan has extensive and relevant experience (inclusive of Magellan Complete Care and affiliates Magellan Healthcare and Magellan Rx) providing CC/CM to similar target populations across the country, including disease or special condition management. This includes our programs in Florida, as well as New York, Wisconsin, Pennsylvania, Louisiana, Virginia, Nebraska, Wyoming, and commercial sector clients. Programs include individuals with SMI, as well as dual-eligible; Special Needs Plans (SNP); Managed Long-Term Care (MLTC); Long- Term Services and Supports (LTSS); physical and intellectual/developmental disabilities; TANF; and ABD.
Our programs and plans, our staff, programs, and systems are all specifically focused on the deserving, but often lost children, parents, friends, neighbors and relatives who daily struggle to manage their most basic needs, much less seek treatment or make a preventative care visit. Our job and our mission is to help our enrollees, one person at a time, find a path to recovery and self-management. Because of our dedicated focus, our programs are a catalyst for system change and transformation. By design, traditional Medicaid health plans serve broad populations. It is difficult to provide the singular focus, tailored programs, and intense follow-up needed to support the difficult to engage or enrollees that can’t be found. Our alternate design retools traditional health plan roles and creates new ones; customizing our systems and predictive modeling tools for our unique population; creating integrated clinical guidelines that address co-occurring medical and behavioral health conditions; and developing innovative new programs.
Below, we summarize 13 key Magellan contracts where we apply these solutions, and that are directly applicable for this ITN:
1.2.a. Florida Agency for Health Care Administration; Magellan Complete Care - Areas 2, 4, 5, 6, 7, 9, 10, and 11 (Medicaid Specialty Plan for Persons with SMI) – Magellan Complete Care: a. Enrollees: Medicaid Enrollees (TANF, ABD, Duals): >Serving 52,600 Medicaid recipients living with SMI, including 31,360 adults and 10,545 children or youth b. Years: 2014-Present c. Unique specialty health plan designed to integrate care for Medicaid enrollees with SMI including medically necessary primary and acute medical care, pharmacy, behavioral health, vision, dental, and non-emergency transportation. Health plan management services include: care coordination; claims processing/payment; IT; care management and UM, including intensive case management; QI; reporting; network development/management; and coordination with physical health providers; utilizing the expertise of sister companies including
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Magellan Rx Management; and National Imaging Associates, Inc.) a radiology benefits management company.
1.2.b. Florida Agency for Health Care Administration/Child Welfare Prepaid Mental Health Plan (as the Managing General Partner of the CBC Partnership) – Magellan Healthcare: a. Enrollees: Medicaid Enrollees (TANF, ABD, Duals) – Children >Serving 19,778 children and adolescents in the Florida Safe Families Network system (Child Welfare) and Medicaid eligible b. Years: 01/15/07-01/31/15. Membership ended 6/30/14 as a result of the State of Florida’s Medicaid Reform process that ended all Prepaid Mental Health Plans and the Specialty Plan for adults with serious mental illness began c. Magellan Behavioral Health of Florida, Inc. and the Community-Based Care (CBC) agencies in 58 of Florida’s 67 counties formed a limited partnership in 2006 that successfully bid on the State’s procurement for a specialty Medicaid health plan. The specialty plan, titled the Child Welfare Prepaid Mental Health Plan (CW PMHP), was designed to meet the behavioral health needs of children involved in Florida’s child welfare system.
Management of behavioral health covering inpatient hospital care, outpatient hospital care, psychiatric physician services, community mental health services, intermediate levels of care, residential substance abuse treatment, psychiatric medical institutional services, behavioral intervention services (BHIS), rehabilitative services, mobile counseling, crisis services/referral, intensive psychiatric rehab, ACT, community support services, school-based services, targeted case management.
1.2.c. Florida Agency for Health Care Administration – Magellan HCM: a. Enrollees: FFS Medicaid Enrollees b. Years: 2001-2017 >Qualified Evaluator Network – 2001-present (16 years) >Care Coordination – 2003-present (14 years) >UM/Audits – 1997-2014 (17 years) c. Utilization management for behavioral health prior authorized and continued stay mental health services; retrospective-eligible reviews and peer review and provider/peer training; care coordination; quality reviews; audit services; fraud, waste, and abuse reporting; Qualified Evaluator Network
1.2.d. NY State Department of Health (3 contracts: AlphaCare of New York, Inc., AlphaCare Renew, AlphaCare Total, AlphaCare Signature) – Magellan Complete Care: a. Enrollees (18 and over): >Medicare Advantage with Part D (MAPD): Medicare members >DSNP: Medicare Advantage members >Managed Long Term Care (MLTC): Medicaid members >FIDA: Medicare and Medicaid members (duals demonstration) b. Years: 2013-2018: >MLTC: 08/01/2013-12/31/2014 (contract renewal in process, term duration in discussion) >MAPD/DSNP/ISNP: 9/26/2013-12/31/14 with renewals (contract renewal in process, term duration in discussion) >FIDA: 7/3/2014-end of demonstration (2018)
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c. AlphaCare, a Magellan Complete Care owned health plan, operates a Managed Long-Term Care (MLTC) plan, serving the boroughs in and around New York City, as well as a Medicare Advantage Plan (MAPD), a Dual Special Needs Plan (D-SNP) and an Institutional Special Needs Plan (I-SNP)
AlphaCare coordinates integrated healthcare and LTSS, including non-covered benefits such as Medicare or Medicaid primary benefits, pharmacy, ER and hospital services. LTSS, behavioral and physical health covered benefits include: outpatient rehabilitation; inpatient hospital; personal emergency response systems; prescription drugs (except MLTC); non-emergency transportation; hospice; chiropractic care; diabetes supplies and services; dental physical therapy (MLTC, FIDA,), speech therapy (MLTC, FIDA), 24/7 on-call services (MLTC); optometry/ eyeglasses; home safety modifications and improvements (MLTC); hearing; nursing home care; outpatient SUD treatment; kidney disease care; home health care; medical social services; adult day healthcare (MLTC); home-delivered meals (MLTC); personal care; durable medical equipment; social services (connection to community resources); and wellness programs.
1.2.d. Wisconsin Department of Health Services, IRIS Consultant Agency and Self-Directed Personal Care Oversight Agency – The Management Group (TMG): a. Enrollees: Older adults and individuals with physical and intellectual/developmental disabilities b. Years: 1987-present c. TMG is a provider of IRIS Consultant Agency (ICA) services under Wisconsin’s Medicaid program. An ICA provides flexible and specialized support that is responsive to a participant’s needs and preferences for long term care services.
TMG’s roles and responsibilities as a State certified ICA focus on supporting the participant in self-direction, which includes enrollment, service planning, and continued eligibility.
1.2.e. HealthChoices, Pennsylvania, Department of Human Services, Office of Behavioral Health (Bucks, Cambria, Delaware, Lehigh, Montgomery, Northampton Counties) – Magellan Healthcare: a. Enrollees: Medicaid Enrollees (TANF, ABD) b. Years: >>Bucks: 2000-2019 >>Cambria: 2017-2020 >>Delaware: 1997-2019 >>Lehigh: 2001-2019 >>Montgomery: 2000-2018 >>Northampton: 2001-2019 c. Manage a comprehensive array of services for children and adults, including self-directed care for children with ASD and their families; family-based case management; functional family therapy (FFT); multi-systemic therapy (MST); family-focused solution based services (FFSBS); inpatient psychiatric, non-hospital, and intensive outpatient drug and alcohol (D&A) services; mental health and D&A partial hospitalization and outpatient services; behavioral health rehabilitation services (BHRS); residential treatment; crisis management; psychiatric rehabilitation; peer support; and D&A case management and mobile engagement.
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We also provide the full range of UM services, 24-hour crisis counseling and referral, management information system, network development, claims processing, QI, and reporting.
1.2.f. State of Louisiana, Department of Health and Hospitals, Office of Behavioral Health, Louisiana Behavioral Health Partnership – Magellan Healthcare: a. Enrollees: Medicaid Enrollees (TANF, ABD, Duals) b. Years: >3/1/12-2/28/15 original contract >3/1/15-11/30/15 emergency contract extension 7.c. Magellan’s role and scope of work included comprehensive management of behavioral health services, including: >Behavioral health crisis and access line >Utilization and case management for behavioral health services >Provider network development and management >Claims management and payment for all provider types >MIS support services, including Electronic Health Record development, implementation and network training >Quality Management
1.2.g. State of Louisiana, Department of Health and Hospitals, Office of Behavioral Health, System of Care for Children – Magellan Healthcare: a. Enrollees: Medicaid Enrollees (TANF, ABD, Duals) b. Years: >>12/1/15-11/30/16 original contract >>12/1/16-1/31/18 extension 7.c. Magellan worked closely with DHH/OBH to transform an unmanaged system of care to one that effectively uses managed care principles and processes. We coordinated services across multiple agencies, working actively with stakeholders and providers, and with DHH to implement a CSoC for children with behavioral health challenges.
We also worked with OBH to introduce and implement new services, including recovery and resiliency-focused programs and services covered under new treatment waivers. The program was broadened to include non-CSoC children’s mental health services.
We established collaborative protocols with several child-serving agencies, including the Department of Child and Family Services (DCFS) and Office of Juvenile Justice (OJJ). Our team was very involved in child placement and services to youth in DCFS or OJJ custody.
1.2.h. Commonwealth of Virginia, Department of Medical Assistance Services – Magellan Healthcare: a. Enrollees: Medicaid Enrollees b. Years: 2013-2018 c. Our responsibilities under this contract include: care coordination; monitoring and encouraging appropriate behavioral health service utilization; behavioral health crisis and access line (24/7); claims management and payment for all provider types; clinical management services; cross system coordination; eligibility and enrollment; provider network development and management; authorization and UM; participant/provider assistance and communication;
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quality management; recipient/provider appeals and grievances; reporting and data exchange services; customer service; and program integrity to prevent Medicaid fraud, waste, and abuse. Our scope of services includes: inpatient hospital care, residential treatment, outpatient hospital care, psychiatric physician services, outpatient therapy, community mental health services, intermediate levels of care, residential substance use disorder treatment, crisis intervention, crisis stabilization, psychiatric rehabilitation, intensive community treatment, mental health skill building, therapeutic day treatment, intensive in-home treatment, partial hospitalization, and targeted case management. Our team coordinates regularly with State and local agencies, including the Department of Social Services for clients in foster care and the Department of Juvenile Justice for individuals in the justice system.
1.2.i. Commonwealth of Virginia, Department of Medical Assistance Services – Magellan Healthcare: a. Enrollees: Dual eligible members who qualify for Managed Long Term Services and Supports (MLTSS) b. Years: 2017-2022 c. Comprehensive managed long term services and supports (LTSS), including self-directed care, provided to: >Dual eligible individuals with full Medicaid and Medicare coverage >Non-dual eligible individuals who receive LTSS services through an institution or through HCBS waiver programs >ABD individuals (beginning January 2018)
1.2.j Nebraska Department of Health and Human Services, Division of Medicaid and Long-Term Care − Magellan Healthcare: a. Enrollees: Medicaid Enrollees (TANF, ABD) b. Years: 2013-2016 c. Magellan was contracted with DHHS to provide comprehensive administrative services that coordinate mental health, substance use, and addiction treatment services for more than 225,000 Medicaid eligible adults and children. Our role and scope of work performed for this contract included management of child and adult behavioral health covering inpatient acute and sub-acute hospital care, partial hospital care, psychiatric physician services, community mental health services, intermediate levels of care, residential substance use disorder treatment, psychiatric residential services, rehabilitative services, outpatient substance use disorder counseling and psychiatric therapy, crisis services/referral, intensive psychiatric rehabilitation, ACT, community support services, injectable psychiatric medication management, and sexual offense specific outpatient, intermediate and residential services (youth only).
Magellan offered Recovery Care Management services to the most vulnerable enrollees in the state.
Our behavioral health clinical staff also offered health integration services to member Physical Health MCO staff and physical health providers through targeted case conferencing interventions, the PCP toolkit and PCP assistance line, and WholeHealth Rx pharmacy UM activities.
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1.2.k Comprehensive Administrative Service Organization (ASO) with the Nebraska DHHS Division of Behavioral Health − Magellan Healthcare: a. Enrollees: Medicaid Enrollees (TANF, ABD) b. Years: 1994 – 2016: >Initial ASO contract began in 1994 with a significant expansion in 2008. The ASO contract with DBH continued after MLTC converted their contract to risk in 2013. The current contract began in August 2014 and has a two year term with one additional one year renewal. c. Behavioral health services: Management of adult behavioral health services covering inpatient acute and sub-acute hospital care, partial hospital care, community mental health services, intermediate levels of care, residential substance use disorder treatment, psychiatric residential services, rehabilitative services, intensive psychiatric rehab, ACT, and community support services
1.2.l Wyoming Department of Health, Division of Healthcare Financing – Magellan Healthcare: a. Enrollees: Medicaid-eligible children and youth receiving waiver High-Fidelity and related wraparound services b. Years: July 1, 2015-June 28, 2018 (possible two, 1-year extensions) c. Magellan functions as both an administrative and service management level regarding High Fidelity Wraparound (HFWA), access to flex funds, respite, family care coordination, youth support, parent support and youth and family training related to the children’s mental health waiver.
1.2.m Additional Relevant Experience Includes: 1. Commercial Sector Experience – Magellan Healthcare: 1.a Enrollees: As of January 2017, we have 44 State/Local Government accounts covering approximately 393,368 Employees (756,042 Members) 2. Medicaid experience in Pharmacy – Magellan Rx Management (MRx): 2.a Enrollees: 23 million Medicaid members 2.b Years: >45+ years of Medicaid experience overall, including experience as a Fiscal Agent >35+ years of PBM: >>Provides full PBM contracts for 12 Medicaid agencies >>Provides Medicaid services (including the full PBM and PDL contracts for 25 Medicaid agencies >>Provide pharmacy services for 27 government contracts (this includes Medicaid as well as other government experience such as ADAP and Pharmaceutical Contracts for Seniors
CRITERIA 2: THE EXTENT TO WHICH THE DESCRIBED EXPERIENCE DEMONSTRATES THE ABILITY TO… The complexities of managing the SMI population makes it clear that Magellan Complete Care must use all available enrollee touchpoints to assess enrollee health and deploy targeted interventions when needed. Our Model of Care reinforces and prioritizes recovery, stabilization, health maintenance, optimal safety and quality, and independence through partnering with our enrollee, their natural supports and providers.
Our recovery expertise and sound evidence-based practice approaches have been used in the development of our behavioral health program, including best practice protocols in the areas of
AHCA ITN 009-17/18, Attachment A, Exhibit A-4-d, Page 19 of 100 EXHIBIT A-4-d SPECIALTY SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA addiction and recovery services. Using an integrated, high-touch, team-based approach, Magellan Complete Care addresses the full continuum of biopsychosocial care and services simultaneously rather than in a linear or sequential manner. This allows us to continually adjust interventions based on evolving enrollee needs and circumstances including indications of decomposition or instability in the enrollee’s mental or physical health or changes in social dynamics, which can trigger cascading effects.
Since the launch of Magellan Complete Care our dedicated care coordination and medical teams have focused their efforts on fully understanding the unique needs of a very complex population. We successfully launched our clinical programs and have continued to review, enhance and refine our program approaches based on the specific needs of our enrollees, provider resources and capabilities, and community supports and services. The Magellan Complete Care population continues to present with a variety of complex medical, behavioral health, and psychosocial conditions with key population cohorts including maternal, pediatric and adolescent, adult, advanced illness, and end-of-life. In addition, a segment of our membership has continued to present with ultra-high-risk needs and situations, resulting in the need to further develop targeted and focused clinical programs.
2.1 Fully-Integrated MOC Though this section specifically focuses on the care coordination model, it is important to emphasize that the Magellan Complete Care MOC is a complete system of inter-related elements in support of the enrollee, including:
>Comprehensive clinical analytics and reporting to understand enrollee needs and characteristics and the effectiveness of interventions
>Customized and expanded enrollee risk assessment, stratification and segmentation to support assignment of individuals to case management and care coordination based on biopsychosocial risk and complexity
>Provider development programs and practices to broaden network scope, develop provider capabilities, monitor outcomes, and collaborate to create integrated solutions
>Integrated biopsychosocial case management and care coordination that is comprehensive and supports the enrollee to achieve stability, health, and move toward recovery
>Integrated Health Neighborhood (IHN) which is customized by region and which provides a system of support for enrollees’ care, quality of life, and health outcomes; and
>Comprehensive quality monitoring, management, and improvement initiatives that are linked to our analytics, care delivery, and care management programs, driving continued refinement of all program elements.
Our risk stratification model demonstrates how we have applied the concepts of risk stratification and segmentation to the integrated care management and coordination process to assign enrollees to an appropriate level of care management and care coordination. This model is built on the concepts of the SAMHSA Four Quadrant Integration Model (Mauer, Barbara J., “Behavioral Health/Primary Care Integration and the Person Centered Healthcare Home,” April
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2009, The National Council for Behavioral Healthcare) which describes levels of integration in terms of primary care complexity and risk and mental health/substance use complexity and risk. Consistent with the concepts established in the development of the Four-Quadrant Model, and supporting models of care, we believe that management of SMI is a critical element for ensuring the overall health of enrollees, but that all elements, behavioral health, physical health, and social supports must be balanced to achieve targeted results with everything else cascading under that primary condition. We also use multiple mechanisms to capture information on key social determinants affecting healthcare outcomes, including housing, food and employment insecurity, and childhood stressors (ACEs – Adverse Childhood Experiences) and incorporate solutions tied to those issues, to enhance enrollee opportunities for recovery and health. We actively manage the treatment of the “whole enrollee,” focusing on the SMI, physical health and wellness issues, and social stressors or destabilizing influences. Our programs are built around a fully-integrated approach to managing all of those issues in combination and recognizing key interdependencies of each.
2.1.a Model of Care Our Model of Care has continued to evolve since the implementation of the SMI Specialty Plan as Magellan Complete Care has further expanded and defined services to meet the complex, specialized needs of our enrollees. While we have continued to expand more traditional programs for such areas as disease management (DM) and utilization management (UM), we have also incorporated a paradigm shift in our CC/CM approaches that includes the establishment of a fully-integrated approach that incorporates complex case management (CCM) and disease state specialty teams.
Our specialty teams focus on assisting enrollees with both short and long-term care coordination and case management activities, along with managing unnecessary resource utilization and reducing preventable events. We have developed these teams based on our ongoing analyses of enrollee characteristics including social determinants, key drivers of outcomes and utilization, and increasing understanding of which interventions have the greatest affect for improving enrollee outcomes and overall health. The disease state specialty teams are focused on the following illness categories: high risk diabetes, high risk pregnancy, congestive heart failure, and sickle cell, schizophrenia, and first episode psychosis.
The teams are equipped with analytics and information which guide focused case management efforts in addition to emergency department diversion (EDD) activities. For our highest risk enrollees (Ultra High Risk Level), we have decreased the Integrated Care Case Managers (ICCM) caseloads to 1:25 creating the capacity for individualized clinical activities, including:
>Complete in-home assessments and evaluating the home environment >Increase coordination with medical management to focus on skilled and unskilled care >Increase time for ICCMs to accompany enrollees to PCP visits and collaborate on the plan of care >Improve coordination with Magellan Rx to evaluate and improve medication adherence >Coordinate with partner vendors for DME and home health services >Lead the discharge planning process and complete post discharge follow up >Provide discharged enrollees with meals, recovery support services, and peer support services >Assist homeless enrollees to access short/long-term housing programs
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>Support enrollees with care management services while engaged with the criminal justice system
These specialty programs further enhance and supplement our case management and care coordination programs to target specific diagnoses that pose the greatest risks for our enrollees. As part of this MOC, Magellan Complete Care has also further enhanced its health risk assessment, predictive modeling, and risk stratification processes to identify those enrollees at greatest risk of physical or behavioral health destabilization.
We serve a very complex population, including those enrollees who may present with a primary diagnosis of SMI, severe emotional disturbance (SED), and SUD, who also have complex medical and additional behavioral health issues, as well as social stressors such as homelessness and incarceration. Enrollees that have multiple chronic conditions are designated as high-risk enrollees and receive complex and enhanced care coordination services.
2.1.b Study Outcomes Associated with Participation in CC, CCM, and DM Programs Through our tenure as the current SMI Specialty Plan provider, we have been able to demonstrate the value of CC/CM and DM interventions in improving enrollee outcomes. We present major findings from a study of outcomes associated with both participants and non- participants in these programs. For purposes of this analysis, enrollees were grouped as follows:
>Those enrolled in CC/CM, DM (treatment) >Those who we were unable to contact/never touched (control)
We analyzed data from 1/1/2015 through 9/15/2016 (to allow time for completion of program for the enrolled group and six months of post discharge claims including three months of claims runout). Only enrollees who were continuously eligible for the duration of the study (12 months for the not enrolled/engaged group or 12 months plus time in case management for the enrolled/engaged group). We studied adults (21+) and studied children/youth independently. We operationalized the study design based on the following criterion:
>RISK: High Risk (2+ Comorbid Conditions and 3+ Any Cause Admissions)/Moderate Risk (Either 2+ Comorbid Conditions or 3+ IP Any Cause Admits)/Low Risk (< 3 IP Any Cause Admits)
>COMORBID CONDITIONS: Sum of clinical indicators included in this analysis: >>Use of DME, Sickle Cell, Cancer, Hypertension, CHF/Cardiovascular Disease, Substance Use Disorder, Alcohol Use Disorder, Asthma, Schizophrenia, Transplants, HIV/AIDS, Bipolar, Eating Disorder, Major Depressive Disorder, COPD, Congenital Birth Defects, Diabetes, and COPD
>ENGAGED/ENROLLED: To count as enrolled, an enrollee must have had a care plan, received contact from case managers at least 10 percent of the time he/she was enrolled in the case management program, and had an outcome of “Goals Met” or “Change in Clinical Status or Condition” for one of these reasons: Program Completed, Reached Maximum Gain, Change in Clinical Status/Condition, Pregnancy-Terminated, or Pregnancy-Delivered.
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In adults, inpatient (any cause) admissions were reduced more for the engaged/enrolled group than the not engaged and enrolled group, including:
>Any cause admissions, which include potential preventable admissions and readmissions for the enrolled group were reduced by 49 percent: >>This reduction was statistically significant (over time and between enrolled and not enrolled enrollees) >This reduction was present at all risk levels: >>Low Risk admissions for the enrolled/engaged enrollees decreased by 47 percent >>Moderate Risk admissions for the enrolled/engaged enrollees decreased by 36 percent >>High Risk admissions for the enrollee/engaged enrollees decreased by 38 percent >>All readmissions were statistically significant (over time and between enrolled and not enrolled)
In adults, all-cause ER use decreased for both the engaged/enrolled group and not engaged and enrolled group, but these groups were not statistically, significantly different:
>Any cause admissions for the enrolled group were reduced by 34 percent Rates of ER use for physical (non-trauma) causes decreased more for the enrolled/engaged enrollees than for not enrolled/engaged enrollees, including: >Low Risk admissions for the enrolled/engaged enrollees decreased by 82 percent >Moderate Risk admissions for the enrolled/engaged enrollees decreased by 85 percent >High Risk admissions for the enrolled enrollees decreased by 68 percent >All re-educations were statistically significant (over time and between enrolled and not enrolled)
Enrolleess who were enrolled and engaged in CM had longer periods of community tenure than any other group (those not enrolled, those who were enrolled but had staff contact 0 or less than 50 percent of the time during their enrollment):
>The likelihood of adverse outcomes for enrolled and engaged enrollees is statistically significantly lower than the other groups (enrolled enrollees spent more time in the community) >The health rate (community tenure) for those enrolled and engaged is 37 percent lower than those who are not enrolled.
2.1.c Recovery-Oriented Systems of Care and the Four Quadrant Clinical Integration Model One of the most important elements of national health care reform is the expansion of coverage for those with mental health disorders and substance use disorders. Magellan Complete Care shares in the Substance Abuse and Mental Health Services Administration’s (SAMHSA) establishment of the Resiliency and Recovery-oriented Systems of Care (ROSC) to enhance prevention, treatment, and recovery services.
These elements are incorporated throughout our case management/care coordination programs and are integrated as part of our broader outreach and enrollee support efforts. One important component of that model is our Integrated Health Neighborhood (IHN) shown in [Specialty SRC #02, Attachment 1: Care Coordination Program Description].
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The IHN, which incorporates many of our ICCM outreach staff and services, is also closely linked with other community services and supports that are critical for the stability, health and resiliency of our enrollees. Magellan Complete Care’s goal is to improve enrollee’s care, quality of life, and health outcomes within the context of where the enrollee lives – their neighborhoods and communities. Our IHN team members live and work with these communities and have first- hand knowledge of community strengths, resources, services and service gaps. IHN team members include the enrollee’s ICCM, Health Guides, Peer Specialists, and Community Outreach Specialists supported by Housing Specialists, Employment Specialists, Clinical Pharmacists, Medical Directors and others.
Magellan Complete Care created the IHN concept to support strong relationships and collaboration with community partners which enable us to effectively coordinate care with community supports and services that the enrollee knows and trusts and that the provider delivery system can easily access. The IHN is our vehicle to drive close collaboration with community partners, allowing us to customize care for our enrollees, and to provide a seamless, one-stop system of services and supports. It also naturally bridges language and cultural barriers and more effectively and efficiently facilitates access to services in their communities. Magellan Complete Care designates care coordination teams to carry out procedures required in care coordination, complex case management, and other related care management programs. The care coordination team includes the enrollee or designated representative, the primary behavioral and medical treating providers, a Health Guide, and if indicated by the enrollee’s circumstances, an ICCM. A clinical pharmacist, peer support specialist, and medical directors (with physical and behavioral health expertise) are also available to the Care Coordination teams at all times. The CareLine is available to enrollees 24 hours a day/7 days a week, and is staffed by ICCMs. Enrollees can call the CareLine anytime for assistance as a backup after hours, on weekends, or if they are unable to reach their assigned Case Manager, including when their assigned Case Manager is on paid time off.
Depending on the enrollee’s needs, the care coordination team may also include: >Integrated Care Case Manager (ICCM): The ICCM is either an RN or masters-prepared mental health or social work professional, and is engaged for all high-risk enrollees. The ICCM is responsible for developing the care coordination plan consistent with the enrollee’s health care needs and goals. The ICCM monitors and intervenes for enrollees with complex situations and ensures implementation of the care plan. The ICCM is actively involved at times of transitions of care, including, but not limited to planned and unplanned admissions. The ICCM works in conjunction with the enrollee’s Health Guide to ensure care plan communication between all providers and enrollees.
>Health Guide: The Health Guide is the enrollee’s advocate and helps the enrollee navigate through the delivery system. The Health Guide is community-based, where they can help the enrollee make and keep appointments with behavioral and physical health providers, and provide follow-up after appointments and coordinate with community agencies and other resources, as needed. The Health Guide assists the ICCM in ensuring that the care coordination plan is implemented as designed.
>Care Worker: The Care Worker is a non-clinical staff member who is responsible for supporting the care coordination teams. Activities may include, but are not limited to, mailing of letters/educational materials, obtaining authorizations for disclosure of protected health
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information, assisting with referrals, scheduling appointments, scheduling case conference meetings, and assisting with other basic care coordination activities.
>Peer Support Specialist: The certified Peer Support Specialist is trained in applying resiliency and recovery principles and tools such as wellness recovery action plans, a wrap-around process, family and person-driven care, and systems of care that use these skills to provide emotional support and inspire hope for the future. They model and assist enrollees in making lifestyle improvements and the self-management of chronic conditions. Peer support specialists provide additional outreach to individuals who require assistance to obtain access to and engage in needed services.
>Pharmacist: The pharmacist participates to review the medications enrollees receive and in collaboration with the prescribing physicians on the team, is responsible for identifying potential over and under-utilization, potential drug-disease interactions, and optimal therapeutic regimens. The pharmacist consults on complex cases where there is risk to the enrollee due to potential drug interactions between drugs for chronic medical conditions and psychotropic medications. The pharmacist will also take advantage of the sophisticated analysis of claims data to identify gaps or potential concerns.
Through the IHN, Magellan Complete Care Staff coordinate with service providers and community organizations to meet enrollee needs. These may include, but are not limited to, health care providers, behavioral health providers, Florida Assertive Community Teams, Managing Entities, Department of Children and Families, and homeless organizations/coalitions. The goal is to link enrollees with the appropriate service providers so that the providers can address the ongoing needs of the enrollees. Once linkage is made and the enrollee is engaged with the provider, Magellan Complete Care’s Care Coordination Staff monitors enrollee progress through periodic contact with the enrollee and provider. We also coordinate with other managed care/health plans on shared enrollees. This most often includes Long Term Care plans and Medicare plans. Health Services staff identifies enrollees who have long-term care benefits and/or Medicare benefits and shares clinical information, when appropriate, to ensure the enrollee’s needs are accounted for and that there is no duplication of service between the plans.
As mentioned previously, Magellan Complete Care uses the Four-Quadrant Clinical Integration Model developed by the National Council for Community Behavioral Healthcare which describes levels of integration in terms of primary care complexity and risk and behavioral health/SUD complexity and risk services related to different populations, including the population with SMI.
The Four Quadrant Model describes the need for a bi-directional approach, addressing the need for primary care services in behavioral health settings as well as the need for behavioral health services in primary care settings.
2.1.d Stakeholder Input for Program Improvement Magellan Complete Care’s CC/CM and DM programs are informed by input from those most closely involved – Florida residents with SMI, their families and supports, and the professionals who provide behavioral and physical health treatment.
Enrollee satisfaction highlights of data based on Magellan Complete Care Florida Experience of Care Surveys for both adults and minors in 2015 and 2016 include the following:
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>General satisfaction with Magellan is 91.62 percent for minors, and 89.96 percent for adults >89.3 percent of respondents feel Magellan is helping them take care of their illnesses >95 percent of respondents indicated that the place where services were received was good for them (6 percent improvement over 2015) >18 percent improvement for minors in the ease of getting care for their child – from 76.3 percent in 2015 to 90.26 percent in 2016
CRITERIA 3: THE EXTENT TO WHICH THE CARE/COORDINATION ACTIVITIES PROPOSED ARE RELEVANT… 3.1 Evolution of Our Model of Care Before Magellan Complete Care was created as a SMI Specialty Plan, Magellan Healthcare managed the Florida Agency for Health Care Administration/Child Welfare Prepaid Mental Health Plan from 2006 to 2015, as the Managing General Partner of the CBC Partnership. Many of the clinical and UM staff transitioned to the current program bringing their knowledge and Florida experience. We also draw on Magellan corporate resources and expertise in behavioral health from many decades of contract implementations. When needed we are able to involve Magellan corporate resources especially when we use project managers, data analysts, and clinical intervention teams.
As we have gained even more experience with our enrollees, providers and community stakeholders we have worked collaboratively with them and with AHCA to evolve our MOC in support of the unique needs of the populations we serve. This collaborative, enrollee-centered approach to develop effective solutions to manage the health of our SMI enrollees continues and grows to the present day. This Florida-specific experience as a partner for AHCA and our enrollees and our providers, differentiates us from any other health plan.
As we continue to refine and enhance our MOC we will continue to focus on system transformation and provider-led models and how we will continue to support the shift in care coordination and quality improvement resources to the point of care through the integrated provider models through health homes and similar solutions. We will also focus on advancing technology in how we work with enrollees and providers through increased use of telemedicine, smart phone apps, kiosks in CMHCs and FQHCs, group care for individuals with diabetes, remote monitoring, etc.
The demonstrated efficacy at the heart of our care coordination system stems from a systems- level integration of behavioral and physical health services; disease- and condition-specific expertise; and a focus on population health. We excel in the development of innovative strategies to combat vulnerabilities linked to social determinates of health (e.g., employment, housing, food security, health literacy, access to transportation, and education level) that further compromise the health status of our enrollees. This experience allows the AHCA to have confidence that the needs of its most vulnerable subpopulations are being addressed in a proactive and holistic fashion.
An additional cost-saving driver is our innovative delivery model for behavioral health services. Enrollees with behavioral health diagnoses incur twice the medical costs of those without these diagnoses. For enrollees with substance use disorders, medical costs are three-times higher.
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Magellan Healthcare has partnered with the Human Services Research Institute to develop a self-direction program for enrollees with behavioral illnesses that focuses on building independence skills and setting and achieving attainable health goals. Individuals who use self- direction are better prepared to reach personal recovery milestones and have fewer unmet needs than enrollees using a traditional model of care. This model provides individuals with greater flexibility and control over their own care, empowering them to actively seek positive outcomes, and ultimately lead healthier lives. Magellan Complete Care is leveraging that expertise from our sister-company The Management Group (TMG), a leader in the field of self- direction. TMG developed and implemented this program for populations like the SMI population included in this response. This program seeks to increase access to effective treatment for enrollees with behavioral health diagnoses and subsequently lower the overall cost of care. As Magellan Complete Care has grown, our data analytics and understanding of enrollees and intervention effectiveness have become more sophisticated, allowing us to drill down further into subpopulations with unique or very specific needs. This has allowed us to continually improve and optimize clinical programs and develop targeted, new clinical initiatives to meet the needs of individuals and specific subpopulations.
Magellan Complete Care embeds and operationalizes analytics in all parts of our programs to create insight that leads to the evaluation of changes that we make to enhance CC/CM. Some of the results of the data analytics have led to paradigm shifts within the care coordination department, leading to better outcomes and more effective programs overall for the enrollees.
Examples of some of the refinements we have made to our programs include:
>Targeting High and Ultra-High-Risk Enrollees >>Expanded and defined services to meet the specialty needs of these groups of enrollees >>Enhanced predictive modeling and ER Diversions >>Utilization of financial models to identify and target high cost enrollees >>Focus on enrollees identified through Predictive Machine Modeling with a likelihood to admit to an inpatient facility within a 90 day period. The predictive model will allow care managers the opportunity of early intervention and prevention of an inpatient admission. >>Decreased ICCM caseloads will create more capacity for enrollee care
>High-Impact, Targeted CC/CM: Targeted the initial phase of the CC/CM shift to Regions 10 and 11. Our analysis and ongoing service in these regions allowed us to identify that these remained the highest cost regions with poor performance in admissions/readmissions. Further analysis showed us that contributing factors included inappropriate Baker Act admissions, lack of medication and treatment compliance, and chronic homelessness.
>CC/CM statewide and Regional Specialty Teams: These multidisciplinary teams were developed for those enrollees who could benefit from a special program focus, with the goal of improving outcomes and reducing preventable admissions: >>Statewide specialty teams are focusing on the following disease states: Diabetes, CHF, Sickle Cell Disease, Schizophrenia, mood disorders, substance abuse, Bipolar Disorder, pain management, Depression, maternity, and enhanced care coordination >>>Sickle Cell Disease (SCD) Team is currently a statewide specialty team managing 150 enrollees with Sickle Cell Disease. The SCD Team will soon offer referrals to enrollees to the Broward Center of Excellence, a hospital home established for enrollees in Region 10.
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>>>Statewide Transplant Team is a dedicated ICCM team managing all transplant cases. >>>Diabetes Team is currently in development. ICCMs will partner with specialized Diabetes vendor(s), to collaborate and manage High Risk Diabetic enrollees and focus on reducing preventable admissions. Program started in January 2017 >>>Schizophrenia, Mood Disorder, First Episode Psychosis, and CHF Specialty Teams are being implemented in 2017 >>Local/regional teams focused on interventions with enrollees identified as at-risk through meeting enrollees where they are, and providing supports (access to housing, food, peer support, working with ALFs or other community resources) that are required for enrollee recovery and health. Additionally, based on our analysis of our enrollees, and assessments of the need for interventions and supports, we have decreased ICCM caseloads to 1:25 to create capacity for individualized clinical activities. Activities include: >>>Completing In-home assessments and evaluating the home environment >>>Increasing coordination with Medical Management to focus on skilled and unskilled care >>>Allowing more time for ICCMs to accompany enrollees to PCP visits and collaborate on care plan >>>Improving coordination with Magellan Rx to evaluate and improve treatment adherence >>>Coordinating with partner vendors for DME and Home Health Services >>>ICCM will be able to lead discharge planning process and complete post discharge follow up >>>Assisting homeless enrollees to access short/long term housing programs >>>Transitioning non-impact able enrollees >>Monitoring Non-Engaged Enrollees: We have also created a monitoring program for enrollees who are not engaged in CC/CM Special Teams but continue to meet established criteria.
Through this program, we monitor cases that should be referred back to regional teams for monthly monitoring and follow up by case owners. Monitoring risk criteria and related processes have been established and this program is currently ongoing. We are also continuing support in Regions 6 and 11 from Integra for outreach and engagement of difficult to locate enrollees. Magellan Complete Care has also been actively collaborating with our provider partners to build health home models built on the SAMHSA/CMS models for integrated behavioral health/physical health delivery of care that was developed and launched as part of healthcare reform. These include:
>Integrated Behavioral Health Home (IBHH) Pilot Program with Jackson Behavioral Hospital (Region 11). The IBHH will be vertically integrated with CC/CM program and will include: >>Enrollee referrals would be coordinated by designated specialty team >>Focus on management of high users >>Collaboration with IBHH on plan of care
>Hospital Homes which are similar to IBHH, and which are built around hospital centers of excellence for delivery of all physical health and behavioral health care services. We are partnering with inpatient providers to develop hospital home programs for enrollees throughout the state. They also incentivize providers to focus on coordination of all aspects of care: >>Referrals for specialty care >>Coordination of outpatient and inpatient treatment including substance abuse
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We also collaborate with and have extensive programs with several Magellan Complete Care partners including:
>Magellan Complete Care supports enrollee treatment adherence goals by completing medication reconciliation activities >QMC Hospitalists support care coordination by identifying enrollees with preventable ER admissions and diverting these to the appropriate outpatient level of care
The current membership continues to present with complex medical, behavioral health, and psychosocial conditions, with populations ranging from maternal, pediatric/adolescent, and adult to end-of-life. In addition, a segment of our membership has continued to present with ultra-high risk needs and conditions, resulting in the need to further develop targeted and focused clinical programs.
Target metrics are established to monitor and manage each the overall ICCM program and each specific focused program area. This includes metrics tied to gaps in care, HEDIS/EPSDT metrics, preventable events, managed care metrics (e.g., days/1000, ER visits/1000, PCP encounters, etc.), and specific outcome targets for each program. The metrics are monitored by our ICCM teams using multiple tools including ImpactPro, and performance dashboards that present summary and detailed enrollee data.
Because all of our enrollees have a diagnosis of SMI, Magellan Complete Care is constantly analyzing all available enrollee data to determine factors that affect enrollee health that may trigger destabilization of the enrollee’s mental or physical health, or may signal that an enrollee is decompensating in an area of functioning.
3.2. Specialized Focus on SMI Diagnosis Magellan Complete Care provides the full continuum of care for enrollees with co-occurring behavioral health, substance use disorders, co-morbid medical conditions, and pregnancy. We have learned that addressing the SMI diagnosis first is essential as we plan and thoughtfully assess the other unique needs of the enrollees with SMI. It is often difficult to stabilize and support improvements in physical health without first stabilizing the enrollee’s mental health because enrollees may be resistant to treatment plans and may be aggravating physical health conditions through poor nutrition or other personal behaviors. Additionally, some pharmaceuticals used in the treatment of mental illness may contribute to other health conditions such as weight gain, diabetes, etc.
“Meeting the enrollee where he is” is important as we recognize that interventions such as deploying ICCM and Health Guides in the community leads to increased access and compliance to individual care plans. Recognizing this need we decreased the caseloads for ICCMs so they could spend more time out in the field, more often. Health Guides go with enrollees to scheduled appointments, arrange transportation and pick up medications if necessary. Our approach is tailored to the needs of the enrollee, including coordination of housing and food availability.
Magellan Complete Care CC/CM programs are built around the concepts of the Four Quadrant Clinical Integration Model developed by the National Council for Community Behavioral Healthcare. That model describes the enrollee management and delivery focus and levels of
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integration for management of care in terms of physical health complexity and risk, and behavioral health / SUD complexity and risk. Care management, interventions and supports and services can then be targeted to different populations, based on their needs. The Four Quadrant Model describes a framework for segmenting and stratifying enrollees with SMI, and the need for a bi-directional care coordination and delivery approach, addressing the need for primary care services in behavioral health settings as well as the need for behavioral health services in primary care settings.
3.3 Specialized MOC Our MOC reinforces and prioritizes recovery, stabilization, health maintenance, optimal safety and quality, and independence through partnering with our enrollee, their natural supports and providers. Our recovery expertise and sound evidence-based practice approaches have been used in the development of our behavioral health program approaches, including best practice protocols in the area of addiction and recovery services.
Building on the deep experience we have gained by providing integrated care to SMI enrollees in the specialty plan, our integrated, flexible, and comprehensive Model of Care continues to evolve to further expand and define services to meet the specialty needs of our highest-risk enrollees. This model reflects our enrollee’s unique needs as well as the understanding of Florida behavioral and physical providers’ capabilities, services and resources that we have gained since the launch of the program.
Recognizing those unique needs and requirements, we have recently implemented a paradigm shift in our care coordination and case management approaches, focusing on the establishment of complex case management (CCM) and disease state specialty teams, including:
>Disease management for chronic medical conditions or pregnancy which manages these conditions with BH and SA >Pharmacy clinical programs emphasize psychopharmacology expertise and prioritizing identification of psycho-pharm gaps in care Our screening process is integrated into our clinical programs which comprise the Magellan Complete Care Model of Care for CC/CM, care transition, DM and population health protocols. Behavioral health screenings occur at multiple “touch” points in the enrollee’s continuum of care, including but not limited to interaction with enrollee services and case management, primary care providers and specialists visits and nurse line calls.
Our Model of Care is built upon the principles of:
>Medical, behavioral, and psychosocial integration >Recovery and resiliency >Self-management and self-directed care >Evidence-based medical and behavioral health care >Transparency >Shared decision making >Ensured access to care >Case management >Care transition management >Disease management, condition management, and population health approaches
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>Health and wellness prevention
Our multidisciplinary Magellan Complete Care Care Coordination teams carry out procedures required in care coordination, complex case management, and other related care management programs. The Care Coordination Team includes:
>The enrollee or designated representative >The primary behavioral and medical treating providers >Health guide >Integrated Care Case Manager (ICCM), if indicated by the enrollee’s circumstances
Additionally, the following individuals are available to the team at all times:
>Clinical pharmacist >Peer Support Specialist >Medical directors (with physical and behavioral health expertise)
All enrollees have access to some level of the care coordination services and team engagement. Through the use of stratification algorithms, the frequency of meetings and type of participants on the team vary, addressing the specific needs of the enrollee. Enrollees can call the CareLine anytime for assistance as a back-up after hours, on weekends or if they are unable to otherwise reach their assigned Case Manager, including when their assigned Case Manager is on paid time off.
3.4 Enhanced Management for High-Risk Enrollees Integrated Care Case Managers (ICCMs) are registered nurses or masters level social workers or mental health professionals who are primarily responsible for carrying out the case management process, provide systematic enrollee assessments and coordination of care and services using evidence-based clinical guidelines (EBG). They are available to coordinate complex care needs, provide case management services, and connect high risk enrollees to the services they need while maximizing the use of their benefits. For our most complex enrollees this often means coordination of care for multiple physical health and behavioral conditions, as well as coordination of social supports, including connecting them to community agencies and services, assisting with finding housing, etc. The ICCM is key to identifying and coordinating those services to support enrollee management of their illnesses and recovery, and to limit the need for higher acuity services.
ICCMs assist high-risk enrollees who are enrolled in the complex case management (CCM) program to proactively obtain the care and services needed to avoid the unnecessary or inappropriate utilization of more intensive health care resources. This is accomplished by assessing and re-assessing their needs, providing personalized health information, supporting CC/CM among multiple behavioral and physical health providers, and connecting enrollees to the appropriate resources within the integrated health neighborhood (IHN). ICCMs act as a liaison between the enrollee and providers, ensuring the enrollee is receiving proactive behavioral health, medical and specialist care as needed along with addressing the enrollee’s psychosocial issues whenever necessary.
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~~Enrollee Story: Critically Ill Enrollee~~ Since July 2014, we provided services for a 53-year-old female enrollee who is in a comatose state with a tracheotomy, peg tube, and Foley catheter in place.
This enrollee also has a LTC plan case and case manager through Molina Healthcare. The current assigned ICCM has worked with the enrollee since September 2016. The ICCM has specifically been coordinating care through the enrollee’s healthcare proxy, her daughter. Enrollee has a history of seizures as per the proxy and was previously given the diagnosis of schizophrenia. The enrollee was in a car accident many years ago which led to her current medical state.
The proxy has elected to keep enrollee in the home environment despite alternate level of care options provided by the health plan as well as recommended by treating physicians. The ICCM has had to work with not only ensuring enrollee received appropriate medical follow up but also respecting the rights and wishes of the family.
Services Offered/Recommended:
>Hospice Care: The proxy refused this service stating that in the past she had agreed, but since enrollee’s condition had not worsened, the proxy stated that the enrollee does not meet hospice criteria.
>Nursing Facility: The proxy refused this service stating that she wants to maintain her mother in the home and is not trusting of quality of care in nursing facilities.
>Home Health Care: The proxy had discontinued this service several times due to her dissatisfaction with various home health agencies. However, after continued collaboration and joining with the proxy by the ICCM, the enrollee currently has home health in place under her LTC plan.
>Durable Medical Equipment: Enrollee is receiving needed supplies through the LTC plan. However, there were instances where the LTC plan was not acknowledging their role in covering this benefit. Therefore, the ICCM served as an advocate for enrollee’s needs.
Coordination of Care Activities: Collaboration with Proxy: ICCM has provided education on health plan processes, redirection on priority needs, assistance with medication issues, guidance on covered Magellan Complete Care benefits, and education on LTC-MMA responsibilities, in addition:
>ICCM has escalated several medication denials to Magellan Rx and also communicated with point of sale pharmacy.
>ICCM has reached out to the LTC plan to discuss LTC-MMA plan responsibilities and worked to partner on ensuring enrollee received needed medical supplies and services.
>ICCM has connected with current and past treating providers to obtain a history of enrollee’s medical needs.
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>ICCM did extensive research to locate both in-network and out-of-network providers that would see the enrollee in the home setting for not only primary care but also specialty care needs.
>ICCM also used the support of the Provider Support Specialist to outreach to providers and encourage their assistance with enrollee’s care.
>ICCM coordinated with in-network and out-of-network providers as well as our Utilization Management Department to secure needed single case agreements and obtained clinical information on present needs and treatment progress.
>ICCM facilitated staffing between Magellan Complete Care Medical Director, Network Director, and LTC Plan Leadership to achieve consensus on health plans’ roles in supporting the enrollee’s plan of care.
>ICCM presented case to Medical Director during weekly rounds and also used supervision with Clinical Manager for guidance and feedback.
3.5 Specialized Health Risk Assessment An essential element to enhanced care coordination is using an assessment and planning process with the enrollee, and the unique needs of those with SMI, at the center. Screening for behavioral health and substance use disorders begins at the time of enrollment using a standardized HRA called the Magellan Complete Care Initial Clinical Assessment. This assessment tool is a SMI-tailored HRA that includes components that identify key areas of risks and needs of the SMI population.
The core domains of the HRA include:
>Living situation >Hospital/Office visit history >Substance abuse history >Social activity/social connectedness >Preventive test history >Chronic condition history, and >Rating of health
The SMI-specific HRA, along with additional data are used to screen enrollees, score their level of risk, document those risks and stratify enrollees for assignment to the various levels of care management and planned interventions. Our screening tools are also specifically adapted to capture indicators around social determinants of health and ACES (Adverse Childhood Experiences), both of which have been shown to have significant impacts on incidence of illness, illness severity, and outcomes. In fact, we participate in the National Quality Forum (NQF) and have been instrumental in efforts to develop measures to assess severity and impact of these indicators.
Magellan Complete Care uses multiple tools to identify enrollees at risk and refer them to the appropriate care coordination or provider programs based on their level of risk. Methods to screen enrollees and identify risks may include Health Risk Assessment (HRA) process and scoring, utilization and medication reports and patterns, direct referral, or having special high-
AHCA ITN 009-17/18, Attachment A, Exhibit A-4-d, Page 33 of 100 EXHIBIT A-4-d SPECIALTY SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA risk conditions or social dynamics. Enrolleess that have multiple chronic conditions or are medically, behaviorally, or socially unstable are designated as high-risk and receive complex and enhanced care coordination services. Based on this scoring, enrollees are stratified into care coordination risk level segments, for assignment to separate care management teams appropriate for their level of risk and complexity. All enrollees are screened and rescreened at various points along the Enrollee Journey with goals and interventions embedded in each plan of care. Screening is integrated into the clinical programs which comprise the Complete Care Model of Care including case management, discharge transitions, DM, and wellness.
We employ the analytics of predictive modeling using machine learning to identify integrated comprehensive care needs for enrollees. Based on that information and all other available inputs, enrollees are screened for assignment to case management based on level of complexity and need.
The Care Coordination team is also focused on detecting, and educating enrollees to identify triggers, and healthy ways to manage away from escalating to crisis levels; partnering with them to understand how their health improves functioning and how it reduces exacerbation of mental health symptoms; and working closely with their behavioral health provider to increase services if it is deemed medically necessary to prevent hospitalization.
The complexities of managing the SMI population mean that Magellan Complete Care must use all available enrollee touchpoints to assess enrollee health and deploy targeted interventions when needed.
Our MOC reinforces and prioritizes recovery, stabilization, health maintenance, optimal safety and quality, and independence through partnering with our enrollee, their natural supports and providers. Our recovery expertise and sound evidence-based practice approaches have been used in the development of our behavioral health program approaches, including best practice protocols in the area of addiction and recovery services.
The elements of our approach to the management of high-need enrollees include identifying health risks, biopsychosocial, and chronic care needs, assessing the enrollee, designing a plan of care to proactively address the most immediate needs, engaging the interdisciplinary care team, and proactively identifying and monitoring enrollee changes or triggers that might destabilize the enrollee’s illness.
Our care team seeks to fully understand why an individual may be in crisis and we identify strategies to assist them on the path to higher functioning. The elements of our approach include identifying health risks, biopsychosocial, and chronic care needs, assessing the enrollee, and designing a plan to proactively address the most immediate needs.
Based on this ongoing analysis, we have developed targeted screenings and interventions specifically focused on:
>Schizophrenia >Mood disorders >Substance Use Disorder (SUD)
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>Care transitions >Excess emergency department utilization >Homelessness >Interaction with the criminal justice system
3.6 Other Care Coordination/Case Management Activities Magellan Complete Care has developed a number of additional, unique programs and services targeted at the specific risks and vulnerabilities of SMI enrollees and gaps in public services and delivery system knowledge of capabilities to address their needs. Some of these programs were successfully pioneered by Magellan in places like Maricopa County, Arizona. Others have been built around the deep understanding of the needs of Florida’s SMI population gained through our experience, partnerships, and collaboration with our enrollees, providers, government agencies and social support organizations. These special programs include:
3.6.a. Jail Diversion Program Magellan Complete Care staff have met with representatives from the Miami Eleventh Judicial Circuit Mental Health Project to discuss opportunities to work collaboratively to support jail diversion and therapeutic alternatives for individuals with a serious mental illness. We are now working with the courts to pilot care coordination programs to include the following:
>Initiate person-centered whole health discharge planning at the point of incarceration incorporating community-based providers
>Collaborate with jail staff to assess and plan for clinical needs during incarceration and post release
>Incorporate evidence-based treatments into discharge plan, such as cognitive behavioral therapy proven to reduce criminogenic factors and recidivism
>Work with all applicable providers to promote charge mitigation opportunities and encourage provider participation in specialty (Mental Health Courts) courts as appropriate and needed
>Coordinate release from jail that would include transportation to home and/or treatment provider
>Confirm Magellan Complete Care eligibility upon release and coordinate re-activation of SSI benefits
>Place a “Welcome Home” call within 48 hours of release to address questions about medications, the treatment plan and assessment of symptoms, risk indicators, and social supports
Our plans are to work with the project to develop processes to share HIPAA-compliant information related to enrollees’ diagnoses, treatment plans, medications, etc.; implement alert technology that links health plans to the sheriff’s booking data systems; and, build a network of crisis stabilization options offering law enforcement therapeutic behavioral health alternatives to jail.
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3.6.b Jail In-Reach Program Magellan Complete Care is partnering with Miami-Dade County on the Jail In-Reach Project. The project is a collaborative effort among community partners that seek to improve the assessment, referral, diversion, and care coordination among individuals with SMI, and possible COD that are reentering the community from the criminal justice system. The proposed project will create a specialized Jail In-Reach Team that will be guided by a shared commitment to cross-system collaboration and division of responsibilities among criminal justice and community partners to:
>Gather and review information to make determinations about eligibility for diversion programs >Develop and implement evidence-based transition and reentry plans emphasizing continuity and coordination of care >Monitor ongoing linkages to evidence-based treatment and services in the community >Measure outcomes to facilitate performance improvement
The target population for this program is adults with SMI who are frequent recidivists to the justice and acute care treatment systems. The project has set a goal to screen a minimum of 400 individuals annually.
The following testimonial from Judge Leifman, a key stakeholder in the creation of this program, speaks to its importance for our SMI enrollees:
~~Testimonial, Judge Leifman~~ “I appreciate Magellan Complete Care's understanding of the unique needs of those with serious mental illnesses. All too often, individuals with serious mental illness find themselves in our criminal justice system, which is unprepared to deal with needs such as comorbid conditions, trauma-informed care and addressing underlying issues to recovery, such as medication adherence. Magellan Complete Care of Florida strongly believes in community- based care, and their outreach is predicated on keeping those who need services as close to their community as possible. I look forward to continuing our work together, particularly as it relates to jail diversion and other similar programs."
3.6.c Homeless Housing Initiative Magellan Complete Care’s Homeless Housing Initiative is not only an organizational program identity, but also a philosophy. The core tenets of the program recognize:
>Recovery, which is “a process of change, through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential,” is unable to be achieved without a home.
>Stable housing is an essential determinant in the health outcomes of our enrollees >Homelessness ultimately effects our organization’s ability to provide timely, cost-effective care to meet the needs of our enrollees.
At a basic level, housing provides safety and access to basic needs; laying a foundation for engaging enrollee in healthy lifestyle and development. Recognizing these issues, Magellan Complete Care launched a homeless housing initiative in 2015 that included the following action steps:
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>Community Outreach Specialists (COS) developed regional community housing resource guides >COS developed regional housing work flows that outlined each region’s homeless housing application process
>COS participated in regional Continuums of Care (CoC) meetings
>COS developed regional monthly housing meetings to discuss housing opportunities with Magellan Complete Care Care Coordination clinicians
>Established HMIS agreements with many of the CoC
>Developed staff expertise in completing VI-SPAT (Vulnerability Index-Service Prioritization Decision Assistance Tool)
>Developed reporting mechanisms within enrollee care management record to identify homeless enrollees
>Developed relationships with state and local housing agencies and organizations
>Met with providers to develop partnerships to expand and/or create housing opportunities
>Developing data reports to identify cost savings from housing the homeless
Our efforts to date have resulted in over 50 placements since late 2015, and have yielded tangible results for our enrollees as demonstrated by the enrollee story below.
~~Kevin’s Story (name changed to protect privacy)~~ Kevin, a Magellan Complete Care enrollee, is a 59 year-old man who had been chronically homeless for three years. Prior to receiving stable housing, he survived outdoors in parks and behind stores; sleeping on benches to avoid the ground and what comes with the ground; dampness, dirt, and bugs. He also used hospitals when he “couldn’t take it anymore.” The emergency room would provide respite, a hot meal, a climate controlled environment, safety, and a good night’s sleep. Kevin was admitted into a hospital seven times in the last half of 2015. He reported having suicidal ideations as a result of his homelessness. He expressed feeling worthless and no longer could find meaning in his life. He talked about ending his life and had a specific plan to do so. Kevin did not have any social supports.
This all changed when his Magellan Complete Care Health Guide found a new permanent supported housing project targeting homeless disabled individuals in West Palm Beach. His health guide completed the referral paperwork for the Goodwill Industries program and he was approved within two weeks. Kevin left the hospital and moved into his own apartment on Christmas Eve. Since that time, he has not been hospitalized. Kevin is now independently scheduling and attending his behavioral and physical health appointments. He reported being reluctant to attend appointments in the past due to feeling ashamed of his appearance. He has made friends in the neighborhood and has recently re-established a relationship with his
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3.7 Specialized Customer Service Magellan Complete Care operates a toll-free help line equipped with caller identification, automatic call distribution equipment capable of handling the expected volume of calls, a telecommunication device for the deaf (TTY/TDD), and access to the interpreter services for non-English speaking beneficiaries. We also have English-Spanish bilingual staff available to support our enrollees. We operate the enrollee help line as part of an inbound call center where Customer Service Representatives staff telephones to field incoming calls.
The enrollee help line is operated 24 hours a day, seven days a week (24/7) to handle care related inquiries from enrollees and caregivers. The staff are trained to respond to enrollee questions in all areas, for example:
>Customer Service staff have ongoing “in-service” training on best practices in customer services, along with an annual retraining. Topics include the following, but are not limited to: >>Orientation to the organization >>HIPAA >>Privacy, compliance, fraud, and abuse, covered services, Health Services, PCP assignment >>Cultural competency, definitions, contract requirements, telephone etiquette, interpreter >>Resources, TTY, first call resolution, warm transfers, and crisis call
We have developed performance standards and monitor help line performance by recording calls and employing other monitoring activities: >Average speed of answer (ASA) shall not exceed 30 seconds >Call blockage rate for direct calls to Magellan Complete Care will not exceed 0.5 percent >Average call abandonment rate for direct calls to Magellan Complete Care sill not exceed 3 percent >A system, which places calls in queue, may be used but the wait time in the queue shall not exceed 60 seconds.
Customer Services staff provide communication and education on available services and community resources to the enrollee from numerous sources including the ICCM, other members of the care team and customer service, the Member Handbook, the welcome call to new enrollees and the documents distributed during a face-to-face visit.
3.8 Specialized Provider Network Magellan Complete Care has selected and approved its Primary Care Providers (PCPs) that practice in one of the following areas:
>General practice >Family practice >Pediatrics >Obstetricians >Internal medicine
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We will ensure that physicians with training and demonstrated experience in treating persons diagnosed with SMI are members of the provider network and can be designated as PCPs. We designate psychiatrists with demonstrated experience in primary care OR psychiatrists with primary care integrated into their practices as PCPs. Magellan Complete Care will maintain enhanced provider ratios as indicated for the Specialty Plan. We understand that AHCA will determine regional provider ratios based upon 120 percent of Magellan Complete Care’s actual monthly enrollment measured at the first of each month by region. We will also comply with the regional standards for each measure as specified in the Provider Network Adequacy Standards.
Magellan Complete Care provides increased availability and accessibility of psychiatrists and other specialty providers relevant to the specialty population through multiple mechanisms, including contracting with CMHCs, providing access through telehealth, etc. This expanded access is included in our annual network plan submitted to AHCA in accordance with Attachment II and its Exhibits.
We require formal training or verification of completed training for network providers in the use of behavioral health assessment tools, assessment instruments and in techniques for identifying individuals with unmet behavioral health needs, evidence based practice and the principles of recovery and resiliency.
We include Specialty Plan-specific information in our Provider Handbook regarding proposed policies and procedures that include information such as:
>Specialized provider education requirements >Contract requirements >Requirements for care in accordance with the most recent clinical practice guidelines for psychiatric, mental health, and substance abuse treatment >Treatment adherence services available from the Specialty Plan >PCP criteria including procedures for required use of approved assessment instruments for mental health and substance abuse >Specialist Case Management policies and procedures including role of the provider in the Specialty Plan’s medical case management/care coordination services >Referral to services including services outside of the Specialty Plan’s covered services and services provided through interagency agreements >Quality measurement standards for providers and requirements for exchange of data
3.9 Specialized Enhanced Benefits Magellan Complete Care offers enhanced benefits (discussed in greater detail later in this proposal) to address the unique needs of SMI enrollees. These benefits are based on our regular and ongoing analysis of enrollee patterns of utilization and expense and support improved quality, health outcomes, and total enrollee costs as well as best practice clinical guidelines. They also reflect a more detailed understanding of underlying provider capabilities and practice patterns in the communities served by Magellan Complete Care, ensuring that required provider capacity is available to support those benefits. As part of this ITN response, Magellan Complete Care has adopted all of the expanded benefits identified by AHCA.
We have also adopted additional expanded benefits that include:
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>Nutritional Counseling >Post Discharge Meals >Waived Copayments >Intensive Outpatient Treatment – Mental Health >Intensive Outpatient Treatment – Substance Use Disorders
In addition to the covered benefits, expanded benefits and the additional expanded benefits listed above, Magellan Complete Care offers several of the in lieu of services outlined in the current contract. These services include:
>Crisis Stabilization Units >Detoxification or Addictions Receiving Facilities licensed under s 397, F.S. >Mobile Crisis Assessment and Intervention >Ambulatory Detoxification Services >Self-Help/Peer Services >Partial Hospitalization Services
By offering in lieu of services, enrollees can receive some services in a different location, different intensity and different modalities to fit their level of functioning and in helping the enrollee get the right services in the right location at the right time.
Magellan Complete Care has learned over the past four years that not all enrollee needs can be addressed through Medicaid covered services and expanded benefits. The SMI specialty enrollees have unique needs that Magellan Complete Care feels are important to address for the holistic wellbeing of the enrollee. Magellan Complete Care care managers work with enrollees to address the social determinants of health. Magellan Complete Care assists enrollees in locating appropriate housing options including shelters, temporary housing and permanent housing, works with the criminal justice system to reduce recidivism and increase diversions to care, supports enrollees through the internal peer support process and assists enrollees in locating local community resources to assist with day to day living needs. We believe these additional benefits are important for managing the health of our SMI enrollees and supporting the delivery of care in the right place, at the right time, and to improve quality, outcomes and enrollee and provider satisfaction.
In addition to these more traditional services, as noted earlier in this response, Magellan Complete Care provides enrollees with new treatment and care management options, including:
>Telemedicine >Remote monitoring >Online and mobile monitoring and health management tools >CCBT (Computerized Cognitive Behavioral Therapy)
Services provided through the IHN are also a significant enhancement for our SMI enrollees, providing needed navigation and recovery support through solutions such as our Homeless Housing Program, Jail In-Reach, and Employment Support. All of these benefits serve to support our complex and vulnerable SMI enrollees with a fully-integrated system of care that supports wellness, prevention, care management, recovery and resiliency.
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3.10 Specialized QI Program Magellan Complete Care uses an enterprise-wide and fully integrated approach to carrying out key quality improvement, HEDIS, and clinical performance measure activities. The health services team collaborates with the quality team to ensure that the quality improvement and HEDIS initiatives are fully integrated with the clinical enrollee facing programs. Our employees are educated on targeted quality, HEDIS, and quality measures. Current and new initiatives are discussed at the cross-functional oversight and operational meetings to determine which key initiatives will be the focus for improving the key measures. Outcome measures are determined by the results of the HEDIS and state specific performance results, including those HEDIS measures which are specific to individuals with SMI, such as those addressing care for individuals with schizophrenia. The quality, HEDIS and performance improvement strategy uses a multi-faceted approach incorporating clinical, data, and provider based efforts. Enrollee-facing staff members carry out HEDIS and quality measure initiative calls encouraging enrollees to obtain care and preventive services they need to improve overall health and to establish a medical/behavioral health home. In addition, Magellan Complete Care has developed both provider and enrollee incentive programs (discussed elsewhere in this proposal) specifically targeting enrollee gaps in care related to quality and HEDIS measures.
3.10.a Evidence-based Risk Assessment Tools Early identification of high-risk enrollees through behavioral health and substance use screening tools is critical to get enrollees the care they need at the right time, in the right place and in the right amount. This leads to prevention and/or early intervention and promotes community tenure, which results in improved quality of life, satisfaction for our enrollees, and cost effectiveness.
Magellan Complete Care uses the TruCare care management system to coordinate care for all enrollees, including those who have the most complex health needs. TruCare is the Magellan Complete Care application providing clinical systems support for UM, case management, health promotion, care transitions, DM, and care coordination tasks.
TruCare integrates with our claims processing and provider data applications to enable health services staff to assess enrollee needs, complete care coordination plans, and authorize services.
All enrollee contacts are documented in the system and notes are made on all elements of the care management processes and services. Information sent to us by the providers, facilities, and other treatment team enrollees are able to be uploaded and attached to each enrollee’s record. This provides for a comprehensive tracking of all activities, information, services, treatment plans, discharge plans, etc., related to the enrollee.
System support for enrollees in complex case management operates seamlessly within TruCare, establishing a single platform for Magellan Complete Care staff across the whole continuum of care (both behavioral and physical), and encompassing all care settings. TruCare effectively tracks enrollee programs and case artifacts in one place. When baseline assessments are completed for an enrollee, the TruCare system provides the ICCM with prompts to create a care management plan for the enrollee.
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The system also provides a list of recommended problems and interventions for a user to select from when building the care management plan, based on the enrollee’s assessment responses. The problems and interventions are based on opportunity areas for care management to focus support. For instance, if the enrollee responds on the initial assessment that he/she often forgets to take his/her medications, a problem of “medications” will be recommended for the user to select from when building the enrollee’s care plan.
3.10a.1 Evidence-based risk assessments in TruCare: Magellan Complete Care uses standardized behavioral health screening tools to measure and re-measure an enrollee’s symptom burden and monitor treatment response. Those tools include, but are not limited to, the following available in TruCare in the Initial Clinical Assessment:
>Depression Screening and Management (PHQ-9); (PHQ-2) >Edinburgh Post-Natal Depression Scale >Milliman Behavioral Health Assessments >Initial Clinical Assessment (Adults) >Pediatric Clinical Assessment >Substance Abuse and Chemical Dependency >Child and Adolescent Needs and Strengths (CANS)
3.10.b Self-management Practices Magellan Complete Care provides an ICCM or other support staff member who meets with the enrollee either face-to-face or telephonically, to review the care coordination program, contact information, including name and information for reaching the ICCM and other members of the care team. This same information is included in the enrollee Welcome Kit received upon enrollment.
The ICCM and care team members instruct the enrollee on placing the contact information in an easily accessible place for the enrollee, family, and caregivers. Magellan Complete Care of Florida works closely with the enrollee to ensure that the enrollee agrees with the ICCM and care team member assignment.
The ICCM and care team members use a person-centered approach engaging enrollees about available services and supports to assist in achieving optimal health, wellness, and self- management goals. The ICCM and care team members also explain the support provided to the enrollee for self-direction and self-management.
However, we understand from previous experience there will be enrollees who decline care coordination services. The ICCM will explain our role is to support the enrollee in accessing services and supports to meet their goals. The ICCM provides the enrollee with contact information with each interaction.
Self-management support and development of self-management plans and/or relapse prevention plans are typical topics for CC/CM care plan goals and interventions, including:
>ICCM supports the enrollee with self-management skills to access care by arranging for peer support and education
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>ICCM also assists in accessing community support agencies who offer education and training on self-management skills >A Certified Peer Support Specialist who is trained in applying resiliency and recovery principles and tools such as wellness recovery action plans, a wrap-around process, family and person- driven care, and systems of care that use these skills to provide emotional support and to inspire hope for the future: >>They model and assist enrollees in making lifestyle improvements and the self-management of chronic conditions >>Peer Support Specialists provide additional outreach to individuals who require assistance to obtain access to and engage in needed services >The case managers and Health Guide s coordinate care for the enrollee by focusing efforts on proactive care management interventions to prevent the unavoidable including facilitating enrollee self-management capabilities.
3.10.c Practice Guidelines The Magellan Complete Care staff use national evidence-based guidelines (EBG) as a basis for assessment, evaluation, quality management and improvement, identification of care gaps, enrollee and provider education, key interventions and outcomes measures. Staff has additional resources available to them including:
>Magellan’s proprietary, evidence based integrated care guidelines >Magellan’s proprietary behavioral health medical necessity guidelines >MCG medical necessity guidelines are currently in use >Healthwise and Milliman Chronic Care Guidelines for health education materials in English and Spanish >The American Society of Addiction Medicine (ASAM) Criteria
Magellan Complete Care clinical practice guidelines (CPG) give guidance to providers on the evidenced based tools which support screening for behavioral health and SA:
>CPG cover conditions such as depression, anxiety, insomnia, panic disorder, OCD, substance use/abuse, opioid use/abuse and smoking
>CPG outline the next step in clinical management based on the disease specific assessment, for example: prescription medications, referral to psychotherapy, psychiatric consultation or urgent/emergency evaluation.
For behavioral health this is based on the following types of behavioral health guidelines from the American Psychiatric Association that have been adopted by Magellan Complete Care:
>Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post- Traumatic Stress Disorder
>Practice Guideline for the Treatment of Patients with Major Depressive Disorder
>Practice Guideline for the Treatment of Patients with Bipolar Disorder
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>Practice Guideline for the Treatment of Patients with Eating Disorders
>Practice Guideline for the Treatment of Patients with Panic Disorder >Practice Guideline for the Treatment of Patients with Schizophrenia; and
>Practice Guideline for the Management of Children with Autism Spectrum Disorders
Examples of Magellan Complete Care guidelines include: >Asthma – National Heart, Lung, and Blood Institute (NHLBI) guidelines
>Diabetes – American Diabetes Association (ADA) guidelines
>Congestive Heart Failure – American Heart Association/American College of Cardiology (AHA/ACC) guideline
>Hypertension – National Institutes of Health (NIH) Joint National Committee on
>Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
>HIV/AIDS – NIH guidelines
>Chronic Obstructive Pulmonary Disease (COPD) – the Global Initiative for Chronic Obstructive Lung Disease (COLD) guidelines
>Immunizations – the Advisory Committee on Immunization Practices (ACIP) recommendations
>Preventive care – United States Preventive Services Task Force (USPSTF)
>Practice Guideline for the Treatment of Patients with Attention Deficit/Hyperactivity Disorder
>Practice Guideline for Assessment and Management of the Suicidal Patient
3.10.d Case Management Staff Qualifications, Training and/or Experience Our CMO and Behavioral Health Medical Director oversee the entire health services team working together to carry out all aspects of our model of care and clinical programs. Our CMO is a Family Practice physician who is also board certified in Urgent Care Medicine. He is also a Certified Physician Executive and holds a Master’s Degree in clinical psychology and an MBA. His expertise in Managed Healthcare is steeped in an In-depth knowledge of the managed care field including Medicaid, Medicare, Commercial Insurance, Hospital Administration and IPA Management and held a position in the US Air Force medical corps as a senior officer. He has demonstrated continued success in leading and overseeing disease management, benefits management, physician network development, contracting, utilization and quality improvement and strategic healthcare planning programs within multiple health care and health plan settings. He is considered one of the leading experts in Accountable Care Organizations, Full Risk and Shared Risk Capitation, and the Medical Home.
Our CMO has been the Chief Medical Officer for Magellan Complete Care in Florida since December, 2016 and has been an integral part of operational and outcome improvements in the
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quality, care management and utilization management programs. Prior to that, he was Chief Medical Officer for Access MediQuip from 2012 to 2015 and served for 3 years as Chief Medical Officer for Virginia Premier Health Plan. He has also held chief medical officer positions in the Medicaid, Medicare and Commercial sectors of healthcare and management positions in hospital administration and physician provider groups (IPA's).
Our CMO has also achieved national recognition in financing, implementation and certification of inpatient and ambulatory Electronic Health Records and has held high level national positions on the Board of Commissioners of CCHIT and the Board of Directors of HIMSS. He has authored books and articles on EHR Implementation and is a sought-after speaker on EHR and other healthcare related issues. All clinical and non-clinical staff receive training upon hire for HIPAA privacy, confidentiality, and all Magellan Health, Inc. required compliance training. Our Behavioral Health Medical Director is a Child, Adolescent and Adult Psychiatrist who completed his residency and fellowship at Tufts University and Harvard Medical School’s McLean Hospital. He is a former member of President Bill Clinton’s Task Force on Healthcare reform, former Healthcare Legislative Assistant to US Congressman James McDermott, and Co-Chair of Massachusetts Governor Deval Patrick’s Healthcare Committee.
After working over two decades as a Medical Director, Chief Medical Administrator, and Chief Medical Officer in both Medicaid and Commercial sectors of managed care and provider hospital delivery systems, our BH MD joined Magellan Complete Care as their Chief Behavioral Health Officer. Both our CMO and BH MD also have access to specialists to support the care of unique populations, including specialists who are double-boarded OB/GYN Psychiatry, triple- boarded in Pediatrics, Psychiatry, and Child/Adolescent Psychiatry.
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A Clinical Pharmacist, Peer Support Specialist, and Medical Directors (with physical and behavioral health expertise) are also available to the Care Coordination Teams at all times. The Care Line is available to enrollees 24 hours a day/7 days a week and is staffed by ICCM. Wellness Specialists assigned to the Disease Management (DM) program are also available to assist the enrollees and care coordination team with any aspect of the designated DM programs.
Enrollees can call the Care Line anytime for assistance as a back-up afterhours, on weekends or if they are unable to otherwise reach their assigned Case Manager including when their assigned Case Manager is on paid time off.
Depending on the enrollee’s needs, the care coordination team members may include: >Peer Support Specialist: >>A Certified Peer Support Specialist who is trained in applying resiliency and recovery principles and tools such as wellness recovery action plans, a wrap-around process, family and
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person-driven care, and systems of care that use these skills to provide emotional support and to inspire hope for the future >>They model and assist enrollees in making lifestyle improvements and the self-management of chronic conditions >>Peer support specialists provide additional outreach to individuals who require assistance to obtain access to and engage in needed services.
>Clinical Pharmacist: >>Participates as needed to review the medications the enrollee receives and in collaboration with the prescribing physicians on the team, is responsible for identifying potential over or under utilization, potential drug disease interactions, and optimal therapeutic regimens >>Consults on complex cases where there is risk to the enrollee due to potential drug interactions between drugs for chronic medical conditions and psychotropic medications >Participates in care team meetings and conferences for pharmacy consultation as needed >>Utilizes sophisticated analysis of claims data to identify gaps or potential concerns.
>Integrated Care Case Manager: >>Either an RN or a masters-prepared mental health or social work professional, is engaged for all High Risk enrollees including the sub-population identified to receive complex case management >>Responsible for carrying out the case management process, conducting assessments and developing the care coordination plan consistent with the enrollee’s health care needs and goals >>Monitors and intervenes for enrollees with complex situations and ensures assessments and reassessments are carried out and that implementation of the care plan occurs >>Actively involved at times of care transition, including but not limited to planned and unplanned admissions, and works in conjunction with the enrollee’s Health Guide to ensure care plan communication between all providers and enrollees.
>Care Worker: >>Non-clinical staff member, is responsible for supporting the care coordination teams >>Activities may include, but are not limited to, mailing of letters/educational materials, obtaining authorizations for disclosure of protected health information, assisting with referrals, scheduling appointment, scheduling case conference meetings and assisting with other basic Care Coordination activities
>Wellness Specialist: >>Nursing or a combination of Health Education and deep clinical expertise in chronic DM programs >>Responsible for the development and operation of population-based programs for enrollees with chronic conditions, the preventive care program, and initiatives which support healthy lifestyles >>Engages with individual enrollees who have a targeted health condition >>Motivates enrollees to learn and adopt self-management techniques to maintain their health and wellness >>Serves as an expert resource for Magellan Complete Care staff, providers, and community agencies
We also look for the following blended staff structure of RNs and clinician qualifications:
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>Psychiatric background for RNs >Specialized training in psychiatric and physical health conditions; with emphasis on select high risk, high volume disorders >Specialized training for long term and skilled facility based care >Specialized training for substance use disorders >Specialized training for serious emotional disorders >Specialized training in child health and adolescent care/practice >Specialized training in Maternity care/practice >Specialized case management and managed care certification >Work experience in behavioral health understanding of physical health side (co-occurring disorders, socioeconomic factors, homelessness, poverty, access to care, lack of support system) >Target and recruit talent pool that has sufficient experience and expertise in SMI to effectively work with the population, while still understanding the medical comorbidities >Principles of recovery and resiliency for staffing, program development, UM, QM
~~Enrollee Story: Integrated Care Case Manager’s Expertise for Effective Service Coordination~~ One of our ICCMs coordinated care for a 46-year-old male, ultra high-risk enrollee diagnosed with depression, Bipolar Disorder, SUD, and Schizophrenia along with asthma, COPD (Severe), emphysema, and congestive heart failure (CHF).
Our ICCM has been working with and collaborating with vendors, providers, and other team members (Discharge Health Guide) to coordinate care for enrollee. This enrollee has been admitted on an inpatient basis nine times in 2017 alone, all for respiratory related issues and for CHF. This enrollee is a homeless enrollee with no income, and had no providers in place. When this enrollee was first assigned, the ICCM referred enrollee to Healthcare Financial for financial assistance to see if enrollee could get financial assistance for housing. Healthcare Financial said that enrollee would not qualify for assistance due to enrollee not having continuity of care with PCP or psychiatrist. A major barrier the ICCM had with this enrollee was communication.
This enrollee lived in a dumpster and did not have a phone. During one of his IP admissions, the Discharge Health Guide was able to get enrollee a Safelink phone. The second to last admission, the enrollee was taken to the hospital for severe respiratory issues (exacerbation of COPD), and lost all his belongings including his new Safelink phone at the dumpster. The hospital social worker, DCHG, and the ICCM coordinated residential housing at Better Way at Miami since enrollee came out positive for cocaine use.
The enrollee was at Better Way for few days before being admitted again for his COPD. This time, the enrollee was going to be discharged with an oxygen concentrator, but Better Ways could not take the enrollee back with oxygen since they are not equipped to handle this request. Jackson agreed to pay for the oxygen concentrator, as well as placement at Livewell Courtyard Plaza ALF for 30 days. ICCM is now working with the enrollee to see a PCP, PBHP, and completed another Healthcare Financial referral (which was denied again due to the enrollee appears as disabled in the system).
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Per Healthcare Financial, if the enrollee shows as disabled, they are unable to assist with the application and the enrollee needs to apply directly with DCF. The ICCM completed an urgent TCM referral with Chrysalis so they can assist enrollee with the application process for financial assistance and housing as well. This is a fragile enrollee who needs extensive medical care, thus cannot afford to be homeless. If enrollee becomes homeless again, he will be in the hospital repeatedly due to his continual need of oxygen. For this reason, ICCM is working urgently with this enrollee to come up with a future plan for financial assistance and housing.
Evaluation Criteria:
1. The extent of experience (e.g., number of contracts, enrollees or years) in providing care coordination/case management to similar target populations, including disease or special condition management.
2. The extent to which the described experience demonstrates the ability to effectively provide care coordination/case management to the population proposed.
3. The extent to which the care coordination/case management activities proposed are relevant to the specialty population proposed.
Score: This section is worth a maximum of 30 raw points with each of the above components being worth a maximum of 10 points each as described below:
(a) 10 points if the component is excellent; (b) 8 points if the component is above average; (c) 6 points if the component is average; (d) 4 points if the component is below average; (e) 2 points if the component contained significant deficiencies; (f) 0 points if the component was not addressed.
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Specialty SRC#3 – Quality Measures (Statewide):
The respondent shall propose quality management activities to address the needs of the specialty population(s) being proposed for this solicitation, including specific quality measures relevant to the specialty population(s). The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in quality management for population(s) similar to the specialty population(s) being proposed for this solicitation. Include experience with standardized measures, such as HEDIS and Contract-required measures, relevant to the specialty population(s) proposed. Identify specific quality measures relevant to the specialty population(s) the respondent proposes to collect and report to the Agency. Describe any other quality management activities the respondent proposes to improve performance. Describe any instances of failure to meet HEDIS or Contract-required quality standards and actions taken to improve performance. Describe actions taken to improve quality performance when HEDIS or Contract required standards were met, but improvement was desirable.
Response:
OVERVIEW Magellan Complete Care is dedicated to continued improvement of the physical health (PH) and behavioral health (BH) outcomes for enrollees living with serious mental illness (SMI) in Florida’s Medicaid program. Our model of fully integrated care and care management incorporates the concepts of continuous quality and operational improvement, delivery system and care management innovation, and targeted interventions with a goal of demonstrating clinical outcomes and results for individuals with SMI that meet or exceed those for other Medicaid beneficiaries.
We are committed, and we have extensive resources dedicated to monitoring and reporting all key outcome measures, such as HEDIS, EPSDT/CHCUP, birth outcomes, and potentially preventable events. Through our quality committee structure and focused work groups, we develop targeted initiatives, as well as changes and enhancements to our disease and care management programs, delivery system design, and operations to address our population of enrollees living with SMI while driving continuous quality improvement. The results of those efforts have been significant, delivering rapid improvement in outcomes across most key measures, as reflected in both our year over year rates, and in our in-period rates for HEDIS and CHCUP.
CRITERIA 1: THE EXTENT OF EXPERIENCE (E.G., NUMBER OF CONTRACTS… Magellan Complete Care has provided fully integrated physical and behavioral health plan services to enrollees in Florida’s SMI Specialty Plan for more than three years now, currently providing services to more than 70,000 enrollees throughout the state. This builds on our company’s experience providing services to similar populations.
1.1 Corporate Experience with Individuals with SMI 1.1.a Magellan Health, Inc. For more than 40 years, Magellan Health, Inc. (Magellan), has provided comprehensive, evidence-based medical, behavioral health, utilization management, integrated care management, pharmacy management, and employee assistance programs to improve healthcare outcomes. We have experience serving enrollees living with SMI and Medicaid
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As a leading specialty health care management organization, Magellan Health, Inc. was founded in 1969, with expertise in assessing, managing, and ensuring access to appropriate, high quality health services that promote acute and chronic condition management, recovery, and wellness. Magellan Health, Inc. provides healthcare management services to enrollees through health plans, state and local governments, the federal government, employers, and the military.
Magellan Health, Inc. serves approximately 53.5 million members in all 50 states (including 3.95 million in Florida) with more than 7,200 employees nationally, including over 930 individuals currently employed or contracted with Magellan in Florida, representing all Magellan lines of business and numerous locations in every part of the State. Of these more than 930 people, the largest concentration of staff, approximately 260 individuals, are in the Magellan Complete Care Medicaid Center of Excellence in Miami.
A second Florida office, our pharmacy office in Orlando, houses more than 190 employees and contractors, while our pharmacy satellite office in Tallahassee has over 30 employees today working on the State Medicaid pharmacy contract. The remaining employees are counseling staff co-located at federal and military sites across Florida, or work from home in the communities that we serve.
Magellan provides behavioral health, radiology, pharmacy, and Medicaid Managed Care Services to enrollees living with SMI across a broad set of Medicaid eligible groups including Temporary Aid for Needy Families (TANF), Aged Blind & Disabled (ABD), and waiver eligible populations, as well as dual eligible and Medicare Advantage populations. Magellan Health, Inc. provides care management and administrative/managed care services for a broad set of medical benefits including physical, behavioral, and integrated health; complex areas of specialty healthcare; pharmacy; and long-term care services and supports (LTSS). Within Magellan, we operate several corporate units that deliver various services to SMI populations similar to the target population for this response. These include:
1.1.b Magellan Rx Management Magellan Rx Management (Magellan Rx), which is part of Magellan Health, Inc., provides a smarter approach to pharmacy benefits. Magellan Rx serves SMI populations throughout the country, as well as general Medicaid populations, commercial populations, and others. Our integrated solution combines our pharmacy benefit and specialty pharmacy expertise into an organization that allows us to leverage our collective scale and experience in managing total drug spend while ensuring a clear focus on the specific needs of each of our individual customers. Magellan Rx provides customers with easy-to-use tools and insightful cost-saving solutions that improve enrollee health and help customers make more informed decisions.
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1.1.c Magellan Healthcare, Inc. Magellan Healthcare, Inc. (Magellan Healthcare), which is part of Magellan Health, Inc. (Magellan), has a strong focus on managing fully integrated healthcare benefits and programs for special populations with complex health issues and significant comorbid conditions through care management. This includes individuals living with SMI. These programs begin with a health risk assessment and risk stratification and include utilization management of all healthcare services (medical and behavioral); integrated (medical and behavioral) care coordination and complex case management; management of transitions of care; and management of Medicare Advantage and Special Needs Plans.
1.1.d AlphaCare AlphaCare, a Magellan Complete Care owned health plan, operates a Managed Long-Term Care (MLTC) plan, serving the boroughs in and around New York City, as well as a Medicare Advantage Plan (MAPD), a Dual Special Needs Plan (D-SNP) and an Institutional Special Needs Plan (I-SNP). These populations are extremely complex and vulnerable, similar to those served by Magellan Complete Care.
In addition, given AlphaCare’s combined Medicaid and Medicare health plan capabilities, it has been selected as a Medicare-Medicaid Plan to participate in New York’s duals demonstration, the Fully Integrated Duals Advantage (FIDA) program, which began on January 1, 2015.
1.2 Magellan Complete Care Experience Serving Similar Target Populations Magellan Complete Care of Florida (Florida MHS, Inc. d/b/a Magellan Complete Care), which is part of Magellan Healthcare, Inc., is an innovative specialty healthcare plan focused on fully integrated physical health (PH) and behavioral health (BH) care and care management for individuals who are living with SMI. Magellan Complete Care is the nation’s first Medicaid plan specifically created for individuals with SMI. Our mission is to help our enrollees find their way through the health care system by integrating all care in a single solution and managing that care through integrated PH-BH program design, interventions and care management. With collaboration across all types of providers, the enrollees, and their caregivers, the plan holistically manages all physical, behavioral, and specialty healthcare services to deliver better care and improved outcomes for individuals with SMI.
Magellan Complete Care is the first fully integrated physical and behavioral health plan in the U.S. dedicated to improving health outcomes for SMI enrollees, who are some of the most complex, non-compliant, and vulnerable populations managed under the Medicaid program. This specialty health plan is a bold statement of our commitment to demonstrate that improvement in the overall health outcomes for this population is possible by building physical health plan capabilities around a strong core of behavioral health management. Magellan has the capabilities and experience in managing multiple populations and programs across the country that is required to demonstrate success in this innovative model.
Magellan has extensive and relevant experience (inclusive of Magellan Complete Care and affiliates Magellan Healthcare and Magellan Rx) providing CC/CM to similar target populations across the country, including disease or special condition management. This includes our programs in Florida, as well as New York, Wisconsin, Pennsylvania, Louisiana, Virginia, Nebraska, Wyoming, and commercial sector clients. Programs include individuals with SMI, as well as dual-eligible; Special Needs Plans (SNP); Managed Long-Term Care (MLTC); Long-
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Term Services and Supports (LTSS); physical and intellectual/developmental disabilities; TANF; and ABD.
Our programs, plans, staff, and systems are all specifically focused on the deserving but often lost children, parents, friends, neighbors and relatives who daily struggle to manage their most basic needs, much less seek treatment or make a preventative care visit. Our job and our mission is to help our enrollees, one person at a time, find a path to recovery and self- management. Because of our dedicated focus, our programs are a catalyst for system change and transformation. By design, traditional Medicaid health plans serve broad populations. It is challenging to provide the singular focus, tailored programs, and intense follow-up needed to support enrollees who are difficult to engage or find. Our alternate design retools traditional health plan roles and creates new ones; customizing our systems and predictive modeling tools for our unique population; creating integrated clinical guidelines that address co-occurring medical and behavioral health conditions; and developing innovative new programs.
****Trade secret as defined in Section 812.081, Florida Statutes**** As a first-of-its-kind fully integrated health plan for this complex, high-risk population of Medicaid enrollees who are living with SMIs, we have , been exclusively focused on understanding the unique needs of enrollees in Florida since July 2014. We have developed fully integrated health care delivery and care management programs to address their whole health needs, designing targeted interventions to improve outcomes and defining key metrics and outcomes to continuously measure and monitor performance. In 2016, Magellan Complete Care of Florida received full three-year Medicaid Health Plan Accreditation from the National Committee for Quality Assurance (NCQA) with a score of 99.58 percent. Specific strengths cited included a comprehensive Quality Improvement program; linkages between Disease Management and
The challenges of building and delivering on this model are significant but not insurmountable. Local providers are often challenged to understand and may not be equipped to assist in the
In the interim, health plan care management must support those gaps in the local delivery system. Improvement in costs and outcomes also takes time since this is a population that has historically not been managed and may have issues with compliance.
Magellan Complete Care has risen to that challenge, and the improvements in outcomes for our enrollees have been steady. Though we are early in demonstrating the benefits of this model, we continue to show improvements in most key managed care and outcomes metrics. Since its inception, Magellan Complete Care of Florida has
Magellan believes in the value and results for this type of integrated solution and is committed to its continued refinement and improvement. It is a viable and effective solution to improve outcomes for this complex and vulnerable population.
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Lack of engagement and access to primary and specialty care, and the heavy burden of chronic disease is well-known among the SMI population. Magellan Complete Care placed heavy initial emphasis on initiating engagement; identifying enrollee risks; developing individual and population-wide plans for management; and beginning the process of continually improving outcomes for enrollees. We have also placed specific focus on clinical risks that are known to be higher in SMI populations. That includes issues of access, and conditions tied to many of the metrics of focus in this response . All of Magellan Complete Care’s enrollees have at least one SMI, most have at least one physical health comorbidity, and more than 30% have two or more physical health comorbidities. Engagement in prevention and wellness programs, as well as more intensive forms of care management pose additional challenges for individuals with SMI, because many of our enrollees also experience social stressors such as housing and food instability, unemployment, and engagement with the correctional system. Recognizing the issues faced by the SMI population, Magellan Complete Care has developed numerous targeted programs and interventions, in addition to quality monitoring, and data capture and management, taking advantage of multiple enrollee touchpoints for engagement.
Though some of our quality and outcome metrics may not currently meet AHCA’s minimum 50th percentile target for National Medicaid, 90 percent of our reportable measures improved when comparing HEDIS 2016 to HEDIS 2017 with an average per measure percentage point improvement of seven points. This improvement is indicative of the effort Magellan Complete Care has invested in quality initiatives in 2016.
As a basis for comparison, we analyzed the HEDIS scores for the top three Florida Managed Medicaid plans for HEDIS 2016 versus HEDIS 2017 using Quality Compass data for the same 30 measures. Competitor measures with a NR (not reportable) designation for either year were excluded from the count. Comparative performance was as follows:
>Format of the following data: Florida MMA Plan, number and % of measures improved, average percentage point improvement per measure: >>Magellan Complete Care, 27 of 30 (90%) measures improved, a .67 average per measure point improvement >>Wellcare of Florida, 16 of 30 (53%) measures improved, 0.95 average per measure point improvement >>Sunshine Health Plan, 15 of 28 (54%) measures improved, 1.46 average per measure point improvement >>Amerigroup Florida, 16 of 30 (53%) measures improved, -0.12 average per measure point improvement
The 30 measures included in this analysis and all data points are outlined in [Specialty SRC #03, Attachment 1: HEDIS Improvement 2016-2017].
Magellan Complete Care is proud of the level of improvement we have demonstrated in our HEDIS performance, and we are committed to continuing that trend. To further bolster our capabilities, Magellan Complete Care is partnering with Shared Health, a wholly-owned subsidiary of Blue Cross Blue Shield of Tennessee with 24 years of experience covering 1.3 million members. Magellan Complete Care is leveraging Shared Health’s expertise to bring a
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greater focus to sub-populations through data-driven analyses and a more developed community-based outreach strategy. Shared Health has developed many algorithms through their population health approach to identify health disparities and focus specifically on sub- populations. Additionally, Blue Cross Blue Shield of Tennessee has a rich history of working within the communities they serve, and it conducts greater than 500 community events a year to reach their Medicaid population across the state. An important area of focus for Magellan Complete Care in continuing to achieve population health improvements is to leverage similar data-driven strategies to create tailored programs and to increase our community presence to reach a greater percentage of our members.
Our continued focus and the evolution of our quality strategy appear to be sustaining our level of improvement. Based on claims data submitted through June 30, 2017, our in-period rates for HEDIS 2018 show that 29 of 36 (81%) measures are improved as compared to this same point last year [Specialty SRC #3, Attachment 2: HEDIS 2018 In-Period for Claims]. Magellan Complete Care believes in the promise of improved outcomes for both physical and behavioral health through a fully integrated managed care model for enrollees living with SMI, and we are committed to demonstrating its value.
In terms of meeting quality standards, we do ask AHCA to keep in mind the University of Southern Florida’s recommendations that enrollees with SMI require intensive community-based and specialized services (citation: “Access, Integration and Quality of Care for Individuals with Serious Mental Health Challenges Enrolled in Florida’s Managed Medical Assistance Program: Project #3 Final Report Deliverable #3.4”, University of Southern Florida, June 21, 2016.). The findings from the USF research indicate that it is unrealistic for a plan that works specifically with enrollees living with SMI to generate similar performance levels relative to Florida-based plans supporting a more traditional Medicaid enrollee population (primarily TANF). Note that certain national standards also fail to recognize the low starting point for engagement and management, as well as the unique care complexities and management requirements of individuals living with SMI.
CRITERIA 2: THE EXTENT TO WHICH THE QUALITY MEASURES PROPOSED… Our experience has confirmed the significantly increased complexity of managing the overall health of enrollees when they are facing one or more serious mental illnesses, as well as physical illness. The Magellan Complete Care population is even more complex than most. All of our enrollees have at least one SMI. Fifty (50) percent of our enrollees are living with co- occurring conditions, with two or more behavioral health and/or physical health diagnoses. More than thirty (30) percent of our enrollees have two or more physical health diagnoses.
Additionally, Magellan Complete Care enrollees are diagnosed with diabetes at 2.6 times the rate of the general Medicaid population, asthma at 1.6 times the rate, and hypertension at 2.2 times the rate of the general Medicaid population. Those rates are elevated in part by the effects of psychotropic medications and higher rates of smoking. Our enrollees also have higher rates of substance use disorder (SUD) (16%) and lower rates of primary care utilization. This clinical complexity is often further exacerbated by issues with social supports, co-occurring substance abuse, chronic homelessness, and other stressors. This demands that we focus on the traditional metrics identified above, as well as an expanded set of associated quality
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improvement initiatives and more advanced measures of enrollee stability and recovery that are unique to these populations.
2.1 Understanding the Complexity and Unique Quality Factors for SMI Magellan Complete Care of Florida’s population of enrollees living with SMI, which is a subset of the broader Medicaid population, reflects much higher acuity levels than that in the larger Florida Medicaid population. In 2016, about seven percent (225K) of Managed Medical Assistance program enrollees in Florida were living with SMI. According to data from Milliman, these enrollees cost approximately 2.5 times more than Florida MMA Program enrollees who are not diagnosed with SMI. According to State data, as reported in the Winter 2016 Quarterly Medicaid Managed Care Report, 55.4% of enrollees in standard (non-specialty health plans) Medicaid plans were identified as healthy based on analysis of utilization, versus 23.1% in Magellan Complete Care. In fact, that data shows Magellan Complete Care to have the second least healthy enrollee population among all plans . According to that same data, the top diagnoses for enrollees in Magellan Complete Care are schizophrenia, dementia, hypertension, and depression, all of which are extremely complex illnesses to manage, even before considering common comorbidities.
****Trade secret as defined in Section 812.081, Florida Statutes**** Our experience with Magellan Complete Care of Florida drives home the level of medical and behavioral complexity of the SMI population.
Individuals living with SMI present a particular challenge, especially for Medicaid programs throughout the country. Medicaid is the single largest payer for mental health services and is playing an increasing role in the payment and delivery of SUD treatment and services. Studies of physical health status and outcomes for individuals with SMI also show that these individuals suffer from rates of chronic disease and significantly lower life expectancy than those without SMI. These problems are compounded by significantly lower rates of primary care utilization ; high rates of co-occurring SUD; increased risks of developing some chronic conditions from the medications used to treat mental health conditions; and complications of treating mental health and physical health conditions due to drug-drug interactions and the compounding destabilization caused by each condition. As an example, some psychotropic medications can increase risks for diabetes and hypertension, and pregnancy presents unique challenges for management of SMI and healthy birth outcomes.
Our enrollees also face particularly challenging social support issues, with high rates of homelessness, food insecurity, unemployment, and incarceration. Measuring and monitoring of our enrollees, the design of targeted interventions, and goals for improvements in outcomes must take these issues into consideration.
The mental illness itself can also act as a barrier to seeking out and receiving appropriate primary and preventive care. Medicaid SMI enrollees are complex and may have issues with
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****Trade secret as defined in Section 812.081, Florida Statutes**** engagement and compliance. Enrollees are often not familiar with expectations and requirements for participation in managed health plans. However, Magellan Complete Care’s pioneering approach to supporting people with SMI demonstrates the outcome improvements that can be achieved with fully integrated bio-psycho-social management of this population. Our model connects behavioral, physical, pharmacy and social supports in one integrated model and plan of care that is individualized, coordinated, and cost effective. Though the program only received its first enrollees in mid-2014, we have demonstrated steady improvement in outcomes.
2.2 Implications of SMI Complexity for Measuring Outcomes HEDIS and EPSDT/CHCUP measures are important and valuable measures for assessing the receipt of preventive services and adherence to evidence-based care for all enrollee populations, including enrollees living with SMI. In addition to our required annual reporting to NCQA and AHCA, Magellan Complete Care has made significant investments in analytics and reporting to drive meaningful quality initiatives that are monitored for effectiveness, as part of our cycle of continuous quality improvement. For example, to drive targeted enrollee outreach, we have invested in enrollee-level gap-in-care reports for our internal QI efforts as well as for our provider QI efforts. To ensure our QI efforts are effective and truly driving change, we have invested in in-period performance reports for both our HEDIS and EPSDT/CHCUP metrics to inform our focus areas and outreach strategies throughout the year, rather than just once a year.
In addition to HEDIS and EPSDT/CHCUP metrics, we monitor and report on measures tied to key birth outcomes, measures to track potentially preventable events (note, some of those metrics are also standard HEDIS measures), and measures for chronic illness and co-occurring conditions that are more often seen in SMI populations (substance abuse, smoking, diabetes, hypertension, COPD, CHF, metabolic syndrome, etc.). We also monitor measures such as the use of multiple concurrent antipsychotics for patient safety monitoring and appropriateness through regularly run algorithms, and we communicate with our providers to support coordination of care for our enrollees.
2.3 Recommended HEDIS Measures for Additional Focus While all of the HEDIS and EPSDT/CHCUP measures reportable to AHCA are valuable for measuring the health of our enrollee population, , we have prioritized measures that are particularly important for enrollees who are living with SMI, including:
>HEDIS Adherence to Antipsychotic Medications >HEDIS Antidepressant Medication Management >HEDIS Initiation and Engagement of Alcohol and Other Drug Dependence Treatment >HEDIS Follow Up After Hospitalization >HEDIS Diabetes Monitoring for People with Diabetes and Schizophrenia >HEDIS Cardiovascular Monitoring for People with CV Disease and Schizophrenia >HEDIS Metabolic Monitoring for Children and Adolescents on Antipsychotics >HEDIS Use of Multiple Concurrent Antipsychotics in Children and Adolescents
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>HEDIS Depression Screening and Follow-up for Adolescents and Adults (DSF) >HEDIS Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS) >HEDIS Depression Remission or Response for Adolescents and Adults (DRR) Our performance on many of these measures is among the highest nationally of all Medicaid plans, including scoring at the 90th percentile for Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (Initiation – Total), and at the 75th percentile for Adherence to Antipsychotic Medications, Metabolic Monitoring for Children and Adolescents on Antipsychotics, and Cardiovascular Monitoring for People with CV Disease and Schizophrenia.
2.4 Additional Current and Proposed New Non-HEDIS Clinical Metrics Magellan Health, Inc. is an active participant in the National Quality Forum (NQF) and has been an important partner in developing recommendations for an expanded core set of quality measures for Medicaid enrollees. Some of the recommendations that are specifically applicable for enrollees living with SMI have been included in our recommendations for additional HEDIS measures above. However, we recommend the use of additional measures that will also capture key indicators for many of the program goals identified by AHCA. Recognizing the unique characteristics of the SMI population and the key drivers of outcomes for this population, we propose monitoring of the following additional key outcomes measures, which include some of the new NQF measures:
>NQF Expanded Set Recommended Measures: >>Plan all-cause readmissions (PCR) >>Use of opioids at high-dosage in persons without cancer >>Contraceptive care post-partum >>Contraceptive care – most and moderately effective methods
>Additional Non-NQF Clinical Measures: >>Primary Care Engagement: >>>Primary Care (PCP) Average Utilization/Enrollee >>>Primary Behavioral Health Provider (PBHP) Average Utilization/Enrollee
>Birth Outcome Measures: >>Non-medically indicated cesarean section rates >>Total cesarean section rates >>Pre-term delivery rates >>Infant mortality rates
>>Preventable Event Measures: >>ER Utilization/1,000 >>ER Utilization for Potentially Preventable Events (specifically focused on ambulatory care sensitive conditions) >>Number of preventable admissions per 1,000 enrollees >>Baker Act admissions/1,000 >>30-day readmission rate (PH and BH) >>Inpatient days/1,000 (PH and BH) >>Admissions/1,000 (PH and BH) >>Day-hospital and Observation days/1,000 (PH and BH)
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>>Enrollee Care Management Measures: >>>Enrollee DM/CC/CM Engagement Percentages >>>HRA Completion Rates
2.5 Proposed New Social Complexity Metrics Clinicians and policy makers across the country and within Medicaid programs are increasingly focused on the impact of social determinants of health for the physical and behavioral health status of populations, the risks and complexities of those illnesses. Those affects are magnified for enrollees living with SMI who are already dealing with complex behavioral and physical health conditions. Magellan Complete Care and Magellan Health, Inc., our parent company, have been at the forefront of efforts to understand the impact of these factors, use screening and measurement tools for assessment, and integrate the use of screening results into treatment and engagement of enrollees.
Two specific areas of focus include ACEs (Adverse Childhood Experiences) and screening for social risk factors. Although ACEs screening is more broadly used for children and adolescents, it and social screening tools can, and are, also applied with adult populations. We are currently using ACEs screening and screening results in programs we administer in Wyoming, Pennsylvania, and Virginia, and we propose expanded use with our Magellan Complete Care enrollees.
We are also currently using the Health Leads Social Needs Screening Toolkit to assess social determinants risk with enrollees in a number of our plans, and we are proposing its use for Magellan Complete Care enrollees as well. Social needs screening includes the use of a structured tool to assess social risks, which can affect health outcomes as well as willingness and ability to engage in self-care and care management interventions. Use of this information will allow Magellan Complete Care to measure and assess the impact of these social risk indicators for enrollee outcomes. It will also allow us to identify additional supports that may be needed by enrollees, and when coupled with data and analytics on clinical outcomes, this information will provide us with important information for predicting enrollee risks and needs for clinical interventions.
Recognizing the importance of each of these screening models, we propose inclusion as measures of social complexity for enrollees living with SMI. Specifically, we recommend:
****Trade secret as defined in Section 812.081, Florida Statutes****
>Community Tenure: >>Average Length of Community Tenure
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****Trade secret as defined in Section 812.081, Florida Statutes****
National and regional benchmarks specific to a SMI population are not available for HEDIS, EPSDT, or any of the measures we’ve listed in this response. Recognizing this, the University of Florida drew the conclusion that a plan dedicated to working with enrollees living with SMI would have different performance results when compared to other plans in Florida or national standards.
Magellan Complete Care is committed to achieving results that are consistent with or better than the outcomes achieved for other Medicaid enrollees. However, as an organization committed to serving individuals with SMI, we also recognize that achieving those outcomes requires that we monitor and manage an even more complex set of measures, with an eye toward those factors that influence our ability to achieve broader Medicaid program goals. We believe the metrics we have proposed above support achievement of those objectives.
CRITERIA 3: THE EXTENT TO WHICH THE QUALITY MANAGEMENT ACTIVITIES… We recognize that nationally persons living with SMI often have limited engagement with physical health providers in settings outside the ER and inpatient facilities. Those facts are demonstrated by national studies that have shown that only 24.7% of visits by SMI patients are with primary care providers. Our goal is to shift that paradigm and increase primary care and preventive care engagement, while simultaneously managing and monitoring treatment of chronic and acute physical and mental health illness. Our comprehensive metrics and measures used to monitor performance support that goal.
3.1 Magellan Complete Care Quality Management Approach Our entire system of care is fully integrated to include bio-psycho-social care and support for the enrollee, to encourage enrollee recovery and resiliency, and community tenure. We manage all care in an integrated fashion that recognizes the interdependencies between behavioral health, physical health, and social fragility, as well as the complicating and confounding nature of multiple morbidities. Our system includes data- and analytically-driven segmentation and stratification of our enrollees based on total risk and complexity, and our interventions are specifically targeted to overcoming those risks and understanding enrollee barriers to health. We rigorously analyze and continuously improve our model of enrollee engagement and targeted interventions, based on statistical analysis of outcomes. This same level of discipline is
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applied to improvements in the delivery of care, with a clear and targeted focus on closing the gaps in provider understanding of the complex needs of our enrollees with SMI; their capabilities to meet those needs; and their willingness and enthusiasm to expand access and services for this fragile population. All elements of our model are committed to refinement of our fully integrated, data-driven, and clinically based model for enhancing the total health and well-being of individuals who are living with SMI.
Continuous quality improvement (CQI) has always been the backbone of Magellan’s services. CQI is reflected in the structure of our organization, systems, and processes for Magellan Complete Care of Florida, which is supported in its quality efforts by both a strong local quality and leadership team, as well as with a national quality organization. The goal of our quality program is to ensure the provision of consistently excellent healthcare, health information, and service to Magellan enrollees. Magellan’s core values of patient-centered, community-focused, and evidence-based services give clear direction to the Quality Program. The Quality Program touches every functional area of the plan, including healthcare service delivery; service operations with members and providers; case management, disease management, and population health; core utilization management processes; network composition; compliance and risk management; and information management.
Magellan Complete Care staff obtain input from a broad spectrum of stakeholders, using a Plan Do Study Act (PDSA) framework. We monitor quality with metrics derived from multiple data sources to ensure the timely identification of barriers and interventions that lead to improvement. We use this model in all QI activities to resolve complex or multifaceted issues in a logical and systemic manner, as well as to engage stakeholders in planning efforts. The program has sponsorship from the CEO and top leadership of the organization including the Chief Medical Officer (CMO), who shares joint accountability with the Magellan Complete Care Director of Quality Management (QI Director) for quality outcomes. Quality is everyone’s job and in fact, as evidence of our commitment, all Magellan Complete Care staff have at least one goal tied to quality in their annual performance assessments. Our experience has shown that supporting CQI and plan-wide quality ownership yields optimal service delivery and member outcomes, leads to systems improvement, and instills a pervasive culture of quality.
Magellan Complete Care’s Quality Improvement Program is designed specifically for our enrollees, tailored to unique sub-populations, and is reflective of regional differences in culture, ethnicity, and health status. Quality activities and program metrics specific to our population are continually captured and reported. Quality activities and metrics are analyzed for regional differences in access to care, cultural and economic disparities, population health indicators, and prevalence of chronic disease and other illness.
The Magellan Complete Care Quality Program focuses on the management of high-quality, safe, innovative, and integrated, evidence-based services. We include a focus on regional needs assessments for pregnant women, children, and particularly vulnerable enrollees. We also focus on outcomes beyond HEDIS to include EPSDT/CHCUP, birth outcomes, and preventable events.
We also commission detailed and in-depth studies conducted by Magellan’s Department of Advanced Health Analytics and Solutions. An example, is the study we commissioned this year to assist in driving our HEDIS/EPSDT/CHCUP improvement program. That analysis focused on
AHCA ITN 009-17/18, Attachment A, Exhibit A-4-d, Page 60 of 100 EXHIBIT A-4-d SPECIALTY SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA enrollee’s characteristics associated with adherence to HEDIS measures, understanding the effectiveness of existing interventions, refining those interventions, or developing new interventions and targeting to achieve improved outcomes. The study used multivariate statistical modeling to answer the question of which enrollee characteristics are associated with non-adherence after statistically controlling for other variables. Member characteristics were selected using the industry-standard Anderson’s Model of Health Services Use, which posits that health services use and health practices are driven by: predisposing characteristics (e.g., age, gender); enabling resources/factors (e.g., education, distance to provider); and clinical need (e.g., medical conditions, pain). We used logistical regression to examine dichotomies; analyze adherence/non-adherence; and determine the characteristics associated for adherence/non-adherence after statistically adjusting for other characteristics. The results of this analysis were instrumental in driving a more targeted and effective engagement and intervention strategy for closing gaps in care for our enrollees.
We have also made a strong commitment to collecting data on our enrollee and provider outreach efforts related to appointment scheduling to support our Healthcare Effectiveness Data and Information Set (HEDIS) and Child Health Check-Up Program (CHCUP/EPSDT) QI goals. Assisting our enrollees to connect with their assigned primary care providers to receive screenings, lab tests, and other preventive and recommended care is a Magellan Complete Care-wide operational effort. We have invested in the development of a customized application that is designed to track enrollee outreach efforts via phone or home visit and to document whether an enrollee was reached or not reached (including wrong phone numbers or addresses) and the outcome of successful enrollee connections (appointment scheduled, and confirmation calls on attendance). It allows vendors as well as staff from different functional areas to view and input data. Similarly, Magellan Complete Care has invested in enhancements to our care management application TruCare that are designed to ensure enrollee gaps in care are included in individual enrollee care planning, in order to support integration of multiple enrollee touch-points.
Magellan Complete Care maintains a quality management program that promotes objective and systematic monitoring of the quality of medical, behavioral, and psychosocial care and service delivery, with a focus on recovery and resiliency. Achieving these outcomes while working with individuals who live every day with behavioral health conditions demands that our Quality department function at a high level and that it be an integrated part of our overall model of care. The outcome metrics for the programs we employ to drive health improvement are not always SMI-specific, but they are tailored to the unique requirements and targeted outcomes for our enrollees living with SMI.. We aim our QI initiatives at improving enrollee outcomes. Improvement in metrics are a sign of improving population health. Many of our quality initiatives are identified when reviewing clinical outcome metrics through our quality committee structure and in various work groups. [Specialty SRC #3, Attachment 3: Sickle Cell CCM Evaluation] and [Specialty SRC #3, Attachment 4: Outcomes Associated with Participation in Case Management (CM, CCM, and DM) in Magellan Complete Care] provide examples of ongoing monitoring and reporting for our programs.
3.2 Outcomes Achieved Through Our Programs Because of Magellan Complete Care’s dedicated focus, our approach has been a catalyst for healthcare system change and for supporting individuals with SMI to live healthy, vibrant lives. Our design retools traditional health plan roles and creates new ones by customizing our
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systems and predictive modeling tools for our unique population and creating integrated clinical guidelines that address co-occurring medical and behavioral. The individual benefits resulting from the plan model are fundamentally transforming the way healthcare is delivered by assisting providers in their work and by helping parents, caregivers and other advocates achieve their goals. As our results demonstrate, the Magellan Complete Care SMI Specialty Plan is making a positive difference in the lives of approximately 75-thousand enrollees, while improving outcomes and reducing costs, including:
>Eighteen percent reduction in overall inpatient admissions per 1,000 >Average medical per-member/per-month (PMPM) savings of $2700 by securing access to housing >Fifteen percent reduction in total PMPM medical and pharmacy costs >Twenty-seven percent reduction in total emergency department costs >Seven percent reduction in PMPM total pharmacy costs (during a period of rapid unit cost increases)
Enrollees participating in our DM/CC/CM programs experienced even more significant improvements, including: >Forty-seven percent reduction in admissions for high-risk enrollees (often referred to as super- utilizers) >Thirty-seven reduction in admissions for low and moderate-risk enrollees >Forthy-three percent increase in primary care engagement for adults and 41% increase for enrollees under age 21
Additional detail for the improvements we have achieved in specific HEDIS/EPSDT/CHCUP performance improvement metrics are discussed later in this section.
Magellan Complete Care also has active, ongoing programs to address social determinants that have a significant bearing on the health outcomes we can achieve for our enrollees. As an example, our Homeless Housing Program has developed close relationships with area housing agencies to fast-track access to, permanent supportive housing whenever that is feasible. The program has resulted in more than 70 permanent placements since December 2015. The benefits of that placement are clear, with an approximate 41% reduction in costs of care for these enrollees.
3.3 HEDIS and CHCUP Enrollee Engagement and Quality Management Achievements Significant improvements were made across a broader set of HEDIS and CHCUP/EPSDT measures. Across 30 reportable HEDIS measures (90%) improved when comparing HEDIS 2016 against HEDIS 2017. Additionally, CHCUP/EPSDT participation, CHCUP/EPSDT screening, and Preventive Dental Services (PDENT) also improved. Our goal at Magellan Complete Care is to meet and exceed HEDIS and CHCUP/EPSDT benchmarks for our enrollees through continual improvement year over year. Individuals living with SMI are known to experience much poorer health outcomes and experience much shorter lifespans than individuals without SMI. We are committed to demonstrating the value of a fully integrated health plan solution to reverse those trends.
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****Trade secret as defined in Section 812.081, Florida Statutes****
The results of our baseline year HEDIS 2016 and Child Health Checkup (CHCUP) 2015-2016 measure rates reflected the health disparities for our SMI population and the low starting point for engagement and were predictably low. The clinical and related needs of our enrollees living with SMI are extensive. Individuals with SMI often demonstrate lack of engagement and compliance with care plans and ignore their physical health needs.
This social instability often adds to the difficulty in identifying and engaging our enrollees since addresses and phone numbers may often be incorrect, requiring that Magellan Complete Care invest significant time in finding the individual.
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****Trade secret as defined in Section 812.081, Florida Statutes****
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****Trade secret as defined in Section 812.081, Florida Statutes****
CRITERIA 4: THE EXTENT TO WHICH THE RESPONDENT MET QUALITY… As noted previously, enrollees living with SMI are often hard to engage for preventive and primary care as well as for case management. Evidence of that is demonstrated by Magellan Complete Care outcomes for the year immediately following enrollment of our first plan participants. For HEDIS 2016 reporting, reflecting services delivered in 2015, Magellan Complete Care met AHCA’s minimum threshold of the national Medicaid 50th percentile on 17% (5 of 30) of the reportable measures. This provided us with a solid understanding of the starting point for the level of enrollee engagement in the management of their care and also provided clear evidence of where we needed to target our efforts to achieve meaningful improvement. Recognizing these issues with engagement and compliance among SMI enrollees, Magellan Complete Care has committed significant resources to continuing improvement in these areas. The goal of our fully integrated solution is to counter nationwide trends of significantly poorer outcomes for individuals with SMI. The continued improvement in our results demonstrates that outcome is being achieved.
Our data clearly shows high performance for many behavioral health-focused metrics as well as meaningful improvements in nearly all of our reported medical and behavioral health performance metrics, resulting in improved outcomes for our enrollees. Measures for which Magellan Complete Care met or exceeded the 75th percentile nationally include initiation of treatment for AUD/SUD, medication management for people with asthma, adherence to
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Although some of our quality and outcome metrics may not currently meet AHCA’s minimum 50th percentile target for National Medicaid, we can report that most of our HEDIS measures reported for HEDIS 2016 and HEDIS 2017 have improved. This level of improvement is indicative of the effort Magellan Complete Care has invested in quality initiatives in 2016 which has yielded improvement in 90 percent of the 30 measures reportable to AHCA in 2017. Furthermore, the level of improvement per measure is on average seven percentage points per measure.
When comparing HEDIS 2016 to HEDIS 2017, Magellan Complete Care improved 27 of 30 measures (90%) with an average per measure percentage point improvement of seven points. As a basis for comparison, we analyzed the HEDIS scores for the top three Florida Managed Medicaid plans for HEDIS 2016 versus HEDIS 2017 using Quality Compass data for the same 30 measures. Competitor measures with an NR (not reportable) designation for either year were excluded from the count. Comparative performance was as follows:
>Format of the following data: Florida MMA Plan, number and % of measures improved, average percentage point improvement per measure: >>Magellan Complete Care, 27 of 30 (90%) measures improved, with a 6.67 average per measure point improvement >>Wellcare of Florida, 16 of 30 (53%) measures improved, 0.95 average per measure point improvement >>Sunshine Health Plan, 15 of 28 (54%) measures improved, 1.46 average per measure point improvement >>Amerigroup Florida, 16 of 30 (53%) measures improved, -0.12 average per measure point improvement
The 30 measures included in this analysis and all data points are outlined in [Specialty SRC #3, Attachment 1: HEDIS Improvement 2016-2017].
Of note, Magellan Complete Care met or exceeded the 90th percentile in two measures critical for management of SMI, meaning that on both of these measures, our performance exceeded that of 90 percent of all Medicaid health plans, none of which are composed entirely of Medicaid enrollees living with SMI. These included:
>Initiation of Alcohol and Other Drug Dependence Treatment (Initiation – Total) >Medication Management for People with Asthma (75% - Total) We also met the 75th percentile for Adherence to Antipsychotic Medications, which is particularly relevant for our enrollees living with SMI. We met the 50th percentile for Controlling Blood Pressure, which is critical from a clinical outcomes perspective.
Magellan Complete Care is proud of the level of improvement we have demonstrated in our HEDIS performance, and we are committed to continuing that trend. To further bolster our capabilities, Magellan Complete Care is partnering with Shared Health, a wholly-owned
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subsidiary of Blue Cross Blue Shield of Tennessee with 24 years of experience covering 1.3 million members. Magellan Complete Care is leveraging Shared Health’s expertise to bring a greater focus to sub-populations through data-driven analyses and a more developed community-based outreach strategy. Shared Health has developed many algorithms through their population health approach to identify health disparities and focus specifically on sub- populations. Additionally, Blue Cross Blue Shield of Tennessee has a rich history of working within the communities they serve, and conducts greater than 500 community events a year to reach their Medicaid population across the state. An important area of focus for Magellan Complete Care in continuing to achieve population health improvements is to leverage similar data-driven strategies to create tailored programs and to increase our community presence to reach a greater percentage of our members.
Our continued focus and the evolution of our quality strategy appear to be sustaining our level of improvement. Based on claims data submitted through June 30, 2017, our in-period rates for HEDIS 2018 show that 29 of 36 measures (81%) are improved as compared to this same point last year [Specialty SRC #3, Attachment 1: HEDIS Improvement 2016-2017]. Magellan Complete Care believes in the promise of improved outcomes for both physical and behavioral health through a fully integrated managed care model for enrollees with SMI, and we are committed to demonstrating its value.
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Evaluation Criteria:
1. The extent of experience (e.g., number of Contracts, enrollees or years) in achieving quality standards with similar target populations, including HEDIS or Contract required measures.
2. The extent to which the quality measures proposed are relevant to the specialty population(s) being proposed for this solicitation.
3. The extent to which the quality management activities proposed demonstrate the ability to improve quality for the population(s) proposed in a meaningful way.
4. The extent to which the respondent met quality measure targets, successfully remediated all failures or achieved improvement to overall performance.
Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each.
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C. RECIPIENT EXPERIENCE
Specialty SRC#4 Eligibility and Enrollment (Statewide):
The respondent shall propose detailed and specific criteria (age, medical condition and/or diagnoses) for the specialty population proposed in response to this solicitation. The respondent shall include proposed methods for identifying the specialty population proposed, including any data sources/system, specific medical codes for procedures (e.g. Current Procedural Technology (CPT), Healthcare Common Procedure Coding System (HCPC), International Classification of Diseases (ICD-10)) or diagnoses (e.g. ICD-10, Diagnosis Related Groups (DRG), American College of Gastroenterology (ACG)) associated with the population, clinical assessment and/or referral protocols required. The respondent shall identify the estimated number of recipients meeting the criteria for the specialty population proposed, along with the source or methodology for such an estimate.
Response:
OVERVIEW: THE IMPACT OF A SPECIALTY PLAN FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS Magellan Complete Care initially proposed and is currently serving enrollees, who are enrolled in the State’s specialty plan, and are living with serious mental illness (SMI). Our experience supporting these enrollees over the past few years highlights the importance of such a plan for this complex and vulnerable population. Since the launch of our specialty plan in Florida, other states have followed suit (Arizona, Virginia and Texas have integrated SMI plan options or are in the process of implementing them). AHCA led the creation of a plan to address the inadequacies and disparities of healthcare for individuals living with SMI, and Magellan Complete Care is extremely committed to serving these individuals.
CRITERIA 1: THE EXTENT TO WHICH THE PROPOSED CRITERION PRODUCES… The SMI identification algorithm currently used by the MMA program to establish eligibility for the SMI Specialty Plan was developed by AHCA in close collaboration with Magellan Complete Care at the outset of the MMA program in 2014. We recommend no change to the current identification criteria associated with the data sources/systems, procedural codes associated with the population or the clinical assessment, and/or referral protocols being used to identify this specialty population. The current SMI identification algorithm criteria, which include the specific diagnostic codes and related medications we have identified and recommended for identifying enrollees who are living with SMI, are detailed as part of Milliman’s 2016-17 rate development supporting documentation [Specialty SRC #04, Attachment 1: SMI Algorithm Memorandum] and represent Appendix E of the October 13, 2016 Milliman Memorandum “State of Florida Agency for Health Care Administration Risk Adjustment Methodology for Managed Medicaid Assistance Program, September 2016-September 2017”. An appendix to this memorandum – which we have shared with AHCA previously - includes diagnosis codes for SMI and Off-Label Use, as well as National Drug Codes (NDCs) for indicator drugs (Clozapine, injectable antipsychotics, MAOI antidepressants, and Clomipramine) antipsychotic medications, mood stabilizers, and behavioral health polypharmacy.
Within this population of enrollees, we know a significant proportion have co-occurring substance use and/or co-morbid physical health conditions that lead to costs which are 2.5 times greater
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than similar enrollees who are not living with SMI. We have also found that 28 percent of Florida Medicaid program enrollees, who are living with SMI, have one or more co-morbid chronic physical health conditions. The most common medical conditions that occur in the population who are living with SMI are cardiovascular disease, diabetes, obesity, chronic obstructive lung disease (COPD) and substance use disorders. The first three conditions, cardiovascular disease, diabetes and obesity, are often exacerbated by the drugs used to treat the enrollee’s mental health condition. The rate of COPD is due, in large part, to the disproportionate number of enrollees who smoke. The absence of effective preventive care also creates an environment that leads to a very high prevalence of modifiable risk factors such as tobacco use, a lack of physical activity, and poor nutrition among enrollees. We have found that effective coordination and care management address the reality that the mental illness itself is a barrier to effective management of physical health conditions. We also know that individuals, who are living with a mental illness, have a harder time accessing care, adhering to a therapeutic regimen, keeping follow-up appointments, and generally navigating the health care system.
1.1 Criteria for Eligibility and Enrollment The SMI identification algorithm is currently implemented in a manner that treats serious mental illness as a permanent enrollee condition, such that the entirety of available historical enrollee claims are considered for the purposes of establishing the SMI enrollee marker, which is retained indefinitely. Similarly, Magellan Complete Care recommends no change to this aspect of the current algorithm application. In addition, SMI diagnoses do not present in younger children. Magellan Complete Care supports the current age limitation in the current algorithm of no enrollees younger than five years old being eligible for the SMI Specialty Plan.
1.1a. Diagnostic Categories Summaries of the main diagnostic categories that define the population characteristics of individuals living with a SMI include:
>Psychotic Disorders including Schizophrenia, Schizo-Affective Disorder, and Delusional Disorder—Psychosis refers to an abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality." Schizophrenia is a chronic, severe, and disabling brain disease. Approximately one percent of the population develops Schizophrenia during their lifetime and more than two million Americans suffer from the illness in a given year.
>Bipolar Disorders—More than two million Americans have Bipolar Disorder (also known as Manic-Depressive illness). It typically begins in adolescence or early adulthood and continues throughout their life.
>Major Depression—Depression is one of the most common behavioral health conditions, affecting the majority of people, through either personal experience or through depression in a family member. Each year over 17 million American adults experience a period of clinical depression.
>Obsessive-Compulsive Disorders—Obsessive-Compulsive Disorder is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions).
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We also use the following drug categories to identify additional unique recipients. Details of indicator drugs, antipsychotics, mood stabilizers and polypharmacy are included in the appendix to the SMI Identification Memorandum discussed above. Indicator drugs – These medications are only used for individuals who are diagnosed with a SMI.
Thus, these individuals automatically qualify for Magellan Complete Care enrollment. Examples of these drugs are: >Clozapine >Long acting injectable antipsychotic medications >MAOI antidepressants >Clomipramine
Antipsychotic medications – These medications may be used by individuals who are not diagnosed with a SMI. We have provided logic to qualify the inclusion of individuals in Magellan Complete Care who are taking antipsychotic medications. These medications and their associated logic are use on oral antipsychotics for greater than 75 days. Mood stabilizing medications – Individuals utilizing Lithium or Equetro for greater than 30 days. Polypharmacy – Individuals using five or more different behavioral health medications for more than 30 days are included in our target population.
The complete diagnostic descriptions on which the above summary descriptions are based are maintained by AHCA and we propose that they remain unchanged.
CRITERIA 2: THE EXTENT TO WHICH THE PROPOSED CRITERION RESULTS…
2.1 Estimated Number of Recipients The size of the SMI Specialty Plan eligible population defined by the proposed identification algorithm, measured as a percentage of total MMA program enrollees, represents approximately 7.5 percent of the approximately 3.1 million total state-wide MMA program enrollees in Florida. The eligible membership, representing actual membership counts summarized from Milliman supporting rate development work papers in reference to the 2017-18 rate year rate development, is detailed in [Specialty SRC #04, Attachment 2: SMI Specialty Plan Eligible Population].
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Evaluation Criteria:
1. The extent to which the proposed criterion produces a clearly defined and readily identifiable target population.
2. The extent to which the proposed criterion results in a specialty population that does not exceed ten percent (10%) of the total population of MMA eligible recipients.
Score: This section is worth a maximum of 40 raw points as indicated below.
For Item 1:
(a) 20 points if the proposed criterion produces a clear target population that is data driven and not dependent on assessment or referral; (b) 10 points if the proposed criterion produces a clear target population that is in any way dependent on assessment or referral; (c) 0 points if the proposed criterion does not produce a clear target population that can readily be identified.
For Item 2:
(a) 20 points if the estimated size of the specialty population does not exceed ten percent (10%) of the estimated total population of MMA recipients; (b) 0 points if the estimated size of the specialty population exceeds ten percent (10%) of the estimated total population of MMA recipients.
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D. PROVIDER EXPERIENCE
No SRCs in this Category for Specialty.
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E. DELIVERY SYSTEM COORDINATION
Specialty SRC#5 - PROVIDER NETWORK (Regional):
The respondent shall propose provider network standards that meet the needs of the specialty population(s) being proposed for this solicitation, including specific provider access ratios that exceed MMA standards for provider types relevant to the specialty population(s). The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in managing provider networks for population(s) similar to the specialty population(s) being proposed for this solicitation, including experience with provider contracting and performance measurement relevant to the specialty population(s) proposed. Identify specific requirements for provider contracts, credentialing, provider handbooks, etc., the respondent proposes for network providers serving the specialty population(s) proposed. Describe any additional provider services the respondent proposes to make available to the provider network serving the specialty population(s).
Response:
OVERVIEW Magellan Health, Inc. (“Magellan”), parent company of Magellan Complete Care, has been an engaged and committed partner of the Florida healthcare community for more than 20 years. We have a clear understanding of the Florida landscape, provider community, and AHCA’s expectations and requirements. Magellan has a long-standing commitment to serving Medicaid recipients and more specifically supporting individuals living with serious mental illness (SMI). Magellan has demonstrated this deep rooted mission by building and supporting behavioral health contracts (excluding pharmacy) for Medicaid and/or Medicare programs in 36 states through direct contracts with state and local government, as well as through sub-contracts with health plans. Our experience and dedication to serving the SMI population is reflected in our network development and maintenance approach to ensure each enrollee’s unique needs are met. Additionally, we strive to bring innovation to the network through creative, evidenced-based programs that drive outcomes and improve enrollee’s lives, while leveraging the network’s strengths and expertise.
Magellan provided services for AHCA through the Qualified Evaluator Network, Care Coordination for Youth, and Utilization Management contracts, and for AHCA’s Child Welfare Prepaid Mental Health Plan (as the CBC Partnership’s Managing General Partner) in Regions 2, 4, 9, 10, and 11.
As AHCA’s only SMI Specialty Plan, Magellan Complete Care continues to evolve and build upon our experience and qualifications to further develop our existing statewide provider network to meet the needs of the SMI population. In the construct of our overall network, it has taken time to carefully find the right mix of traditional and non-traditional providers. This mix has resulted in a network that allows for better access for our enrollee population, which has traditionally been a barrier.
Magellan Complete Care has created a provider network of qualified practitioners who are licensed, competent, and have completed a formal credentialing review to ensure consistent delivery of high-quality, affordable health care services to our enrollees. We have made a
AHCA ITN 009-17/18, Attachment A, Exhibit A-4-d, Page 75 of 100 EXHIBIT A-4-d SPECIALTY SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA significant investment in building and maintaining a unique provider community that truly understands the enrollees, believes that recovery is possible, and are willing to adopt best practices that address the enrollee’s social and emotional needs to optimize outcomes.
CRITERIA 1: THE EXTENT OF EXPERIENCE…MANAGING A PROVIDER NETWORK SERVING THE PROPOSED POPULATION(S). [Specialty SRC #05, Attachment 1: Magellan Health, Inc. Experience Managing a Provider Network Serving the Proposed Population] summarizes our relevant company-wide experience managing provider networks serving similar target populations with other contracts. In the attachment, we describe our existing Florida contracts with (1) AHCA as the Managed Care Medicaid SMI Specialty Plan in Regions 2, 4, 5, 6, 7, 9, 10, and 11; (2) AHCA as the Qualified Evaluator Network, Care Coordination for Youth, and Utilization Management (3 contracts); and (3) AHCA Child Welfare Prepaid Mental Health Plan (as the CBC Partnership’s Managing General Partner) in Regions 2, 4, 9, 10, and 11. We follow the description of our Florida contracts with information regarding our contracts in Arizona, Iowa, Louisiana, Nebraska, New York, Pennsylvania, Virginia, and Wyoming, which demonstrate our experience managing a provider network serving the SMI population.
As mentioned in the Overview, Magellan provided services for AHCA in the Qualified Evaluator Network, Care Coordination for Youth, and Utilization Management contracts; and for AHCA’s Child Welfare Prepaid Mental Health Plan (as the CBC Partnership’s Managing General Partner) in Regions 2, 4, 9, 10, and 11. Magellan Complete Care’s extent of experience managing provider networks includes serving as Florida’s first managed Medicaid SMI Specialty Plan for the comprehensive care of enrollees diagnosed with SMI.
Our SMI Specialty Plan experience and capabilities include provider contracting and performance measurement that fully integrates and coordinates behavioral and physical health that spans the continuum of care. As a national thought leader in this area for nearly two decades, Magellan understands the value of the network’s expertise and has developed a robust provider engagement strategy to support the network management process. The core values of the network management strategy are provider partnerships, community connectedness, and enrollee centricity. The Integrated Health Neighborhood structure allows the Magellan Complete Care field-based teams to support and manage the network from a local perspective, focusing on building meaningful relationships that will translate to improved quality of care for enrollees and a positive experience for the provider.
The Integrated Health Neighborhood team provides both clinical support as well as operational, business support to minimize barriers to care and ensure a bi-directional relationship between the providers and the health plan. Currently in the State of Florida, Magellan Complete Care built and continues to expand an integrated, contracted network of more than 32,245 credentialed network providers, serving approximately 70,000 SMI Specialty Plan enrollees in 86,185 locations, including behavioral and physical health hospitals, primary care providers, a wide variety of specialists, behavioral health providers, and ancillary providers to deliver a full array of services to our membership.
In addition, Magellan Complete Care has embedded Community Outreach Specialists into local neighborhoods statewide to identify community-based organizations and social service agencies. This has deepened our reach and connection to the communities where our enrollees
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reside. As a result, we have established relationships with more than 4,000 non-traditional community resources to address the social determinants and have the ability to connect enrollees, family members, and caregivers to the services and supports they need. Magellan Complete Care leverages our core strength of serving special populations with complex conditions – combining broad expertise in physical health, behavioral health, pharmacy benefits management, diagnostics, and specialty and traditional services.
CRITERIA 2: THE EXTENT TO WHICH THE DESCRIBED EXPERIENCE DEMONSTRATES THE ABILITY TO… Magellan Complete Care has used one of its core competencies, behavioral health, to meet the needs and fill the gaps for needed care for the SMI population that does not regularly receive integrated physical and behavioral health care. Our experience providing recovery-oriented behavioral health services to people with SMI dates back to 1984, when Magellan first began working with health plan customers. All Magellan health plan contracts include adults with SMI. Our first intensive case management initiatives evolved as a result of working with these complex cases through our early health plan accounts more than 25 years ago. All of Magellan’s Medicaid contracts require programs and services for individuals who experience severe emotional and behavioral challenges.
In 2016, Magellan Medicaid programs managed services to more than 190,000 enrollees with SMI through our direct to state and county contracts. Through our experiences, both in Florida and nationally, we have broad capabilities to implement evidence-based practices and recovery and resiliency-oriented programs that effectively support individuals with SMI. Our ability to successfully manage a provider network for AHCA’s SMI Specialty Plan includes the combination of Magellan’s national public sector experience managing provider networks for the care of enrollees with SMI and Magellan Complete Care’s demonstrated experience managing the SMI Specialty Plan provider network.
Our SMI Specialty Plan provider network is one of our most valuable assets—we are committed to continuing to develop collaborative relationships to serve individuals with SMI.
Based upon our experience managing provider networks, we know that developing collaborative relationships begins with provider support. This specialized support allows providers to build the skills and knowledge necessary to successfully serve enrollees with SMI, and for Magellan Complete Care to be the “no hassle” plan of choice. Our experience as the first SMI Specialty Plan for AHCA and our experience managing a provider network for SMI enrollees includes an array of provider support services to improve the coordination of care between and satisfaction of providers caring for the unique needs of our enrollees. Our provider services feature the following strategies:
>Integrated, high touch Provider Relations Team >Clinically-focused Provider Support Specialists Team >Open access to health plan Chief Medical Officer and Medical Directors >Network leadership involved with provider engagement >Provider Partnership Program to engage providers in practice facilitation >Provider Optimization Delivery System >Provider outreach, engagement, and communication documented in Salesforce platform
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>Ongoing provider training >Technical support tools via the provider website, handbook, bulletins, and newsletters.
2.0.a Integrated, High-touch Provider Relations Team Our provider support approach delivers an integrated, high-touch Provider Relations Team organized for each strategic region. The approach fosters healthcare integration at the systems and services level by ensuring superior collaboration and communication with all providers across the continuum of care. Our strategy allows us to successfully communicate with providers, with a minimum of 30 days notice, whenever there are programmatic changes. The Provider Relations Manager serves as the primary contact to providers and manages the overall support needs of their region. This includes the management of provider issues and concerns and ensures they are addressed in a timely manner.
2.0.b Clinically-focused Provider Support Specialists Team The Provider Support Specialists are strategically located in the service regions throughout the state, which allows Magellan Complete Care to manage both provider networks and care delivery at the local level. As licensed behavioral health clinicians, the Provider Support Specialists engage the network providers through the use of practice facilitation principles to ensure that behavioral health integration and SMI orientation is incorporated into health plan provider relations. The Provider Support Specialists facilitate trainings with specific emphasis on improving quality, best practices modeling, medical record reviews, implementation of our clinical initiatives, and processes from a clinical perspective with a focus on the characteristics of the SMI population.
Our Provider Support Specialists are committed to our providers and establish a positive experience working with us by:
>Acting as a Practice Transformation Coach- employ practice facilitation principles to support integration >Providing an orientation to Magellan Complete Care >Providing education and support to facilitate best practices and cultural competency >Assisting with strategies related to the development and management of our provider network > Providing training and education to providers to improve quality, outcomes, and efficiencies and adoption of best practices >Brokering relationships between behavioral health and physical health providers >Implementing provider practice-based quality initiatives—(e.g., patient registries, pay for performance programs, provider scorecards) >Providing education around behavioral health diagnoses and treatment to reduce stigma >Distributing and reviewing various Magellan Complete Care reports, including performing medical record review and HEDIS gap-in-care reports.
Provider Support Specialists are assigned to network providers for “a hands-on approach” to assist in provider orientation and education for the purpose of improving quality outcomes, efficiencies, and adoption of best practices. Provider Support Specialists facilitate relationships with other Magellan Complete Care departments to support provider questions or concerns that address complaints, claims, contracting, and credentialing. We hire Provider Support Specialists who live in the communities of our enrollees.
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The Provider Support Specialist team makes daily face-to-face visits with network providers in their regions. The primary focus of these visits changes depending on the needs of the business and current contractual needs. We optimize provider learning by utilizing Provider Support Specialists to educate both medical and behavioral health providers on our plan operations and policies, health topics, and to coordinate community-based events around health promotion. Similarly, we use medical and behavioral health subject matter experts to provide learning opportunities for primary care providers, placing special emphasis on cultivating our steadfast commitment to the recovery philosophy. In addition, Provider Support Specialists link a provider’s practice with tools that help with process mapping, policies and procedures, protocols, and decision support. This specialized group also assists providers with the integration of mental and physical health requirements for enrollees with SMI.
~~Region 5 Provider Support Specialist Quote~~ “As a Provider Support Specialist, I am committed to educating our providers on our Specialty Plan, our initiatives, our incentives, and commitment to helping our enrollees obtain quality healthcare to improve the enrollee’s quality of life. I work with providers to foster collaborative, integrated care for our enrollees. I work with our Health Services staff to foster collaboration and effective communication with our providers as they work together to help our enrollees. Here is one example:
One of my pediatric providers was concerned and frustrated with the providers that they were utilizing for behavioral health referrals. The concerns were mostly about communication. I was able to set up and facilitate, a face-to-face meeting with their Medical Director, Referral Coordinator, and Director of Managed Care, and the leadership of a smaller behavioral health provider in the area. This meeting was successful in establishing a working relationship for referrals, working out the methods, timing, and needed items for communication, and service authorizations. I checked in with both parties at least monthly as we were laying the groundwork and getting this implemented.
The outcome was that it is now running smoothly and both parties are very happy to have each other to work with to provide integrated care for their patients. When I get involved with my providers to help them network and establish collaborative partnerships for integrated care, they are surprised that I am not just doing this for Magellan Complete Care enrollees, but that I am doing this to help them. I go the extra mile to get the communication and procedures in place for this to happen for all of their patients.”
2.0.c Open Access to Health Plan Chief Medical Officer and Medical Directors Magellan Complete Care places a high premium on communication between the SMI Specialty Plan and providers. Ease of communication and rapid response to the needs of providers are quintessential to coordination and continuity of quality healthcare delivery. Therefore, it is our policy to provide 24/7 access to our Medical Directors, including our Chief Medical Officer. The Medical Director’s business cards provide not only the Medical Director’s office phone number but also his/her mobile number. The Chief Medical Officer is available, on call, 24 hours per day and may be reached either directly or through the after-hours call center. When the Chief Medical Officer is known to be unavailable due to vacation or holiday, another Medical Director is always on call. Magellan Complete Care of Florida’s Medical Directors cover
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providers’ physical health and behavioral health concerns for our enrollees and, through the use of phones and emails and smart phones, assistance and records of the transactions are available at any time and in any place where internet and/or cellular data access is available.
2.0.d Network Leadership Involved with Provider Engagement Our overarching provider engagement goal is to ensure timely access to quality health care services for all enrollees and an improved provider experience. Magellan Complete Care’s Chief Executive Officer (CEO), Chief Medical Officer (CMO), Chief Operating Officer (COO) and provider network leadership set priorities and actively support our provider network engagement efforts. Our CEO regularly reports updates on our provider engagement activities to the Board of Directors. Our leadership has assigned our provider network one of our highest organizational priorities and engaged staff, cross-functionally, to establish an annual plan, which includes strategic goals and activities for system transformation, provider engagement and commitments to improve the provider experience. Our annual plan is informed by input from the provider community gathered through various forums, such as:
>CEO Direct Reports Meetings: Provider engagement is a standing agenda item on our CEO’s direct report management team meetings. This forum provides an opportunity for senior leadership to continue to inform and shape our evolving strategy and tactics.
>Face-to-Face Meetings: Since we initiated our current contract with AHCA in 2013, our Executive team and Network leadership regularly meet with local and regional health systems, hospitals, rehabilitation hospitals, community-based providers, community mental health centers (CMHCs) and federally qualified health centers (FQHCs) to better understand the patterns of care of our population and better meet the needs of our providers. We recognize the level of importance in effectively engaging with our provider community, because our model of care requires the integration of multiple provider types to support the complex and comorbid conditions related to our enrollees’ SMI condition.
>Provider Advisory Committee: Magellan Complete Care facilitates Florida Provider Advisory Committees (PACs), chaired by our CMO and attended by our CEO, COO, and network leadership. Providers play an active role in our program oversight, strategic planning, and program initiatives. The PACs have had a positive impact and have made a difference for providers, enrollees and the community. The PACs meet quarterly to review and provide feedback on new programs and QI initiatives. They provide insight into local population health concerns, review program evaluation and Performance Improvement Project results and provide guidance on how we can help improve the provider experience. PACs also represent the provider network by providing ideas and feedback on innovative strategies to transform the health delivery system, such as our value-based payment programs. The PACs have had such great success that we recently launched Hospital Advisory Committees in Florida.
>Physician Advisory Board Participation: The Magellan Complete Care’s Physician Advisory Board was launched in April, 2016 to provide a venue for mutual sharing of clinical quality ideas and to foster a better understanding of the barriers to healthcare delivery that affect a special needs population shared by both the clinicians in the community and Magellan Complete Care. The Physician Advisory Board includes physicians in both primary and specialty community care and leaders from Magellan Complete Care, including the Chief Medical Officer, the Senior Director of Health Services, the Chief Operating Officer, Chief Executive Officer, and other
AHCA ITN 009-17/18, Attachment A, Exhibit A-4-d, Page 80 of 100 EXHIBIT A-4-d SPECIALTY SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA clinical leaders. The Physician Advisory Board has been instrumental in the genesis of several quality of care programs at Magellan Complete Care, including those designed to improve preventable ER and admission events, those designed to foster better communication between and among PCPs, specialty physicians, and the Health Plan, better access to primary care, better coordination of care, and better continuity of care.
>Provider Organizations: The critical nature and work of the Florida Medicaid provider requires communication and collaboration on a shared advocacy strategy between the health plan, provider, and community associations. Magellan Complete Care supports this strategy by collaborating with the Florida Council for Mental Health, Florida Behavioral Health Association, Managing Entities, DCF, Florida Hospital Association, Florida Association of Community Health Centers and other organizations. By fostering these relationships, we are able to advance care delivery strategies that have improved care and increased enrollee access to care. Our partnerships have taught us about the specific challenges providers face in the development of new programs and when policies are changed. By learning from our partners, sharing our collective experiences and resources, we are able to obtain provider consensus that results in improved care and access for our enrollees.
>Joint Operating Committees: Joint Operating Committee (JOC) meetings are established with high volume facilities and providers. Meetings occur monthly or quarterly and allow an opportunity for providers and health plan to communicate updates, address claims, credentialing and/or any other area for concern: >>Magellan Complete Care conducts JOC meetings on a monthly and quarterly basis with hospital systems, delegated subcontractors, vendors and multi-specialty provider groups as well as clinics, facilities and hi-volume practitioners. The joint operating meetings are cross- functional by design to incorporate representation from our Medical Directors, care coordination, utilization management, network development, provider relations, claims, quality improvement, compliance and legal. >>Each JOC meeting jointly addresses with the provider community, issues, concerns, and functional considerations as providers administer the Magellan Complete Care program to increase communication, provide transparency and accountability to providers and to establish rapport in future partnership initiatives. The following are specific areas of emphasis that our representatives address with providers: >>>Health Plan updates >>>Contracting/credentialing >>>Magellan policies and procedures >>>Network adequacy and contract compliance >>>Care coordination and patient access and care quality >>>Appeals/grievances >>>Claims under/over payment >>>Correct coding, fraud, waste, and abuse >>>Policies and procedures >>>Education and training on plan procedures, specialty population management, continuing education
2.0.e Provider Partnership Program to Engage Providers in Practice Facilitation As an example of our experience managing the provider network serving the SMI population in Florida, the Provider Partnership Program was developed to support providers across the
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network to enhance their continuum and service delivery model to focus on coordination and integration of care to support enrollees. The purpose of the Provider Partnership Program is to partner with valued providers that support an integrated model of care to increase the quality and access to care as well as promote a positive enrollee experience. The process involves understanding provider organizations, practices, and operations to be the best partner. Beginning with an observation that is tailored to reflect the uniqueness of a practice. Based on the observation, we collaboratively develop a practice plan to reflect your goals, strategies, and improvement efforts that drive forces to change.
Through the Provider Partnership Program, the Provider Support Specialists help providers identify clear targets and enact change through data informed strategies to improve the overall quality of enrollee care. Outcomes of the Provider Partnership Program include the following:
>Increased PCP utilization by tracking claims reports >Increased closed HEDIS gaps from last year enrollee’s gaps to 2016 enrollee’s gaps >Increased score for the “Coordination of Care” items on medical and behavioral health record reviews >Improved overall provider office workflows to be more seamless to promote the Triple Aim of Healthcare specific to Patient Satisfaction (e.g., reception areas recognizing potential PHI issues and addressing issues, making scheduling changes, and appointment setting to ensure patients are seen in a timely manner, cultural competency training from frontline staff medical practitioners to ensure patients receive courteous and caring treatment from initial encounter to appointment) >Several providers implemented changes within their practices to promote population health and expanded already established chronic conditions programs and care coordination to their pediatric population >Increased primary health care providers monitoring enrollee's behavioral health needs, increasing utilization of the screening tools PHQ-9 and SBIRT administered annually for all patients >Our Health Services team has been invited to participate in several interdisciplinary teams regarding ultra-high-risk and high-risk enrollees to facilitate the best care coordination.
2.0.f Provider Optimization Delivery System Our Provider Optimization Delivery System (PODS) team is at the core of our provider network management and relations activities in Florida. PODS provides a Provider Relations Team organized for each strategic region in the state. Each of the teams have a Contract Manager, Provider Relations Liaison and a Contract Network Coordinator for each region reporting to a Network Manager and then to a Vice President of Network Development. Additionally, each region has a Provider Support Specialist who is responsible for addressing the clinical and quality practice needs of the network. As licensed behavioral health clinicians and Registered Nurses, they bring value to the network through offering a host of practice transformation activities by employing principles of practice facilitation.
Each region has an assigned Provider Relations Manager who addresses the business and operational needs of the providers. The Provider Relations Manager’s focus on claims resolution, education around payment, authorizations, billing, and compliant resolution. We offer this approach because it provides the optimal structure to accentuate our existing medical and behavioral health provider knowledge-base, our existing knowledge of resources, community,
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The PODS model also shows our continued commitment to our high touch involvement with our providers to maximize plan operations and health care outcomes for our enrollees. To ensure Magellan Complete Care is providing the clinical support, the Provider Support Specialist team conducts onsite education such as: treating individuals living with serious mental illness, care coordination, psychopharmacology and much more. The Provider Support Specialist team also builds a connection between the Magellan Complete Care Care Coordination team and the providers to ensure communication and collaboration to support positive outcomes for enrollees.
2.0.g Provider Outreach, Engagement, and Communication Documented in Salesforce Platform Salesforce is a tool we us to help manage provider relationships and document statewide, regional, and individualized provider education, support, strategy, development/monitoring of projects, improvement plans, gap closures, practice management, and integration. This platform serves as a key connector enabling transparency, real-time support, and enhanced customer service. The Provider Support Specialist team also conducts onsite medical record reviews with providers in partnership with our quality department. This team arranges and plans the monthly regional meetings across the state with all departments. The Provider Support Specialist team documents all of the provider outreach, engagement, and communication on the Salesforce platform.
Salesforce is Magellan Complete Care's Provider Support Specialist and Community Outreach Specialist Team's Customer Relationship Management Platform. Salesforce is a cloud-based application used for the purpose of managing network providers, resources, and stakeholder relationships as well as the daily tasks of each team's preparation/planning/research, outreach/follow up and tracking/reporting data. We have tracked all interfaces with providers for the last two years (e.g., phone contacts, email messages, in-person meetings).
2.0.h Ongoing Provider Training Magellan Complete Care provides comprehensive training opportunities through the Magellan Learning Alliance to network providers within the scope of AHCA’s contract requirements and needs of the community for working with enrollees with SMI. We recognize that learning can take place in less formal environments. For this reason, we emphasize that our Field Network team attends to provider inquiries as they arise within their assigned regions. This dedicated approach provides a familiar face to the provider office and allows Magellan Complete Care to develop lasting, collaborative relationships with providers.
In the interest of creating a transparent and collaborative whole-health system of care, our provider training is also designed around interdisciplinary learning and community collaboration. Magellan Complete Care staff members, network providers, primary care network providers, enrollees, family members, system partners, and a multitude of valued stakeholders have the opportunity to participate in cross-disciplinary learning through ongoing training events. As a result, participants also learn from each other and training content becomes more culturally relevant for all stakeholders.
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In addition to providing online courses, instructor-led training sessions, customized technical assistance, and self-study alternatives, all providers are invited to quarterly training programs. These programs focus on specific areas of concern for the Magellan Complete Care team and also serve as refreshers on key items. Training is delivered in-person or facilitated through written or electronic communication. Depending on the content, invitations may only be extended to the relevant sub-group of the provider network. A summary of these training sessions is posted to our provider portal and our Provider Network team is always available to review the content with providers who are unable to attend. Participation in these training sessions is not mandatory.
Training includes both medical and behavioral health topics, managed Medicaid concepts and focuses on our philosophy of meeting all of an individual‘s needs across a comprehensive continuum of care whether medical, behavioral or social in nature. Themes of independent living, recovery and resiliency, person-centered planning, cultural competency, accessibility and accommodations, wellness and prevention principles, and trauma informed services are embedded throughout the training models. Some of the training topics include:
>HEDIS and Access to Preventative Care >Integration of Primary Care and Behavioral Health Care >Treatment for Individuals Living with Serious Mental Illness >Magellan Complete Care: Community Resource Guide >Substance Abuse Toolkit >Magellan Complete Care Peer Support Services >Specific trainings on: Bipolar Disorder, Schizophrenia, Major Depressive Disorder, Obsessive Compulsive Disorder >Suicide Prevention >Claims and Encounters >Provider Portal Tutorial and Refresher
All providers are requested to attend an annual refresher course to review updates to the Provider Handbook and any other key issues that are important for providers to know. Some annual trainings are initiated via written or electronic means. Our Provider Network team works to schedule ad hoc time with providers who are unable to attend. Additional training topics include: provider recognition initiatives, Incident management, cultural competency, compliance and fraud, waste, and abuse, and disaster recovery.
Magellan Complete Care understands the need to provide resources to the network about new and emerging best practices in healthcare. In 2015, to speak to this need, we offered access to the well-known Relias training platform to network providers as another access point to trainings. Once logged into the website, providers access Relias and the hundreds of training opportunities offered within the system. Providers also earn CEU’s as an additional benefit to fulfill their licensure requirements. The Provider Support Specialists educate the network on how to log on and provide a “What’s New in Relias” list to highlight valuable trainings they can obtain.
2.0.i Technical Support Tools via the Provider Website, Handbook, Bulletins, and Newsletters Network providers have access to technical support tools via our website, which includes Magellan Complete Care specialty plan-specific information regarding proposed policies,
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instructions, and guidelines. The administrative tools include ready information on submitting electronic transactions and a function to check and view claims.
The Provider Handbook, Provider Bulletins, and Provider Newsletters are all available for view or download from the website. We create and distribute Provider Bulletins to communicate procedures, reminders, and other information to our valued network providers and to alert all providers with critical information. The Bulletins are found on our website. An example of recent topics include: online resources and tools; a listing of Magellan Complete Care services during Hurricane Irma; FAQs about services during Hurricane Irma; update on the 2017 practitioner fee schedule; and balance billing. Our quarterly Provider Newsletter is designed to inform our provider community of new health services initiatives. It also includes friendly reminders and helpful tips, quality and HEDIS measures as well as other topics.
CRITERIA 3: THE EXTENT TO WHICH THE PROVIDER CAPACITY RATIOS PROPOSED… Magellan Complete Care maintains and contracts with a provider sufficient network that meets and exceeds network adequacy specific to the SMI population for number, provider type and related travel time and distance requirements for enrollees to access our providers as specified in this Contract. This will be done though the continuous monitoring of our provider recruitment using various tools, inclusive of Quest Analytics software. Specifically designed reports have been built to meet both the urban and rural county access standards to ensure Magellan Complete Care’s success in building a dense and diverse pool of providers to meet enrollee’s primary care and specialty care needs.
Magellan Complete Care’s network currently has more than 32,245 credentialed providers, yet we continually add providers based on the needs of our specialty population. It is our goal that enrollees choosing to participate in the Magellan Complete Care SMI Specialty Plan would take comfort in knowing that they have all their physical and behavioral health care needs available from in-network providers and/or single case agreements, as appropriate.
Magellan Complete Care has sufficient facilities, service locations, and practitioners to provide the covered services as required. In addition, we have the provider capacity to provide covered services to all enrollees, by region, as indicated in this Contract. We continue to broaden our network of health care practitioners, which include acute and primary, institutional, behavioral health, organizational, and specialty practitioners and professional practices to support the availability and timely access to health care services. Magellan Complete Care selects and approves its PCPs that practice in one of the following areas, including: general practice; family practice; pediatrics; obstetrics; and internal medicine.
We make sure that physicians with training and demonstrated experience in treating individuals diagnosed with SMI are enrollees of the provider network and can be designated as PCPs. We designate psychiatrists with training and demonstrated experience in primary care as PCPs.
3.0 Provider Capacity Ratios As the State’s current SMI Specialty Plan, we collaborated with AHCA on the type and appropriateness of provider to enrollee ratios; specifically to account for high acute care requirements of an SMI population. These ratios have become standard by which network adequacy and accessibility is adjusted for an SMI Specialty Plan.
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Since inception of the SMI Specialty Plan, we have carefully monitored and evaluated the effectiveness of the ratios in meeting the desired intention of ensuring access while removing barriers to care and gaps in the network of providers. We are currently meeting and exceeding the SMI Specialty Plan ratios in all of the Regions where we are serving enrollees. Having specified ratios for an SMI Specialty Plan network, is the right course of action to further deliver upon Magellan Complete Care’s practice of high touch care coordination for individuals with SMI.
Magellan Complete Care leveraged extensive experience, since 2013, with regional knowledge in how enrollees access their care to identify patterns of care to specifically guide how best to configure a network of facilities and multi-disciplinary practitioners. This experience has enabled Magellan Complete Care to more accurately arrange providers around regional variations, practitioner distinctions, and general access or availability barriers to make sure enrollees have the ability to obtain the health care services they need and the doctors they trust. With this experience in mind, we have identified additional provider specialties, which we propose for consideration, to modify the ratios as we did with the initial SMI ratios in the previous ITN in 2013. Doing so, more closely aligns the increased projection of the number of enrollees in the SMI Specialty Plan and the increasing demand by our enrollees accessing these specialists.
Magellan Complete Care continues to refine the ratio of primary care and specialty providers to enrollees as previously emphasized, through monitoring and oversight of network development and provider management activities. Therefore, the listed practitioners below more appropriately ensure that our enrollees can access the right care at the right time without delay under the proposed standards:
Proposed Povider: Allergy Measure: Practitioner to enrollees AHCA Standard: 1:20,000 Magellan Complete Care Proposed Standard: 1:12,000
Proposed Povider: Dermatology Measure: Practitioner to enrollees AHCA Standard: 1:7,900 Magellan Complete Care Proposed Standard: 1:3,500
Proposed Povider: Infectious disease Measure: Practitioner to enrollees AHCA Standard: 1:6,250 Magellan Complete Care Proposed Standard: 1:3,500
Proposed Povider: Orthpedic surgery Measure: Practitioner to enrollees AHCA Standard: 1:5,000 Magellan Complete Care Proposed Standard: 1:3,500
Proposed Povider: Otolaryngology Measure: Practitioner to enrollees
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AHCA Standard: 1:3,500 Magellan Complete Care Proposed Standard: 1:2,500
Proposed Povider: Podiatry Measure: Practitioner to enrollees AHCA Standard: 1:5,200 Magellan Complete Care Proposed Standard: 1:3,500
Proposed Povider: Therapist (respiratory) Measure: Practitioner to enrollees AHCA Standard: 1:1,500 Magellan Complete Care Proposed Standard: 1:1,250
Proposed Povider: Urology Measure: Practitioner to enrollees AHCA Standard: 1:10,000 Magellan Complete Care Proposed Standard: 1:7,500
Finally, Magellan Complete Care is closely monitoring enrollee accessibility to 24-hour pharmacies, home health providers, adult family care, and assisted living facilities for an approaching restriction to enrollee access to these type of facilities and practitioners. Our network contracting and oversight experience as the SMI Specialty Plan, has shown that unique patterns of care emerge. Therefore, we maintain continued vigilance to ensure we have contracted with every provider accepting Medicaid, and when necessary, will ensure, access through single case agreements (with practitioners who are not accepting Medicaid), contracting with providers in neighboring states, and increasing driver capacity for local non-emergency transportation.
3.1 Ensuring Adequacy of the SMI Specialty Plan Provider Network The initial and ongoing development of our provider network is anchored upon anticipated enrollment and the understanding of complex health acuity of enrollees accessing the provider panel. Health risk assessments, care coordination requirements, access capacity of providers to deliver care, and facts related to service sites, technology, and transportation all further direct how we configure our network. To anticipate enrollee utilization and care needs within a region, we use eligibility data, specific diagnosis patterns, enrollee surveys and feedback, as well as, industry and local demographic information to determine how enrollees access care and the established patterns used in gaining such access. We maximize the use of enrollee assignment data to further refine our network composition and to anticipate the demand for services to ensure accessibility.
Network managers monitor network adequacy on a weekly, monthly, and quarterly basis. The number, provider type, related travel time, and distance requirements are monitored using Quest Analytics software to detect where deficiencies may occur using specific ratios of provider to enrollee access for primary and pediatric care, for example (i.e., 1:1,500 for PCPs), which form accessible, and adequate numbers of facilities, locations, and providers needed to ensure and maintain requisite service levels.
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The list of contracted providers is maintained real-time and is loaded into the Quest Analytics database weekly. As deviancies are noted in the Quest Analytics’ reports, the Network Team deploys the regional Network Managers to actively recruit physicians to fill the gaps. Regional and local Network Managers also conduct weekly monitoring for overall network compliance with contract requirements, including enrollee accessibility and provider retention. Our Network Management staff evaluate geo-access reports each week to understand emerging changes in network composition to effect interventions to remain compliant.
To ensure our provider network is responsive to the needs of our enrollees, we conduct yearly access surveys of our SMI Specialty Plan network. We also use direct and secret shopper approaches as well as online survey tools for primary care, family planning, pediatric, obstetrics and gynecology, as needed. These mechanisms are leveraged to support the SMI Specialty Plan network and further facilitate providers accepting new patients, the quantity of appointment hours accessible for routine, urgent, and crisis appointments, and in-office wait times or other barriers to scheduling appointments.
Internally, we validate provider network capacity through claims data and utilization patterns such as measuring enrollee effective dates to service incurred date for receiving initial health care assessment or adherence to EPSDT schedule of services for pediatric enrollees. When we identify an accessibility issue, a focused review of provider performance is initiated by clinical reviewers or compliance auditors. The issues associated with limited access, constricted availability, enrollee complaints, quality of care or potential fraud, waste, and abuse trigger these reviews.
The findings from these reviews may lead to network interventions, including a Process Improvement Process (PIP), provider education, an increase in contracted providers, or an improvement in care coordination. We understand and employ mechanisms that fully acknowledge the importance of providing enrollees a choice of providers which are neither more than 30-minutes of travel time for practitioners in urban areas and a similar requirement for the number of providers to access that does not exceed more than 60-minutes of travel time in rural areas.
In considering the distance for an enrollee to travel to access a provider, we further understand the importance to provide enrollees with a choice of providers within no more than 15 miles of distance to travel to access a provider in urban areas and no more than 30 miles of travel distance in rural areas. We build our baseline network by assuming at least one enrollee in the center of each zip code by region and perform the required time and distance measurement for each covered specialty and service defined by the specific AHCA designated region. We incorporate our provider network and prospective membership data in the Quest Analytics tool and other Quality Assurance data assessment activities.
We continue to re-evaluate and assess our network composition and compliance with the required standards as enrollment projections are defined. If any deficiencies exist, we will consider approval of out-of-network providers and expanded resources in each region to ensure we meet time and distance standards. If a network gap is identified, which impacts enrollee care, the Care Coordination team works with the Network Team to identify an available provider. If a provider is not found through search of all participating providers, then the search is extended to out-of-network providers. Once an available provider is identified who is willing to
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In addition to our SMI specialty network, we have more than 4,000 non-traditional, community- based providers that complement our broad network. We have developed strong relationships with this non-traditional network over the last four years and have the ability to connect enrollees/family members/caregivers to the services and supports they need. Please refer to [Specialty SRC #05, Attachment 2: Provider Network Adequacy Standards for more information.]
CRITERIA 4: THE EXTENT TO WHICH THE PROVIDER REQUIREMENTS PROPOSED ARE RELEVANT… 4.0 Provider Requirements for Specialty Plan Network Adequacy Standards Magellan Complete Care selects and approves its PCPs that practice in one of the following areas: general practice, family practice, pediatrics, obstetricians, and internal medicine. We ensure that physicians with training and demonstrated experience in treating persons diagnosed with SMI are members of the provider network and are designated as PCPs. We also designate psychiatrists with training and demonstrated experience in primary care as PCPs. As mentioned above, when we identify an accessibility issue, a focused review of provider performance is initiated by clinical reviewers or compliance auditors. The issues associated with limited access, constricted availability, enrollee complaints, quality of care, or potential fraud, waste, and abuse trigger these reviews. The findings from these reviews may lead to network interventions, including, a PIP, provider education, an increase in contracted providers, or an improvement in care coordination. Magellan Complete Care monitors the regional standards for each measure as specified in the Managed Medical Assistance Provider Network Standards Table [Specialty Condition] Specialty Plan Enhancements in the ITN.
Magellan Complete Care continually monitors adherence to the following provider requirements relevant to the SMI Specialty Plan network:
>Provider network adequacy >Network development and management plan >Provider credentialing and recredentialing >Provider agreements >Provider services >Provider payment and claims
4.1 Provider Requirements in the Network Development and Management Plan Magellan Complete Care’s annual Network Development and Management Plan includes processes to develop, maintain, and monitor an appropriate provider network that is sufficient to provide adequate access to all services covered under this Contract. Network staff collaborate with the quality department and the Quality Director to develop an annual provider monitoring plan, which addresses provider accessibility and availability to required health care services.
These processes and policies include but are not limited to:
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>Provider Accessibility Standards >Provider Credentialing and Re-credentialing >Complaints and Grievances / Quality issues monitoring process >Network Changes >Provider Network Standards >Provider Compliance >Provider Network Participation and Appeals >Provider Termination and Continuity of Care >Cultural Competency Plan.
We systematically track and score provider complaints, grievances and quality issues – providers who reach certain thresholds are reviewed by the health plan Chief Medical Officer and may require peer review through the credentialing committee. Magellan Complete Care addresses the availability and accessibility of psychiatrists and other specialty providers relevant to the specialty population in its annual network plan submitted to AHCA in accordance with Attachment II and its Exhibits. [Specialty SRC #05, Attachment 3: Network Development and Management Plan] is provided for more detail.
4.2 Provider Requirements for Credentialing and Recredentialing Credentialing providers is a core component of network development. The recruitment, selection, retention, and training of quality providers ultimately leads to the best outcome-driven network serving our enrollees. Magellan Complete Care offers enrollees choice through a diverse network and a broad spectrum of provider specialties for both behavioral and physical health to support individuals with SMI.
Magellan Complete Care currently has more than 32,245 credentialed network providers serving approximately 70,000 SMI Specialty Plan enrollees in 66,975 locations. In addition to the credentialed network providers, Magellan Complete Care also provides additional support through community engagement offering an online community resource guide to share the information of more than 4,000 non-traditional providers available as support resources across the state. We require formal training or verification of completed training for network providers in the use of behavioral health assessment tools, assessment instruments and in techniques for identifying individuals with unmet behavioral health needs, evidence based practice and the principles of recovery and resiliency.
The Credentialing team performs all required verifications in alignment with NCQA and AHCA standards. In cases where information needed to complete the credentialing review is missing, the Credentialing Operations team outreaches directly to the provider with guidance as to what is missing and instructions for proper submission. Upon completion of credentialing and validation of all other contractual requirements, the executed provider agreement is returned to the provider along with a Welcome Letter officially welcoming the provider to the network and offering additional information on available resources. Magellan Complete Care recredentials providers at least every three years.
4.3 Provider Requirements in Provider Contracts/Agreements Magellan Complete Care includes all relevant contractual provisions in its provider agreements. Upon completion of credentialing and validation of all other contractual requirements, the
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executed provider agreement is returned to the provider. Magellan Complete Care continually monitors all Provider Contract/Agreements to ensure compliance adherence. Upon notification from AHCA of any contractual changes or updates required, Magellan will reach out to all applicable providers to complete all necessary updates and or changes using the appropriate documentation and/or Contract /Agreement Amendment necessary to meet all regulatory requirements.
4.4 Provider Requirements for Provider Services 4.4.a Provider Handbook Requirements Magellan Complete Care includes specialty plan-specific information regarding proposed policies and procedures in the Provider Handbook, which includes information such as specialized provider education requirements; requirements for care in accordance with the most recent clinical practice guidelines for psychiatric, mental health, and substance abuse treatment; treatment adherence services available from Magellan Complete Care; PCP criteria including procedures for required use of approved assessment instruments for mental health and substance abuse; specialist case management policies and procedures including role of the provider in Magellan Complete Care’s medical case management/care coordination services; referral to services including services outside of Magellan Complete Care’s covered services and services provided through interagency agreements; and quality measurement standards for providers and requirements for exchange of data.
In addition, Magellan Complete Care includes the following information in its Provider Handbook:
>Magellan Complete Care Model of Care >Contact numbers >Enrollee eligibility >PCP responsibilities >Provider responsibilities >Risk management and adverse/critical incident reporting >Fraud, waste, and abuse responsibilities >Presence on federal and state exclusions lists >Cultural competency plan >Enrollee rights and responsibilities >Provider complains >Enrollee grievance and appeals >Medical management, including procedures to obtain authorization of any medically necessary services >Covered Services including the Child Health Check-Up Program (CHCUP) Services and Standards, and use of telemedicine, waived copayment and fees, or similar charges on Indians served by an Indian health care provider, Indian Health Service, an Indian Tribe, Tribal Organization, an Urban Indian Organization, or through a referral under contract for health services >Covered pharmacy services >Care and disease management programs >Quality benefit enhancement programs >Enrollee rewards program >Continuity of Care procedures upon provider terminations
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>Medical records standards >Other insurance information >Health care directives >Helpful forms
Initial and ongoing updates of the Provider Handbook are reviewed by subject matter experts and by the Compliance Department to ensure that any edits assist the providers’ education and are in compliance with contractual requirements. The 2017 Provider Handbook of Magellan Complete Care of Florida can be viewed or printed from our website within the provider tab. The Handbook supplies information and guidance to providers who participate in our network.
The Handbook contains our policies, instructions, and guidelines to enable providers to : >Know which services are provided and covered for eligible beneficiaries >Submit proper billings for services rendered >Make inquiries to the proper source when it is necessary to obtain clarification Magellan Complete Care offers a Provider Handbook via the website available to view or download. [Specialty SRC #05, Attachment 4: Magellan Complete Care Provider Handbook] contains the cover and table of contents of our current handbook.
4.4.b Provider Education Requirements Magellan Complete Care has already developed and implemented an online learning system called the Magellan Learning Alliance, that provides ongoing education with continuing education (medical and non-medical) to network providers, at no cost to such providers, on topics including, but not limited to, evidence-based practice, and the principles of recovery and resiliency. Magellan Complete Care employs a multi-faceted education effort delivered through network staff by conducting site visits, orientations, provider and staff trainings, access to provider portals and online tools, resources and related media forms to provide comprehensive learning opportunities to providers serving enrollees with SMI.
As a managed Medicaid specialty plan for the comprehensive care of enrollees with SMI, Magellan Complete Care uses multi-dimensional emphasis to aid us in holistically caring for this fragile population while simultaneously affecting the disproportionate illness burden they face. Magellan Complete Care conducts comprehensive training of our network providers initially upon completion of all contracting activities (generally within 30 days) and then periodically throughout the tenure of the provider agreement. This ensures that Magellan Complete Care‘s high quality standards are met and early involvement of care initiatives by providers and facilities are satisfied.
Magellan Complete Care network providers also have a dedicated web portal with customized information based on the requirements of AHCA. Providers receive training on billing requirements and limitations through in-person sessions, newsletters, provider manuals, remittance advices, authorization requirements, etc. As part of our quality management; complaints, grievances, and appeals; and compliance processes, we regularly monitor results for any potential patterns that may suggest a lack of understanding on the part of a provider, or fraud, waste and abuse. If such a pattern is detected, interventions may include face-to-face
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4.4.c Provider Payment and Claims Requirements Magellan Complete Care Network staff work with providers and their staff to understand the provider payment and claims requirements in accordance with F.S. 641.3155. Magellan Complete Care network providers agree to submit, whether by mail or electronic transfers, all itemized claims for reimbursement within six months after the following have occurred, whichever is later:
>The date the Covered Services were rendered >The provider has been furnished with the correct name and address of Magellan Complete Care.
Network providers will not duplicate a claim previously submitted unless determined that the original claim was not received or lost. All claims for payment, whether electronic or non- electronic, must be mailed or electronically transferred to any secondary insurer within 90 days after final determination by the primary insurer. A provider's claim is considered submitted on the date it is electronically transferred or mailed.
4.4.d Value Based Payment Methods With respect to provider contracting, education, and training, Magellan Complete Care is emphasizing practice transformation with participating providers. We recognize that our SMI Specialty Plan providers are reimbursed under a fee-for-service payment method; however, practice and provider transformation includes use of advanced expanding payment models such as, pay for reporting, payment for meeting certain metrics and benchmarks, or in managing patient care in more effective and efficient means.
We understand through our experience with the SMI Specialty Plan that fee-for-service may at times impede the provision of individualized and highly coordinated care. We believe that effective specialty population management can be enhanced through adoption of value-based payments that may enable providers to develop more innovative approaches to person-centered health care delivery Magellan Complete Care rewards providers that successfully manage all or much of an individual’s care. We know that new payment models may mean providers will make fundamental changes in the way they provide care or consider how such care is reimbursed. Therefore, the Magellan Complete Care Network team identifies and engages with providers who are accustomed to advanced payment methods and who are interested in advancing change to better serve their patients and our enrollees.
Magellan Complete Care will continue to discuss system transformation to reconfigure payments to incentivize value and ensure that activities (e.g., care coordination) are compensated appropriately to optimize the provision of care focused on enrollee needs.
CRITERIA 5: THE EXTENT TO WHICH THE ADDITIONAL PROVIDER SERVICES PROPOSED ARE RELEVANT… Magellan Complete Care has and will continue to offer supportive provider services that enhance provider knowledge and expertise to serve the SMI specialty population. Our Network
AHCA ITN 009-17/18, Attachment A, Exhibit A-4-d, Page 93 of 100 EXHIBIT A-4-d SPECIALTY SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA and Provider Support Specialist teams focus on educating providers on benefits, services, and policies and procedures, which supports access and continuity of care for enrollees. In addition to the standard network support mechanisms, Magellan Complete Care focuses on delivering resources and value that enhances the provider’s ability to serve our enrollees, improve outcomes, and improve the enrollee experience.
This is achieved through the use of three primary vehicles:
1. Practice Facilitation We leverage our unique Provider Support Specialist team to engage and develop close working partnerships with key network providers. The Provider Support Specialist team is trained and educated on the principles of practice facilitation to support practice improvement and transformation activities through the network and across the state. In 2015, Magellan Complete Care developed the Provider Partnership Program to engage and support practice growth and movement towards adopting an integrated model of care to better support the enrollees needs. The purpose of the Provider Partnership Program is to partner with valued providers that support an integrated model of care to increase quality and access to care as well as promote a positive enrollee experience.
The process involves understanding provider organizations, practices, and operations to be the best partner. We begin with an observation that is tailored to reflect the uniqueness of a practice. Based on this observation, Magellan Complete Care and the provider collaboratively develop a practice plan to reflect the provider’s goals, strategies, and improvement efforts that drive meaningful change. Some outcomes of the Provider Partnership Program include: increased PCP utilization; increased closed HEDIS gaps from last year enrollee’s gaps to 2016 enrollee’s gaps; increased use of the PHQ-9 BH screening tool; improved score for the ‘Coordination of Care’ items on medical and behavioral health record reviews; implemented changes within their practices to promote population health; and expanded already established chronic conditions programs and care coordination to their pediatric population.
2. On-site training We provide on-site, regional specific, clinical support to the provider network via the Provider Support Specialist team. There is one Prover Support Specialist in each region who has a behavioral health clinical background (either a licensed behavioral health clinician or an RN with behavioral health experience). Over the past four years, we have educated the network on our membership, including understanding and addressing their unique needs, and provided creative solutions on how to best manage and coordinate care for complex populations, including training on the following:
>Holistic health for individuals living with SMI >Psychopharmacology Education >Stigma Awareness and Reduction >HEDIS and Access to Preventative Care >Integration of Primary Care and Behavioral Health Care >Magellan Complete Care: Community Resource Guide >Substance Abuse Toolkit >Magellan Complete Care Peer Support Services
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>Specific trainings on: Bipolar Disorder, Schizophrenia, Major Depressive Disorder, Obsessive Compulsive Disorder >Suicide Prevention >Care Coordination
Additionally the Provider Support Specialist team created an online substance abuse toolkit to respond to the network need for education on substance abuse diagnosis and treatment. This is a critical resource to ensure providers are identifying emerging substance abuse needs of the enrollees and also referring them to services and supports. For examples of educational handouts, please refer to [Specialty SRC #05, Attachment 5: Educational Handout Examples] which includes: Holistic Care for SMI, Myths and the Truth Fighting Bad Attitudes about Mental Illness, Suicide Education – Spanish, and Depression Education – Spanish.
3. Healthcare Integration As the only SMI-focused integrated health plan, we have adopted behavioral health integration as a leading priority. The Provider Support Specialist team connects behavioral health and PCP providers statewide to improve quality of care and increase collaboration across provider types. We understand that integration of care is a continuous process that takes support at all levels of the healthcare system.
The Provider Support Specialist team established meaningful connections between behavioral health and PCP providers statewide to highlight this movement and ensure the appropriate education, connection, and resources are available to guide the network in this direction. In addition to our response in Evaluation Criterion #2 above, we provide additional provider services to enhance and support the coordination of care between and satisfaction of providers caring for the unique needs of our enrollees, including the following:
>Supporting network providers through an enrollee-centered team approach >Supporting network providers through our online community resource guide >Supporting network providers through CMHC Initiatives >Supporting network providers through preventive care gap communications.
5.1 Supporting Network Providers through an Enrollee-centered Team Approach Magellan Complete Care has created an enrollee-centered team approach connected to innovative models of care delivery and care integration that support our provider network including primary behavioral health providers, primary medical providers, as well as our enrollees. Through our Integrated Health Neighborhood structure our Provider Relations, Health Guides, Wellness Specialists, Provider Support Specialists, Integrated Care Case Managers, Peer Support Specialist, and Community Outreach Specialists available to work with providers.
Our Integrated Health Neighborhood approach delivers an integrated, high touch, community based model organized for each strategic region. The approach fosters healthcare integration at the systems and services level by ensuring superior collaboration and communication with all providers across the continuum of care. Our strategy allows us to successfully communicate with providers, with a minimum of 30 days notice, whenever there are programmatic changes.
Magellan Complete Care sees the value in embedding teams in the communities in which they work and our enrollees reside. As a result, our team based approach is locally-rooted and
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supported through Integrated Health Neighborhoods. Our teams live in the regions in which they work throughout the state giving them a true understanding of the resources, needs, and challenges in those communities to develop unique solutions that fit the local market.
The teams are closely familiar with the providers, facilities, and resources in the neighborhoods to allow quick and seamless access to services for our enrollees. The Provider Support Specialist teams are able to connect the network providers to the local care coordination teams. This connection point has helped enrollee’s access preventative care, improve transitions of care and discharge planning, and assistance to understand the enrollee’s individual needs and recovery goals. Our Provider Relations team frequently communicates with our provider network to ensure providers are continuing to meet the needs of enrollees, to meet our general quality standards, and to provide specialty services to our enrollees with SMI.
Network contracting staff and Provider Relations Managers are located in the service regions throughout the state, which allows Magellan Complete Care to manage both provider networks and care delivery at the local level.
5.1.b Supporting Network Providers through our Online Community Resource Guide Magellan Complete Care also provides additional support through community engagement. We offer an online community resource guide to share available support resources across the state. The goal is to connect health care providers with community-based support resources in high need neighborhoods to increase enrollee access and support and to foster collaboration. We have more than 4,000 non-traditional community-based providers in place complementing our comprehensive provider network. We have developed strong relationships with this non- traditional network over the last four years and have the ability to assist enrollees/family members/caregivers to access services and the supports they need.
With over 30 specialized types of community resources listed statewide, we help providers, enrollees, and the communities at large to understand the resources they have in their neighborhoods. Additionally, the Magellan Complete Care Community Outreach Specialist team has worked to develop working partnerships with these resources. This allows Magellan Complete Care the ability to have solid connection points and pathways for our enrollees to access the services they need when they need them.
5.1.c Supporting Network Providers through Community Mental Health Center Initiatives Magellan Complete Care has a comprehensive approach of care initiatives with the Community Mental Health Centers (CMHC) aimed at coordinating care for our enrollees. We recognize that many of our enrollees seek services at the CMHCs. As a result, we have launched the development of Integrated Health Homes with CMHC partnerships statewide. Through a close collaboration with the Florida Council for Community Mental Health, Magellan Complete Care launched the first statewide Integrated Health Home initiative in Florida. We leveraged our years of experience and successes implementing Integrated Health Homes in other states to inform and drive the Florida strategy.
As part of the planning and development process, we met with Florida Council for Community Mental Health members statewide to understand their current capabilities and capacity to adopt an Integrated Health Home structure, ability to include Primary Care into their enrollee coordination and care management processes, and overall feedback on how to improve the
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current system of care to achieve better health and wellness outcomes for enrollees. The CMHCs provided valuable insight and guidance which helped to shape the development and eventual implementation of the Integrated Health Home program. Key tenants which drove the focus of this program included:
>Providing integrated care based on the unique needs of enrollees >Empowering the CMHCs to deliver creative, person-centered care by reducing the administrative burden and developing a reimbursement structure that supports each enrollee’s unique care needs >Driving quality through focus on outcomes metrics and performance guarantees.
We also leveraged CMHC relationships to:
>Develop direct contracts with CMHC’s to provide transportation for our enrollees allowing CMHCs to bill us directly for transportation services >Address follow-up after hospitalization needs through increased access and telehealth (Road- to-Recovery) >Address the most complex enrollees’ needs through the Integrated Behavioral Health Program (IBHP) Pilot program in Miami-Dade County. Implement the Peer Support Specialist incentive program, working with CMHC’s statewide to build capacity for peer support services.
Finally, during the past three years, we provided technical assistance to providers by: (1) creating an implementation plan to address all operational, business and clinical needs by ensuring organizations are ready to support an increase in peer support workforce, (2) providing trainings to their staff, (3) providing trainings for peer support specialists, and (4) creating an enhanced reimbursement rate to ensure adequate payment for this valuable service.
5.1.d Supporting Network Providers through Preventive Care Gap Communications We support our network providers with preventive care gap information. Our efforts are related to the fact that the SMI population is low utilizing in terms of their preventive care. For this reason, we have made significant efforts to engage our providers in helping enrollees to access needed services. In 2016, we facilitated multiple methods to give our providers care gap information. For example: we delivered reports to the top 85 provider groups with gaps in care noted for their patient panel which represented 90 percent of the care gaps, an dmended gaps in care to provider rosters online.
In addition to the online access to gaps in care, the Provider Support Specialist team conducted more than 900 on-site provider technical assistance meetings to support HEDIS outreach and gap closure during the fourth quarter of 2016. They provided coding guidance, education on the incentive program, and acted as a liaison between the providers and the Magellan Complete Care Quality Team to address any questions or concerns. 2017 will see the addition of provider- level performance reports on HEDIS.
In terms of assisting providers to encourage enrollees to schedule and keep their appointments, we provide the following examples:
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>We make multiple efforts to schedule appointments for our enrollees through three-way and reminder calls, and by confirming, attending and reschuelding appointment as necessary >We attempted Clinic Day events (e.g., blocks of time reserved for our enrollees) >We are developing a provider incentive program that will compensate providers for preventive office visits, as well as the specific tests/screenings to support CHCUP which is a big focus area for AHCA.
As an example of a provider preventive care gap communication, please see [Specialty SRC #05, Attachment 6: Provider Bulletin - MMA Physician Incentive Program for Board Certified Pediatricians and OB/GYNs].
5.1.e Supporting Network Providers through Carved Out Services Magellan Complete Care ensures that SMI Specialty Plan enrollees have a seamless and easy- to-navigate system for coordinating carved out services. All necessary services are included in the enrollee’s care plan regardless if they are carved out or not. Our fully integrated model of care – the Integrated Health Neighborhood approach – is a conduit for any caregiver within the Integrated Health Neighborhood to convey and ask for Magellan Complete Care resolution in the need of care for an enrollee. If a service need is identified (covered and non-covered), our Health Services staff coordinate with service providers and community organizations to meet the needs of the enrollee.
Reciprocal coordination with all care providers, including carved-out services, is critical in addressing enrollee needs. Through reciprocal communication, we now have the ability to identify the full continuum of care needs for the enrollee and coordinate their care as documented in their care plan. Magellan Complete Care employs extensive internal resources to support the enrollee’s continuum of care needs as identified during new enrollee engagement or as the enrollee engages in care, such as through physical and behavioral health care services, ED, inpatient, and outpatient services.
Internal resources include, but are not limited to Integrated Care Case Management (ICCM), Health Guides, Peer Recovery Navigators, and our enrollee and provider call center. All of our employee resources are trained to have knowledge to connect supports within the Integrated Health Neighborhood, including carved-out services. Our role is to coordinate the referral for needed continuum of care services, including carved-out services, along with the reciprocal care needs.
Once the referrals are made, and the enrollee is engaged with all service providers to support the care plan, our Care Coordination staff monitors enrollee progress through periodic contact with the enrollee and provider. ICCM procedures address facilitation of enrollee referrals to resources and follow-up processes to determine whether enrollees act on referrals. Magellan Complete Care is in the process of establishing a solution for an enrollee-centric coordination of all Integrated Health Neighborhood care and support resources through a sophisticated software solution that would allow coordination and exchange of the full continuum of care, which extends well beyond a referral mechanism.
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Evaluation Criteria:
1. The extent of experience (e.g., number of Contracts, enrollees or years) managing a provider network serving the proposed population(s).
2. The extent to which the described experience demonstrates the ability to manage a provider network relevant to the specialty population(s) proposed.
3. The extent to which the provider capacity ratios proposed ensure the adequacy of a provider network relevant to the specialty population(s) proposed.
4. The extent to which the provider requirements proposed are relevant to the provider network serving the specialty population(s) proposed.
5. The extent to which the additional provider services proposed are relevant to the provider network serving the specialty population(s) proposed.
Score: This section is worth a maximum of 25 raw points with each of the above components being worth a maximum of 5 points each.
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F. OVERSIGHT AND ACCOUNTABILITY
No SRCs in this Category for Specialty.
G. STATUTORY REQUIREMENTS
No SRCs in this Category for Specialty.
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