2017-2018 Medicaid Managed Care Budget Carve-Out Provisions
HPA SUPPORTS THE SENATE PROVISIONS THAT CARVE-OUT THE NURSING HOME TRANSITION DIVERSION (NHTD)/TRAUMATIC BRAIN INJURY (TBI) TRANSITION
HPA has significant apprehensions that spreading a relatively small (fewer than 6,000 individuals), but geographically dispersed population with high needs across more than three dozen plans is not an effective way to provide the highest quality and most cost effective care to this population. Plans are likely to incur high costs developing adequate provider networks and care coordination structures, and hiring appropriately trained and qualified staff to help manage the needs of what is likely to be a very small number of people for each plan. HPA believes this population will be better served through continuation of existing waiver programs. The NHTD/TBI waiver services are currently scheduled to be implemented April 1, 2018.
HPA SUPPORTS THE SENATE AND ASSEMBLY PROVISIONS THAT CARVE– OUT THE SCHOOL BASED HEALTH CENTER TRANSITION
HPA also has concerns regarding the school based health center services (SBHC) being transitioned into the Medicaid Managed Care (MMC) benefit package. Discussions between the Department of Health (DOH), SBHC providers, SBHC sponsors and health plans have been occurring for several years and substantial issues remain. The unique relationship between SBHC providers and their sponsors create significant administrative burdens when contracting with MMC plans. For example, issues regarding claiming/billing, credentialing, and, ultimately, contracting remain to be resolved. Based on the open issues that all parties are having difficulty addressing and the significant administrative burden for both providers and plans, we support the Legislature’s carve out of SBHCs from the MMC benefit package. The SBHC transition is currently scheduled for July 1, 2017.
HPA SUPPORTS CARVE-OUT OF CLOTTING FACTOR DRUGS
The 2017-18 state budget should also include a carve-out of the hemophilia clotting factor drugs from the MMC pharmacy benefit to preclude DOH’s plan to transition these drugs to MMC. DOH has identified approximately two hundred individuals who are currently taking clotting factor drugs that account for $61 million in Medicaid dollars. Plans are not alone in their concerns. Patient advocates have also questioned the approach DOH has laid out for carving in these drugs. HPA is concerned that the structure DOH has selected, fails to insure adequate reimbursement of day-to-day costs together with extraordinary episodes that may run into costs over a million dollars per enrollee. HPA supports the continuation of the carve-out from the MMC pharmacy benefit package. The clotting factor drug carve- in is scheduled to be implemented July 1, 2017.