An Act To Implement Managed Care in the MaineCare Program
Sec. 1. 22 MRSA §3174-WW is enacted to read:
§ 3174-WW. Patient-centered MaineCare reform
(1) Accreditation by a nationally recognized accrediting body;
(2) Documented policies and procedures for preventing fraud and abuse;
(3) Experience in serving enrollees and achieving quality standards;
(4) Availability and accessibility of primary and specialty care physicians in the relevant network;
(5) Provision of additional benefits, particularly dental care and disease management, and other initiatives that improve health outcomes; and
(6) The existence of an established presence in the State, or a commitment to establish a presence in the State.
(1) Compensation for physicians for coordination of care, management of chronic disease and avoidance of the need for more costly services;
(2) Compensation for hospitals that reflects mutually acceptable rates, methods and terms of payment and that is not lower than similar fee-for-service rates paid by the department;
(3) Access standards that are specific, population-based standards for the number, type and regional distribution of providers in managed care plan networks to ensure access to care for both adults and children. The standards must allow the managed care plans to limit the providers in their networks based on credentials, quality indicators and price;
(4) An accurate and complete electronic database, available on the publicly accessible website of the managed care plan, of contracted providers, including information about licensure or registration, locations and hours of operation and specialty credentials and other certifications that allows comparison of providers to network adequacy standards and that accepts and displays feedback from patients;
(5) A prescribed drug formulary or preferred drug list available on the publicly accessible website of the managed care plan in a manner that is accessible to and searchable by members and providers. The requirements must require the managed care plan to update the list within 24 hours after making a change and to ensure that the prior authorization process for prescribed drugs is readily accessible to providers, including posting appropriate contact information on the publicly accessible website and providing timely responses to providers;
(6) An encounter data system to collect, process, store and report on covered services provided to all MaineCare members enrolled in prepaid plans;
(7) Specific performance standards and benchmarks or timelines for improving performance over the term of the contract.
(a) A managed care plan shall establish an internal health care quality improvement system, including enrollee satisfaction and disenrollment surveys. The quality improvement system must include incentives and disincentives for network providers.
(b) A managed care plan shall collect and report health plan employer data and information set measures as specified by the department. These measures must be published on the publicly accessible website of the managed care plan in a manner that allows members to reliably compare the performance of plans. The department shall use the measures as a tool to monitor plan performance.
(c) A managed care plan must be accredited by a nationally recognized accrediting body, or have initiated the accreditation process, within one year after the contract with the department is executed;
(8) A managed care plan to establish program integrity functions and activities to reduce the incidence of fraud and abuse, including, at a minimum, a provider credentialing system and ongoing provider monitoring, procedures for reporting instances of fraud and abuse and designation of a program integrity compliance officer;
(9) A managed care plan to establish an internal process for reviewing and responding to grievances from enrollees and submit quarterly reports including the number, description and outcome of grievances filed by enrollees. The grievance procedure must meet the requirements of the department;
(10) A managed care plan to comply with the requirements of the department for enrollment reduction and withdrawal and for reporting encounter data. Failure to meet the requirement of this subparagraph must result in penalties or termination of a regional contract; and
(11) A managed care plan and the plan's fiscal agent or intermediary to comply with the prompt payment requirements of Title 24-A.
Sec. 2. Stakeholder group. No later than October 1, 2013, the Department of Health and Human Services shall convene a patient-centered MaineCare reform stakeholder group to provide input on the implementation of the Maine Revised Statutes, Title 22, section 3174-WW. The department shall invite the participation of providers, patients, managed care providers and Legislators.
Sec. 3. Federal approval; contingent effective date. The Department of Health and Human Services shall seek approval from the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services of a Medicaid state plan amendment under the United States Social Security Act, Section 1932(a) to require MaineCare members with access to employer-sponsored health care coverage to enroll in that coverage and use MaineCare financial assistance to pay for the member's share of the cost for such coverage. The amount of financial assistance provided for each member may not exceed the amount of the MaineCare premium that would have been paid to a managed care plan for that member. The provisions of the Maine Revised Statutes, Title 22, section 3174-WW, subsection 7, paragraph E take effect upon notification from the Department of Health and Human Services to the Revisor of Statutes that approval under this section has been granted.
Sec. 4. Selection of managed care plans. The department shall issue a request for proposals no later than October 1, 2013 to select managed care plans pursuant to the Maine Revised Statutes, Title 22, section 3174-WW, subsection 4. By January 1, 2014, the department shall begin implementation of the statewide managed care program, with full implementation in all regions and all populations by July 1, 2014. Beginning July 1, 2015, at least 2 of the managed care plans must also include all long-term care and home-based and community-based services for those MaineCare populations eligible for those services.
Sec. 5. State plan amendment and waivers; contingent effective date. By November 1, 2013, the Department of Health and Human Services shall apply to the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services for approval of a state plan amendment under the United States Social Security Act, Section 1932(a) to implement the provisions of this Act and for all necessary waivers. The provisions of this Act take effect upon notification from the Department of Health and Human Services to the Revisor of Statutes that all necessary approvals under this section have been granted.
This bill establishes managed care in the MaineCare program. The bill includes requirements for managed care plans and for contracting by the Department of Health and Human Services for managed care services. The bill specifies how MaineCare members enroll in managed care plans. The bill requires the Department of Health and Human Services to apply for approval of a Medicaid state plan amendment to allow use of MaineCare funds to purchase available employer-sponsored health coverage and delays implementation of that provision until approval has been granted.