Brief Issue Description
This best practice document outlines the challenges states have faced when reporting the types of managed care plans in the T‐MSIS Managed Care file record segment MANAGED‐CARE‐MAIN‐MCR00002 using the data element MANAGED‐CARE‐PLAN‐TYPE (MCR024). States should use this record segment to report all managed care plans authorized to operate in the state, a requirement that varies slightly from the way MANAGED‐CAREPLAN‐TYPE (ELG193) in the Eligible file reports any managed care plans in which a beneficiary is enrolled.
Background Discussion
Context
When Medicaid beneficiaries are enrolled in one or more managed care plans, a record segment should be reported in the T‐MSIS Eligible file to capture each enrollment. The state should create as many MANAGEDCARE‐PARTICIPATION‐ELG00014 record segments as necessary to describe a beneficiary's relationship with managed care entities. Although MANAGED‐CARE‐PLAN‐TYPE is a legacy MSIS data element, states should take care when populating the data element since the number of managed care plan types that states can report has expanded in T‐MSIS, and the former category of behavioral health organization (BHO) is now split out into multiple plan types. CMS performs edits to validate that the managed care plan type reported on the Eligible file matches the managed care plan type value reported on the Managed Care file. In addition, checks will be performed to confirm that the managed care capitation payment type of service values and managed care encounter types of service reporting are consistent with the managed care plan type.
Challenge
The healthcare market is constantly changing, and the coverage plans offered by insurers can sometimes be difficult to categorize. With the edited list of MANAGED‐CARE‐PLAN‐TYPE values in T‐MSIS, states need to ensure that they understand the differences between each of these new codes. In some instances, a plan type might embody characteristics from multiple plan types. This raises questions such as how does a traditional primary care case management (PCCM) plan (MANAGED‐CARE‐PLAN‐TYPE code = '02') differ from an enhanced PCCM (code = '03'), and what is the correct plan type to use when reporting a plan that is both an managed care organization (MCO) and an accountable care organization (ACO). States also need to ensure that the plan type value assigned to a given plan on the Managed Care file and the Eligible is consistent across both of these files for each plan.
As part of the Managed Care file, states need to review the OPERATING‐AUTHORITY data element in the MANAGED‐CARE‐OPERATING‐AUTHORITY‐MCR00005 record segment so that it captures the expected type of authority through which an associated managed care entity receives its contract authority. The REIMBURSEMENT‐ARRANGEMENT data element in the MANAGED‐CARE‐MAIN‐MCR00002 record segment also has expected reporting mapping patterns to classify the contracted arrangement between a state Medicaid agency and a managed care organization.
CMS Guidance
Reporting MANAGED‐CARE‐PLAN‐TYPE
States need to know the characteristics of their managed care plans to understand the correct managed care plan type assignment. To determine whether a plan is a traditional PCCM (MANAGED‐CARE‐PLAN‐TYPE code = 02) or an enhanced PCCM (code = '03'), states need to examine the benefits provided. CMS has provided guidance to states on how to determine if a PCCM program is an enhanced. Enhancements can include new features, such as more intense case management or care coordination, specializing staff to coordinate the benefit management, and other additional resources that are devoted to beneficiaries. They might also include improved financial incentives for primary care physicians for meeting specified performance measurement goals.
States are increasingly creating programs to manage and coordinate care that layer newer forms of care management and coordination, such as ACOs, on top of traditional types of managed care which are defined in federal regulations (42 CFR 438), such as comprehensive MCOs. In these situations, states should report the traditional managed care category as the managed care entity's plan type.
- Federal managed care regulations define managed care plan types of MCOs (including both comprehensive MCOs, MANAGED‐CARE‐PLAN‐TYPE code = '01', and health insuring organizations, code = '04'), prepaid inpatient health plans (PIHPs) (codes = '05, 07, 08, 10, or 12', PAHPs (codes = '06, 09, 11, 13, 14, 15, 16, 18'), and PCCMs (codes = '02 and 03').
- Federal regulation do not define the following plan types: accountable care organizations (code = 60), health/medical homes (70), and integrated care for dual eligibles (80).
These examples describe how to report plan type when multiple codes apply:
- Example one The state has a program that layers an ACO on top of comprehensive MCOs. The state is unsure what plan type to report for managed care entities enrolling people through this program.
- Plan Type Reported‐Comprehensive MCO (code=01) is defined in federal regulations, while ACO (code=60) is not. The state should report the plans as comprehensive MCOs (code=01).
- Example two The state is utilizing PCCMs to provide integrated care to dual eligibles.
- Plan Type Reported –PCCMs (code =02) are defined in federal regulations, while integrated care to dual eligibles (code = 80) is not. The state should report the plans as PCCMs.
Reporting for health homes programs occurs both under the MANAGED‐CARE‐PLAN‐TYPE variable, and through a series of health home specific variables in the Eligible file (HEALTH‐HOME‐SPA‐NAME, HEALTH‐HOME‐ENTITYNAME, HEALTH‐HOME‐SPA‐PARTICIPATION‐EFF‐DATE, HEALTH‐HOME‐SPA‐PARTICIPATION‐END‐DATE, HEALTHHOME‐ENTITY‐EFF‐DATE). When states are running a health home program that is part of a traditional managed care program, they should still report the managed care entity's plan type based on the plan type defined in regulations. For example, if a state is running a health home program that is part of a comprehensive MCO program, the state should report the plan type as comprehensive MCO and should report individuals enrolled in the plans as health home enrollees in the Eligible file.
Reporting Variables Related to MANAGED‐CARE‐PLAN‐TYPE
States also need to understand the specifics of their managed care plans to correctly map the OPERATING-AUTHORITY. Some plans have an obvious mapping. For example, a Program of All‐inclusive Care for the Elderly (PACE) managed care plan type (MANAGED‐CARE‐PLAN‐TYPE = '17') will also have an expected PACE operating authority (OPERATING‐AUTHORITY = '08'). Other managed care plans might have more than one option for a designated operating authority. For example, a transportation PAHP managed care plan MANAGED‐CARE‐PLANTYPE = '15') might have an operating authority through either a 1915(b) waiver (OPERATING‐AUTHORITY = '02') or a 1902(a)(70) non‐emergency medical transportation program (code = '11').