Medicaid Network Adequacy: A Key to Access to Care

AHCCCS is rolling out new integrated care contracts on October 1, and most members will be receiving services for both acute and behavioral care from these managed care organizations.  One of the keys to making sure that members have access to a health care provider when they need it is for AHCCCS to make sure each managed care organization has an adequate network of contracted providers.  After all, having health insurance isn’t much good if there’s no place for you to get care in your area or if the doctors are booked and you can’t get an appointment.  That’s where “network adequacy” comes in.

AHCCCS sets their network adequacy standards in what’s called their “AHCCCS Contractors Operations Manuals”, or ACOMs for short.  From now through May 28, 2018 AHCCCS is accepting public comment on their proposed ACOM manuals for network expectations for the integrated care contracts that start on October 1.

Geographic Standards

One of the keys is to make sure that there are providers reasonably nearby Medicaid members.  ACOM 436- Minimum Network Requirements will set the expectations for geographic access to care. It’s pretty long as you’ll see if you click on the link.  But here are a couple examples of the key proposed standards that are out for public comment. 

For kids, they propose requiring their contracted managed care organizations to ensure that 90% of members live within 10 miles or 15 minutes of a primary care provider in Maricopa and Pima counties.  For all other counties, they’re proposing that 90% of members lives within 30 miles or 40 minutes of a primary care provider.  For kids dental in Maricopa & Pima counties, they’re proposing requiring their contractors to make sure that 90% of members live within 15 minutes or 10 miles of a provider.  For the other counties, they’re proposing that 90% of members live within 40 minutes or 30 miles of a provider.

The Manual also proposing a process for managed care organizations ask for an exemption from the standards based on outlined reasons and the criteria by which they’ll consider approving the exemptions.  Those of you that are well versed in these aspects of access to care can comment on the proposed standards and the exemption criteria through May 28 at this web link.

Appointment Wait Time Standards

Another Manual that’s out for public comment is about how long it takes to make an appointment to see various kinds of providers.  That one is called ACOM 417, Appointment Availability, Monitoring and Reporting.

The 417 Manual proposes that routine primary care appointments be set within 21 calendar days of the member’s request.  For more urgent appointments, the proposal is for “… as expeditiously as the member’s health condition requires but no later than 2 business days of request”.  For Specialty provider referrals the proposal is “… as expeditiously as the member’s health condition requires but no later than 3 business days from the request”.  For routine specialty care appointments it’s within 45 calendar days of referral.  For dental provider appointments it’s “… as expeditiously as the member’s health condition requires but no later than 3 business days of request, and for routine care appointments within 45 calendar days of request

They’re also proposing a process for managed care organizations ask for an exemption from the standards based on outlined criteria.  They also outline the criteria by which they’ll consider approving the exemptions.

Those of you that are well versed in these aspects of access to care can comment on the proposed standards and the exemption criteria through May 28 at this web link.  We’ll talk this over with our Public Health Policy Committee and turn in comments sometime in May.  Let me know if you want to get onto our Policy Committee Basecamp and I’ll sign you up.

 

FDA Pursuing E-Cigarette Interventions

Last week the FDA announced several interventions to better regulate e-cigarette makers.  It’s no secret that e-cigarettes have become wildly popular with kids.  E-cig makers have become increasingly crafty in attracting kids to use their products- which often have high nicotine levels.  Some of the new products look like a USB flash drive- making it easier for them to sneak into what are supposed to be tobacco product free-areas.  Many fall under the JUUL Brand but also “myblu” and “KandyPens”.

The strategies that FDA announced last week include: 1) an “undercover” investigation into retailers that are selling these JUUL products to kids and issuing warning letters and other enforcement actions; 2) raising concerns with eBay regarding their listing of JUUL products on their website; 3) contacting manufacturers like JUUL Labs and requiring them to submit like documents like their product marketing strategy, research on the health, toxicological, and behavioral or physiologic effects of the products; and 4) enforcement actions focused on companies that are marketing products in ways that are misleading to kids.

Time will tell whether these strategies make a difference- but one thing is clear- we’ll continue to be in a long-term battle with companies that will continue to creatively find new ways to addict America’s youth to their nicotine products.

 

Legislative Session Update

There wasn’t much action on the public health bills we’re working on and tracking last week. Unless you’ve been out of town or on vacation you know that pretty much all last week was absorbed with the debate about weather and how to fund increases for K-12 schools.  There were huge peaceful marches on the Capitol on both Thursday and Friday.  The Legislature adjourned early last week.

The Governor has proposed increasing teacher salaries by 20% by the year 2020. The teachers are looking for a more robust commitment for all other school staff and a dedicated revenue stream to support the investment.  The Governor proposes paying for the increase in several ways- in part by increasing the assessment on hospitals to help pay for Medicaid, and in part by decreasing planned funding for things like provider increases for programs that serve people with disabilities (because of the increase in the minimum wage).  The plan assumes state revenue will increase by 4.8% per year over the next 3 years (over the last 3 years it’s increased by between 3 and 4% per year). 

Late last Friday afternoon the Governor issued a media release stating that an agreement had been reached with the legislature on a way to fund the 20% by 2020 idea, but the media release didn’t explain how it would be paid for.  Here’s the latest information that I have- but of course this could change when the actual proposal comes out later this week. Robert Robb from the Republic had the most digestible explanation of the plan that I’ve been able to find.

The phased-in cost of the teacher pay increase is $580M. The phased-in school-assistance portion is $370M (a total of $950M).  Maintaining all other state programs over that period is about $850M and that’s without any population increase or inflation.  At 4.8% revenue growth per year (the past 3-year average is between 3 and 4%) there’d be a $150M deficit in 2020 even if there were no increases in spending anywhere else in state government.  If revenue growth were less than 4.8%, there’d be a bigger deficit.  If revenue increases average more than 4.8% things might be OK.  If there’s a recession, we’d be in big trouble. 

You can see how important it is to get the revenue stream right.  If revenues and expenses are unbalanced, the increases for schools and teachers will absorb all other funds and there won’t be anything available to address public health or social determinant priorities and might even force reductions in other state services like health care and public health. 

 

Medicaid Changes Partially Support the Teacher Salary Proposal

There are a couple of “efficiency items” that the Governor identified within our Medicaid program that will partially pay for some of the teacher salary increase.  One relates to the assessment on hospitals that pays the state portion of the Medicaid expansion deal that was reached a few years ago.  The other is a proposed change to eliminate something called “prior quarter coverage”.

Hospital Assessment

One item listed as an “efficiency savings” to help pay for the teacher salary proposal increase the hospital assessment, which pays for Medicaid expansion, by $35 to $39M.  The Governor has proposed moving behavioral health services for childless adults to the same funding stream as acute care (tobacco taxes and the hospital assessment pay for acute care coverage for childless adults and those covered through Medicaid expansion).  The assessment on  hospitals would increase by 12% from $287 million to $326M.

Prior Quarter Coverage

Back on January 1, 2014 AHCCCS began covering people that qualify for Medicaid for the 3 months prior to their eligibility date.  So, if a person applying for AHCCCS qualifies during any portion of three months immediately preceding the month in which the member applied for AHCCCS coverage, they’ll reimburse providers for covered services.  They’ve submitted a waiver request to CMS to stop this practice.  In FY 2017 they spent a total of about $21M for prior quarter coverage- so stopping the practice would save about $11 - $12M in state funds. This waiver is in the hands of CMS right now.

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Here’s a snapshot of where the various bills we’re working on are in the system. 

HB 2038 Drug overdose review teams; records (Signed into Law)

HB 2071 Rear-facing car seats (Stalled in Senate)

HB 2084 Indoor tanning; minors; restricted use (Now called SB 1290 as Striker) 

HB 2127 Children's health insurance program (Now called SB 1087 as Striker)

HB 2197 Health professions, workforce data (Ready for Senate Floor Vote)

HB 2208 Prohibition, photo enforcement (Effectively dead)

HB 2228 Annual waiver, applicability (Signed by Governor)

HB 2323 Schools; inhalers; contracted nurses (Ready for Senate Floor Vote)

HB 2324 Community health workers; voluntary certification (needs Senate floor vote)

HB 2389 Syringe access programs; authorization (Basically dead)

HB 2484 local food tax; equality (Signed by Governor)

SB 1022 ADHS; homemade food products (Signed by Governor) 

SB 1083 Schools; recess periods (Signed by Governor)

SB 1245 Snap Benefit Match (Needs Rules Committee & Budget Line)

SB 1261 Texting while driving (Now HB 2159 traffic violations; traffic survival school)

SB 1420 Medical marijuana; inspection; testing; appropriation (Needs House Rules)

SB 1445 AHCCCS Dental care, pregnant women (Needs House Rules Committee)

SB 1377 Dental therapy, licensure, regulation (Failed in House now HB2235 in Senate)

SB 1389  HIV; needs assessment; prevention signed by the Governor last week.

SB 1394 Abortion reporting (Signed by Governor)

SCR 1005 Voter Initiative Sunset (striker in the House)

 

Public Health-related bills signed so far:

HB 2038 Drug overdose review teams; records was passed and signed.  Once it takes effect later this year, law enforcement agencies will now be required to provide unredacted reports to the chairperson of a local Drug Overdose Fatality Review Team on request. 

HB 2228 Annual waiver, applicability was signed by the Governor.  It’s good. It will direct AHCCCS to exempt tribes from their directed waiver request that asks for CMS permission to implement work requirements for some Medicaid members.  The recently submitted Waiver request includes an exemption for American Indians, however, this would place the exemption into statute.

HB 2323  Schools; inhalers; contracted nurses was signed by the Governor.  This bill adds contracted nurses to the list of people who are authorized to provide emergency inhaler medication in case of respiratory emergencies. Some charter and independent schools don’t employ nurses directly but engage them through contracts.

HB 2484 local food tax; equality, which will ban Arizona cities and counties from taxing sugary drinks as a public health intervention.

SB 1022  DHS; homemade food products ADHS will be required to establish an online registry of food preparers that are authorized to prepare "cottage food products" for commercial purposes. Registered food preparers would be required to renew the registration every three years.

SB 1083 Schools; recess periods was passed and signed!  Beginning next school year K-3 will need to have at least 2 recess periods. Grades 4 and 5 will need to have 2 recess periods the year after that.

SB 1389  HIV; needs assessment; prevention was signed by the Governor last week.  It requires the ADHS to establish and implement an HIV Action Program. 

SB 1394 Abortion reporting was passed by the House and signed by the Governor.  It will require the ADHS to collect and report additional data regarding abortions that are performed in AZ.

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