Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Hausenfluck
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Transcript of Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Hausenfluck
WellCare Health Plans, Inc. Corporate Overview
March 21, 2014
2 As of January 2014
WellCare Health Plans, Inc. Founded in 1985 in Tampa, Fla. • Approximately 3.3 million members nationwide. • 176,000 contracted health care providers. • 67,000 contracted pharmacies.
Serving 1.8 million Medicaid members, including: • Aged, Blind and Disabled (ABD). • Children’s Health Insurance Program (CHIP). • Family Health Plus (FHP). • Supplemental Security Income (SSI). • Temporary Assistance for Needy Families (TANF).
Serving more than 1.5 million Medicare members, including: • 340,000 Medicare Advantage members. • 1.2 million Prescription Drug Plan members. • 50,000 Medicare Supplement policyholders. Serving the full spectrum of member needs • Dual-eligible populations (Medicare and Medicaid). • Managed Long Term Care.
Spearheading efforts to sustain the social safety net • The WellCare Community Foundation. • Advocacy Programs. • Creation of Public-Private Partnerships.
Significant contributor to the national economy • A FORTUNE 500 company. • Ranked #16 in the nation on the Barron’s 500. • Approximately 5,700 associates nationwide. • Offices in all states where the company provides
managed care.
Company Snapshot
Medicare Advantage & Medicare Part D PDP Medicare Part D PDP (49 states & D.C.) Medicare Supplement (39 states)
Medicaid, Medicare Advantage & Medicare Part D PDP
3 As of January 2014
Vision To be the leader in government-sponsored health care programs in partnership with the members, providers, governments and communities we serve. Mission • Enhance our members' health and quality of life.
• Partner with providers and governments to provide quality, cost-effective health care solutions.
• Create a rewarding and enriching environment for our associates. Core Values • Partnership
• Integrity
• Accountability
• Teamwork
WellCare Health Plans, Inc.
4 As of January 2014
What We Do
• Providing managed care services targeted to government-sponsored health care programs, focusing on Medicaid, Medicare and Prescription Drug Plans.
• Serving a variety of people including families; children; and the aged, blind and disabled; includes a focus on low-income, dual-eligible populations.
• Improving quality of care, increasing health care access and improving outcomes for members.
• Relieving providers of administrative work and hassles.
• Providing cost savings for government customers and taxpayers.
Reduce Cost and Improve Quality and Access for Government Health Programs by:
WellCare
Medicaid
Dual-Eligible
Members
Medicare Advantage
Prescription Drug Plans
Managed Long Term
Care
Medicare Supplement
5 As of January 2014
Medicaid Presence
• Broad range of eligibility groups.
• Capabilities to integrate medical, pharmacy and behavioral services.
• Offers coordination with Medicare benefits.
1.8 million members across 9 states
6 As of January 2014
Medicaid Risk Adjustment
2013 Regions by Membership
Georgia 552,100
Florida♣ 473,800
Kentucky 291,300
Illinois (still need to confirm) 144,900
Missouri 106,200
New York 100,500
South Carolina* 49,800
Hawaii* 38,400
Ohio -
TOTAL 1,757,000
♣Moving to risk-‐adjustment in 2014.
*Market not currently risk-‐adjusted.
7 As of Dec. 31, 2013
How it all Fits Together
• Encounter Repor@ng & Analy@cs
• Medical Record Review
• Encounter Opera@ons
• Claims
Quality Risk Adjustment
Rate SeHng
Encounters SLA
8 As of Dec. 31, 2013
• ICD-10 Impacts to Encounters & Risk Adjustment models
• Service level Agreements (SLA’s) and risk of sanctions
• Leveraging Medicare Risk Adjustment processes in Medicaid?
• Linking Encounters to Quality and revenue impacts in real time (Estimating the value of an Encounter)
• Multiple models in use across existing states along with new states implementing various risk adjustment models or parts there of
• Increasing complexity of product offerings and reconciliations with Medicare and Medicaid
• Significant increase in data requests by CMS and the states (ie: All Payers claims database)
• Buy it, Build it, or both?
A Look Ahead - 2014 and Beyond in Medicaid: