Medicaid’s Detailed Response to...Navigant Recommendation 1: DOM should update the MHAP...

Medicaid’sDetailedResponse

toNavigant’sOperationalandPerformanceAssessmentReport

PreparedfortheMississippiStateLegislature

March3,2017

ResponsiblyprovidingaccesstoqualityhealthcoverageforvulnerableMississippians

MississippiDivisionofMedicaid|medicaid.ms.gov Page2

TableofContentsIntroduction...........................................................................................................................................................4

MississippiMedicaidBackground................................................................................................................5

DOMClarificationofLimitations..................................................................................................................6

DOMResponsestoNavigant’sFindingsandRecommendations....................................................8

MississippiHospitalAccessPayments.......................................................................................................8

MississippiCAN:ProgramMonitoring................................................................................................11

MississippiCAN:Quality............................................................................................................................15

MississippiCAN:Cost‐Effectiveness.....................................................................................................20

MississippiCAN:ProgramIntegrity.....................................................................................................21

DOMOperations:StakeholderCommunication.............................................................................23

DOMOperations:StaffTurnover..........................................................................................................28

DOMOperations:Training.......................................................................................................................29

ContactInformation........................................................................................................................................30

Appendices..........................................................................................................................................................31



Introduction

As a result of the 2016 legislative session, House Bill 1650 required the Mississippi Division of Medicaid

(DOM) to expend funds for an outside consultant to perform an operational and performance

assessment in order to evaluate and recommend changes to the structure, process and resources of

DOM in light of the shift from fee‐for‐service, expansion of the Mississippi Coordinated Access Network

(MississippiCAN) program and the implementation of the Mississippi Hospital Access Payment (MHAP)

program.

After the Department of Finance and Administration conducted a competitive procurement, DOM

contracted with Navigant Consulting, Inc. (Navigant) on November 15, 2016, to evaluate and provide

recommendations related to MississippiCAN and the MHAP program.

As indicated by DOM’s letter in response to Navigant’s Mississippi Operational and Performance

Assessment report, DOM disagrees with a number of the finding and assessments. DOM’s initial

responses are included in Appendix H of Navigant’s report. Additionally, DOM wanted to expand on the

initial responses to provide more detailed information.

Any attempt to thoroughly assess the operations and performance of the Mississippi Medicaid program

and the agency would be a monumental task for any outside entity. Medicaid is highly complex and each

state runs its own Medicaid program within a multitude of rules, regulations and federal guidelines, with

oversight from the Centers for Medicare and Medicaid Services (CMS).

DOM employees work tirelessly to serve the beneficiaries and providers of Mississippi, and the agency

also is committed to the state as a whole, recognizing the weight of the responsibility it bears for

taxpayers and elected officials. Exploring opportunities for more direct avenues of communication with

decision‐makers is something the agency readily welcomes.

Fulfilling the requirements set forth was a difficult challenge to meet, however, DOM provided

requested documents in a timely manner, accommodated the time frame established by Navigant, and

adjusted daily tasks and responsibilities accordingly to keep the agency up and running.

Confidentiality: DOM’s report and all attachments are confidential and/or proprietary to DOM, and may

contain sensitive information, including, but not limited to, confidential personal information,

confidential commercial or financial information belonging to third parties, legally privileged

information, protected health information as defined by the Health Insurance Portability and

Accountability Act (HIPAA) of 1996, or material otherwise exempt from disclosure under the Mississippi

Public Records Act. The information contained in and attached to DOM’s report is intended for the

exclusive use of the intended recipient. The use, disclosure, copying, or distribution by any means, to

anyone other than the intended recipient without the prior written permission of DOM, is strictly

prohibited. Any such unauthorized use, disclosure, copying, or distribution may violate federal and/or

state privacy laws, including, but not limited to, HIPAA. If you have received DOM’s report or any

attachments in error, please notify DOM. Thank you for your assistance in the protection of confidential

information.



MississippiMedicaidBackground

The Mississippi Division of Medicaid (DOM) has approximately 1,000 employees located throughout one

central office, 30 regional offices and over 80 outstations. DOM is charged with administering multiple

Medicaid health benefits programs to those who qualify.

1965 ‐ Medicaid was created as part of the Social Security Amendments of 1965, to provide

health coverage for certain eligible, low‐income populations.

1969 ‐ Medicaid was enacted by the Mississippi State Legislature

All 50 states, the District of Columbia, and five territories participate in the voluntary matching

program.

Overview

DOM is designated by state statute as the single state agency responsible for administering Medicaid in

Mississippi.

Medicaid provides health coverage for eligible, low‐income populations in Mississippi. These

populations include children, low‐income families, pregnant women, and the aged and disabled. Eligible

members do not directly receive money from Medicaid for health benefits. Enrolled and qualified

Medicaid providers are reimbursed for health services.

DOM serves nearly 1 in 4 Mississippians who receive health benefits through regular fee‐for‐service

Medicaid, the Children’s Health Insurance Program (CHIP), or Medicaid’s coordinated care program,

MississippiCAN. Medicaid contracts with coordinated care organizations (CCO) to operate the

MississippiCAN program.

WhoisEligibleforMedicaid?

States must cover mandatory eligibility groups defined by federal law, but they have flexibility over

covering optional eligibility groups. Eligibility for these groups is determined by a number of factors

including family size, income and the Federal Poverty Level (FPL). Eligibility for people who receive

Supplemental Security Income (SSI) and the aged, blind or disabled are based on additional

requirements such as income and resource limits.



DOMClarificationofLimitations

In an effort to address operational requirements, and comply with federal and state regulations, DOM

has diligently performed its duties in addition to developing, operating and updating new programs

(MHAP and MississippiCAN) within short time frames. To meet obligations specifically related to these

programs DOM took the following actions, including, but not limited to: drafting three contracts within

six years, implementing a third procurement, and restructuring organizational duties multiple times.

Subject matter experts from each of DOM’s office areas carefully reviewed the findings and

recommendations from the Navigant report that corresponded to their areas, and explained each set of

circumstances as plainly as possible. They also expressed concerns about the clarity of Navigant’s

understanding of the program and original expectations, as each of these dedicated DOM leaders

believed they cooperated with the contractor’s requests to the best of their abilities given the time

constraints, particularly while maintaining their daily responsibilities to the people of Mississippi.

Keeping this in mind, what follows are agency leaders’ candid responses and clarifications to the

Navigant report.

(See Documentation Provided by DOM on page 4 in the Navigant report)

Navigant: All DOM email correspondence with CMS related to DOM’s MHAP CAP. Navigant received one

email thread between DOM and CMS; however, given the amount and nature of the hospital access

payments, Navigant believes there should be more emails than what DOM provided.

DOM: DOM provided all email and hard‐copy correspondence to Navigant, in addition to a Freedom of

Information Act (FOIA) request DOM received on this topic.

Navigant: Monthly management reports submitted by contracted CCOs for reporting periods from 2013

through 2016 (select reports were provided)

DOM: All reporting templates were provided. Due to initial concerns regarding protected health

information (PHI), proprietary information, and information involved in litigation due to fraud, DOM

took a cautious approach with requests for these documents. Since the coordinated care program has

evolved over time, the corresponding reports for each year are different and have changed, with

additional reports being added as needed.

Navigant: CCO monitoring SOPs that were in place 12/1/2016 and any revisions or replacements

thereto. DOM only provided two SOPs related to CCO monitoring, one related to its “Managed Care

Deliverables Compliance Tool” and the other for “Program Integrity/MSCAN Fraud and Abuse”.

DOM: These were the only SOPs requested. Per email correspondence with Navigant staff on Dec. 15,

2016, Navigant recognized DOM has SOPs for every office at a very detailed level, but Navigant only

wanted high level SOPs and a picture flow chart (which DOM does not have).

Navigant: Current CCO issues logs for all operational areas

DOM: Navigant was provided a CCO issue log on Dec. 14, 2016, as well as a list of all CAPs for the CCOs.

Additionally, Navigant requested “any warning, compliance failures and liquidated damages, and any



such documents in any form relating to the performance for the MCOs”. The information request was

broad and vague, and unrealistic in the time frame Navigant mandated. DOM received this request on

Jan. 12, 2017; Navigant set a hard deadline of Jan. 26, 2017, to supply all the documents requested

(there were over 1,000 documents required to fulfill Navigant’s requests).

Navigant: DOM’s Deliverables Compliance Tool, meetings from Monthly Management Meetings, SOPs,

or any documentation that would allow Navigant to verify staff interview claims on DOM’s ability to

review reports in a timely manner

DOM: Upon careful review of Navigant’s document request item log, there is no such request for the

DOM Deliverables Compliance Tool. The reference to “meetings from Monthly Management Meetings”

is unclear. Additionally, Navigant did not request DOM’s SOP outside of those referenced above.

Navigant: Management and dashboard reports specific to MississippiCAN or comparing MississippiCAN

and FFS Medicaid

DOM: Dashboard reports were provided to Navigant on Dec. 21, 2016.

Navigant: Data allowing Navigant to assess progress in meeting the goals for 2016 outlined in the 2015

Annual Quality Strategy Update

DOM: This request was fulfilled to the best of DOM’s ability by providing requested reports and data

when allowed.

Navigant: Inpatient data including monthly enrollment data allowing comparison to benchmarks or

other CCOs

DOM: The available enrollment data was provided to Navigant; Navigant confirmed receipt of the data

on Jan. 18, 2017, per MS Assessment: Document Request Listing Excel file attached to email

correspondence.

Navigant: Inpatient utilization data prior to inclusion of inpatient services in MississippiCAN

DOM: DOM has no record of this request.

Navigant: Consumer Assessment of Healthcare Providers and Systems® (CAHPS®) survey data for

Magnolia


Navigant: Information on Magnolia’s provider incentive programs


Navigant: Select performance measurement data

DOM: DOM is unclear about which data Navigant is referring to.



DOMResponsestoNavigant’sFindingsandRecommendations

On Feb. 28, 2016, Navigant released the Mississippi Operational and Performance Assessment of the

Governor’s Office, Division of Medicaid report to the Legislature. DOM included initial short responses,

which can be found in Appendix H of Navigant’s report.

As indicated in the letter from DOM’s executive director, below are more detailed responses to

Navigant’s report, and each finding and recommendation.

MississippiHospitalAccessPayments

Navigant Finding 1: DOM’s MHAP methodology does not use the calculations required by federal

regulations.

Navigant Recommendation 1: DOM should update the MHAP methodology to use correct “base” period

and update annually.

DOM Initial Response: DOM’s MHAP has CMS approval. In a letter dated March 25, 2016, CMS

approved the managed care contract that provides for MHAP payments totaling $533,110,956 each

state fiscal year. This approval extends through state fiscal year 2017. Additionally, DOM has a model

that properly demonstrates that MHAP complies with the regulatory limit. Furthermore, DOM will

demonstrate compliance for the “base” period of SFY 2018 when appropriate.

DOM Detailed Response: DOM’s Mississippi Hospital Access Payment (MHAP) program has CMS

approval. CMS approved the contracts with the CCOs that require monthly distribution of the MHAP

payments and the contracts with the CCOs showing rates including MHAP. CMS approved MHAP

through June 30, 2017, because that is the last date of the contract amendment submitted for approval.

DOM has every expectation that CMS will approve MHAP for future periods.

Furthermore, DOM is compliant with federal regulatory calculations for MHAP. As suggested, Myers and

Stauffer, the certified public accounting firm contracted with DOM, has prepared the necessary

calculations. In fact, the calculations and explanation of the compliance with the new regulations were

provided to CMS in a letter dated October 27, 2016 (see Appendix 1A, Appendix 1B – Attachment A,

Appendix 1B – Attachment B; see MHAP Implementation Timeline on page 6 in the Navigant report).

CMS has requested additional information related to the calculations and the additional information is

prepared (see Appendix 1C – Attachment A, Appendix 1C – Attachment B).

DOM successfully designed, developed and received approval for MHAP so that the important funding

to hospitals would be maintained, and so that inpatient hospital services would be included in

coordinated care in accordance with directives of state law. Within a span of seven months, DOM and

the CCOs successfully enrolled 300,000 children into coordinated care, seamlessly added inpatient

hospital services to coordinated care, and implemented MHAP keeping hospital funding fully intact.

DOM and the CCOs worked together, against push‐back and a lawsuit filed by stakeholders, to

accomplish these three huge undertakings with minimal disruption to the program by the December 1



deadline. It is to be noted that the Mississippi Hospital Association (MHA) instituted an action against

DOM regarding MHAP on November 30, 2015. The action was stayed shortly thereafter on December

14, 2015, in order for DOM to continue to work toward CMS‐approval for the MHAP. As a result of

MHAP receiving all necessary approvals, the case was completely dismissed on March 2, 2017, at the

request of MHA. There are no outstanding legal issues between MHA and DOM regarding MHAP.

In the January 17, 2017, letter from CMS to DOM (see Appendix 1D), CMS states it “continues to support

the state’s intended goal of integrating inpatient hospital services into its coordinated care program.”

CMS knows that success of MHAP is necessary for the inpatient coordinated care program. This is clearly

explained in the November 20, 2015, DOM letter to CMS (see Appendix 1E). They “appreciate” their

“partnership with the state in its effort to move toward a value‐based payment system.” CMS is

working with Mississippi and providing technical assistance to continue the pass‐through payments and

to ensure a successful transition to a payment structure with clear linkages between the utilization,

quality, or outcomes of delivered services.

The Figure 3 MHAP Implementation Timeline (see MHAP Implementation Timeline on page 6 in the

Navigant report) points out that DOM implemented MHAP prior to CMS approval of the State Plan

Amendment (SPA). Because of extremely short windows of time for implementation of policy changes,

DOM often begins coverage/payment for services before final approval is received from CMS. CMS

allows for an effective date of a SPA to revert back before it was submitted to CMS for approval as long

as all requirements are met, such as for a public notice and Tribal notification. As long as a SPA is

submitted within the quarter that it is effective, the approval date reverts back to the date requested.

Typically, CMS takes 90 days to approve each SPA because of informal questions. A portion of those

SPAs sometimes enter Request for Additional Information (RAI) status, which can take many months (or

even years) to get approval. Once a SPA is approved, the effective date is the date that was originally

requested. Capitation rate contracts are also always approved well beyond the effective date, creating

the need for state Medicaid programs to place rates in operation before CMS approval. Though CMS is

making efforts to shorten the time they take to issue approvals; it may take a year. By comparison, the

MHAP rates were approved within four months of submission to CMS, which represents the high level of

importance CMS placed on the success of our MHAP.

Navigant Finding 2: DOM’s MHAP methodology does not meet federal requirements for phasing out

pass‐through payment programs, such as MHAP.

Navigant Recommendation 2: DOM should transition MHAP to other payment models allowed by

Medicaid regulations on a long‐term basis.

DOM Initial Response: DOM does not agree it is in the best interest of the state’s hospitals and our

beneficiaries to implement in advance the pass‐through transition requirements of federal regulations

that were published in May 2016. The rule requires that the transition begin in SFY 2019. The reason

provided by CMS for the phase‐out over 10 years is to transition the payments “without undermining



access for the beneficiaries they serve.” DOM is committed to complying with the schedule outlines in

the federal regulations.

DOM Detailed Response: DOM disagrees that it’s in the best interest of the state’s hospitals and

beneficiaries to implement in advance the pass‐through transition requirements of federal regulations

that were published in May 2016. The rule requires that the transition begin in SFY 2019. The reason

provided by CMS for the phase‐out over 10 years is to transition the payments “without undermining

access for the beneficiaries they serve.” DOM is committed to complying with the schedule outlined in

the federal regulations.

DOM and CMS are working together to develop the 10‐year process for transitioning the MHAP pool as

required by regulations finalized shortly after initial approval of the project. Because CMS issued its

approval so close to finalization of the regulations requiring transition, CMS required a corrective action

plan (CAP) for Mississippi’s transition. Effectively, the CAP formalizes Mississippi’s compliance with the

regulations that apply to all state Medicaid pass‐through programs, like MHAP. For all states, including

Mississippi, the transition of payments will begin in SFY 2019.

Contrary to Navigant’s finding, there is no requirement that DOM have a phasing out program in place

at this time. DOM has a plan for complying with the phase‐out of pass‐through payments in compliance

with timing required in federal regulations.

This finding restates information presented in letters addressed to DOM and federal regulations. The

table shown in Figure 4 (see Potential Phasing of DOM’s Pass‐Through Payments on page 8 in the

Navigant report) does show a calculation representing a 10 percent annual reduction of the MHAP pool.

DOM believes Navigant should have used the actual MHAP total and added the amount of the reduction

in the MHAP pool that would occur each year in their narrative. In Figures 5 and 6 (see CMS Written

Guidance to DOM Regarding Phase Out of Pass‐Through Payments on page 9 in the Navigant report; see

Potential Options for the Transition of MHAP Payments on page 10 of the Navigant report), there was an

opportunity to develop and present suggestions relevant to Mississippi and compliant with federal

regulations, versus Navigant restating the regulations.

Navigant Finding 3: DOM has not conducted stakeholder engagement or addressed how its payment

structure will align with CMS’s quality initiatives.

Navigant Recommendation 3: DOM should develop a stakeholder engagement strategy.

DOM Initial Response: DOM has publicly committed to CMS and stakeholders our commitment to lead a

compliant transition of pass‐through payments as required by federal regulation. DOM has worked

successfully with CMS to protect the funding pool that is now paid through the MHAP program. DOM

continues its commitment to the state’s hospitals and the beneficiaries they serve to protect this

funding. DOM has a strategy for stakeholder engagement and will begin working with stakeholders

upon receipt of CMS’s approval of the plan.



DOM Detailed Response: As noted by Navigant, DOM is committed to CMS and stakeholders to lead a

compliant transition of pass‐through payments as required by federal regulation. DOM has worked

successfully with CMS to protect the funding pool that is now paid through the MHAP program. DOM

continues its commitment to the state’s hospitals and the beneficiaries they serve to protect this

funding. For this purpose, DOM has a strategy for stakeholder engagement.

DOM engaged our fiscal agent’s Payment Method Development Team to lead the stakeholder

engagement project, and began stakeholder engagement planning in May 2016. As soon as CMS

approves of the plan work with stakeholders will formally begin; work is anticipated to begin April 2017.

The timeline, key metrics and milestones are prepared and risks are identified. Additionally, a tracking

system has been developed for evaluating the progress of key activities. Furthermore, DOM has

developed a starter list of approximately 12 options and has an analytical dataset underway to help the

stakeholder group evaluate options.

We appreciate Navigant’s evaluation recognizing DOM’s commitment to a stakeholder engagement

plan. In their report, Navigant explained that “based on the documentation provided by DOM, we were

unable to identify DOM’s approach for addressing CMS’s quality initiative requirements or conducting

stakeholder engagement.” After reviewing this finding, DOM has determined that Navigant failed to ask

about or request DOM’s stakeholder engagement plan. While DOM appreciates the five broad

categories of suggested stakeholder groups in Section V.A. (see MississippiCAN Key Stakeholders on

page 40 in the Navigant report), and the mention of a risk associated with the provider tax, the report

offers no other recommendations for the stakeholder process. Navigant did not provide a meaningful

list of stakeholders or a complete list of risks, nor did they suggest a timeline, key metrics, milestones or

a tracking method.

DOM has quarterly stakeholder meetings with MHA, periodic meetings with other hospitals/provider

groups, and discusses MHAP updates and information at those events.

MississippiCAN:ProgramMonitoring

Navigant Finding 4: DOM has limited standard operating procedures (SOP) to support the monitoring

and oversight process.

Navigant Recommendation 4: DOM should improve, update, and draft new documentation to outline

report monitoring and oversight processes.

DOM Initial Response: DOM has a current SOP that outlines the report monitoring and oversight

process. DOM trained employees to follow the SOP. DOM provided the SOP to Navigant.

DOM Detailed Response:As part of the DOM Strategic Plan and Office of Project Coordination, each

office is required to develop SOPs for relevant functions, tasks and responsibilities. The SOP process was



established in August 2014, and documents are updated annually. The project coordinator is responsible

for maintaining the standard SOP template, and managing the annual SOP review and update process.

DOM has a current SOP that outlines the report monitoring and oversight process in place (see Appendix

4), and employees are trained to follow the SOP. DOM provided the SOP to Navigant. Additionally, the

Office of Coordinated Care is in the process of updating its own SOP to reflect current monitoring and

oversight processes, as noted by Navigant in the report.

Navigant Finding 5: DOM’s current draft monitoring procedures focus heavily on processes rather than

performance improvement.

Navigant Recommendation 5: DOM should shift its monitoring and oversight focus from processes to

performance improvement as MississippiCAN matures.

DOM Initial Response: The Reporting Manual and Compliance Deliverables Tool allow DOM to monitor

CCO processes; which, in turn, allows DOM to better monitor CCO performance and quality.

DOM Detailed Response: The Reporting Manual and Compliance Deliverables Tool allow DOM to

monitor CCO processes; which, in turn, enables DOM to better monitor CCO performance and quality. A

good example of this comes from the recent review of the Denials Reporting Template where one of the

two CCOs was placed on a CAP. This shows the “performance” aspect of the Compliance Reporting.

From this CAP, DOM expects to see an improvement in provider claims processing, as well as provider

relations and assurance of contract compliance.

Working with our outside accounting firm, Myers and Stauffer, the CCOs are reporting monthly Cash

Disbursement Journals (CDJs) for reconciliation to Encounters. On both a quarterly and annual basis, the

CCOs are reporting Medical Loss Ratios to ensure their expenditures are in line with the minimum

contractual requirements. These reports are monitored internally by DOM staff and then audited by

Myers and Stauffer.

The attached exhibit from Myers and Stauffer (see Appendix 5) highlights these activities and several

other areas where DOM has contracted with the CCOs for increased fiduciary review of the

MississippiCAN program. DOM will continue to refine this process to consider reasons for performance

trends and to identify potential risks.

Navigant Finding 6: DOM developed a detailed reporting manual to promote consistency in reporting

and guidance to CCOs.

Navigant Recommendation 6: DOM should continue to use and refine reporting manual for reports

submitted by CCOs.

DOM Initial Response: DOM will continue to use and refine our Reporting Manual.



DOM Detailed Response: Upon further review DOM stands by the initial response. No further response

is required.

Navigant Finding 7: DOM staff are likely to find it challenging to thoroughly review the large volume of

collected reports.

Navigant Recommendation 7: DOM should develop SOPs for report review, disseminate data internally

and externally, and review reporting requirements to identify opportunities to consolidate and update

reports.

DOM Initial Response: DOM is currently doing this.

DOM Detailed Response: DOM reviews various reports related to MississippiCAN and disseminates data

internally and externally to pertinent stakeholders. DOM currently uses data from reports to identify

trends, which may result in DOM modifying reporting requirements accordingly. DOM annually reviews

the Reporting Manual to identify opportunities to consolidate and update reports.

Navigant did not provide specific recommendations for best practices to review a large volume of

reports in other states. While DOM has sound procedures in place, the agency is continually looking for

ways to innovate and follow the lead of other successful entities. Information on specific ways to

manage the large volume of reports necessary to monitor the Medicaid CCOs would have been

welcome.

Navigant Finding 8: There is no evidence of reports that aggregate MississippiCAN program data.

Navigant Recommendation 8: DOM should develop dashboard report capabilities for program

monitoring.

DOM Initial Response: Currently, MedeAnalytics supplies DOM with dashboard summaries. See below

for a sample dashboard report:

Top 1000 by Total Costs

Top 1000 by Total ER Visits

Top 1000 by Total Readmissions

Quality Measures

Pregnancy

EPSDT Reports

Reports are shared with stakeholders as warranted or requested.

DOM Detailed Response: MedeAnalytics provides dashboard capability that aggregates MississippiCAN

program data. Currently, the dashboard is used to create myriad reports and allows DOM to drill down



into data to look at specific issues. DOM plans to integrate the dashboard into its everyday workflow

throughout the agency. Additionally, DOM continues to develop a number of reports that are still in

progress.

Navigant Finding 9: DOM does not have a centralized platform for sharing monitoring findings.

Navigant Recommendation 9: DOM should implement an electronic platform for receiving reports and

tracking report follow‐up.

DOM Initial Response: DOM is working on this currently.

DOM Detailed Response: The Office of Contract Compliance uses Share File, not Share Point (as

indicated by Navigant), to exchange reports and collaborate with DOM. Share File is a document

exchange service similar to file transfer protocol (FTP). Share File captures document versioning for an

audit trail. DOM recognizes the need for a repository, and has included this in our roadmap for the

future. Meanwhile, DOM actively maintains a central repository to track results of the review of each

report using Microsoft Excel and email. DOM has taken steps to secure and implement a compliance

software tool, and plans to use this tool in conjunction with iMANAGE as our document repository.

Navigant Finding 10: The process for follow‐up and resolution of issues as identified by External Quality

Review (EQR) is ineffective.

Navigant Recommendation 10: DOM should implement follow‐up procedures from EQRs and track CAPs

to completion.

DOM Initial Response: DOM requires the EQRO contractor to follow up quarterly with CCOs and track

CAPs to completion. Attached are Quarterly EQR CAP Updates from contractor, and also attached are

EQR biweekly Progress Reports to DOM.

DOM Detailed Response: DOM contracts with an EQR vendor to audit yearly CCO performance and

quality. The EQR vendor issues findings and recommendations, places CCOs on a CAP, if necessary, and

follows up/monitors CCO completion of the CAP on a quarterly basis. DOM receives biweekly progress

reports from the EQR vendor regarding CAP progress.

The biweekly progress reports are brief timelines and notations, which are reviewed by DOM to ensure

that the external quality review organization (EQRO) contractor is meeting contractual requirements,

and to ensure that the CCOs are compliant with the production of documents and responses to CAPs

and reviews. DOM interacts with the EQRO contractor continuously throughout the year to discuss CCO

performance and plans for the subsequent annual review. The contractor is required to review

compliance of the entire contract; however, as a result of previous annual reviews and CCO CAPs, DOM

refined the review to focus the core areas on: Quality management, utilization management, provider



services, member services, grievances and appeals, and call centers. DOM has incorporated findings

recommendations within subsequent MississippiCAN contracts, such as provider credentialing. The

EQRO contractor has also assisted CCOs in the development of quality improvement projects for validity

and program improvement. Additionally, to ensure greater effectiveness of EQRO Reviews, DOM has

expanded the review of the EQRO reports to multiple offices, including the Office of Contract

Compliance.

MississippiCAN:Quality

Navigant Finding 11: There is a lack of an updated Quality Strategy to guide MississippiCAN quality

improvement activities.

Navigant Recommendation 11: DOM should update the quality strategy to meet federal requirements.

DOM Initial Response: DOM maintains compliance with C.F.R. §438.340 requiring states to review and

update the quality strategy as needed, but no less than once every three years. Updates are in process

to meet the July 1, 2018, deadline.

DOM Detailed Response: MississippiCAN has positively impacted the lives of its members through

quality and clinical programs. Below are a few selected highlights of those improvements from both

CCOs (as received):

Unitedhealthcare Community Plan (UHC) has targeted initiatives to ensure that not only our

diabetic members receive required annual screenings, but also improve the control levels of that

disease process. Of all recommended diabetic screening the eye exam required the most

intervention. Since implementation this rate has improved by 65.9%. Diabetes control levels

also improved by 30.92%.

The Quality, Clinical, and Community Outreach teams collaborated to improve our Women’s

Health measures to ensure our female members completed their required breast and cervical

cancer screenings. As a result of this outreach, the breast cancer screening rates improved

55.58%, while the cervical cancer rates increased by 43.36%.

When pregnant mothers were enrolled in the MississippiCAN program in 2012, we focused on

education and outreach that would improve timeliness of prenatal and postpartum visits.

Within the first two years of working with this population, our prenatal scores improved by

35.59% and our postpartum

Members with Behavioral Health conditions require a great deal of coordination between

clinical and behavioral health case managers, as well as, quality managers to ensure these

members follow up with a Provider in a timely post mental health hospitalization. Since

managing these members, this rate has improved by 51.35% for 7 day and 25.83% for 30 day

follow up.



The EPSDT program has been beneficial in providing access and services that keep children in

Mississippi up to date on their most basic health needs such as immunizations and wellness

screenings. UnitedHealthcare has been diligent in providing member and provider education,

community outreach, partnerships, performance improvement projects and healthy rewards to

assist our members to take advantage of their most important health benefit. From 2012 to

current, our members have experienced a 270% increase in pediatric wellness exams

compliance.

In 2011, CMS published its Oral Health Strategy to improve access and increase utilization of

pediatric dental benefits under EPSDT. In response to the national strategy, UnitedHealthcare

formed a relationship with the Mississippi Department of Oral Health, the state Dental Director

and our national dental director to discuss opportunities to implement a statewide ECC (early

childhood caries) training, education and support program for our medical practitioners and the

parents/guardians of our members who are under three years old. The following represents the

progress in MSCAN members receiving topical fluoride varnish:

Magnolia Health: ER Diversion Initiative Outcomes

Total # ER Visits

o 2014 – 144,976

o 2015 – 198,022

Per Member Per Month (average)

o 2014 ‐ $143.62

o 2015 ‐ $80.32

Member Percentage with 2 or more visits

o 2014 – 2.57%

o 2015 – 1.22%

Member Percentage with 3 or more visits

o 2014 – 0.74%

o 2015 – 0.30%

Magnolia Health: Low Birth Weight Infants

Percentage of infants born less than 2500g

o 2014 – 18.43%

o 2015 – 15.27%

o 2016 – 13.74%

Percentage of deliveries less than 37 weeks

o 2014 – 20%

o 2015 – 17.18%

o 2016 – 13.96%



Navigant Finding 12: DOM has limited performance measure monitoring and improvement processes to

confirm MississippiCAN quality improvement goals are met.

Navigant Recommendation 12: DOM should collect audited performance measurement data from CCOs

and assess CCO performance.

DOM Initial Response: DOM disagrees with this finding as both CCOs are in contract compliance with

submission of performance goals. DOM conducts in‐depth reviews of CCO performance measures

against regional and national benchmarks. Performance measure results are examined internally and

collectively with the Quality Task Force and the Quality Leadership team.

DOM Detailed Response: DOM disagrees with this finding. Both CCOs are in contract compliance with

submission of performance goals. DOM conducts in‐depth reviews of CCO performance measures

against regional and national benchmarks. Performance measure results are examined internally with

the Quality Task Force and the Quality Leadership Team. This information is used to make adjustments

in directing the quality improvement activities of the CCOs. An example of how this is done is through

the case management reviews of targeted beneficiaries based on specific disease categories and levels

of risk ranging from low to high risk beneficiaries.

Navigant Finding 13: There are no quality incentive programs for CCOs.

Navigant Recommendation 13: DOM should implement value‐based purchasing methodologies for

CCOs.

DOM Initial Response: The current MSCAN contract and the Model Contract released with the January

2017 MSCAN RFP indicate that DOM may implement value‐based purchasing at its option

DOM Detailed Response: DOM disagrees with this finding. The current MississippiCAN contract and the

Model Contract released with the January 2017 MississippiCAN request for proposals (RFP) indicate that

DOM may implement value‐based purchasing at its option.

DOM worked with both CCOs to implement inpatient hospital savings during the 2012 calendar year.

The 10 percent savings achieved for inpatient was reflected in payment data used to set capitation rates

to achieve ongoing savings. The two attached letters from DOM’s actuary, Milliman, dated January 14,

2016, (see Appendix 13A) and January 19, 2016, (see Appendix 13B) reflect the savings achieved and the

savings bonus or penalty paid to each CCO. Thereafter, Milliman reflected an expected Inpatient Savings

Assumption by Rate Cell such as shown in their Annual Rate Setting letter dated June 15, 2015, (see

Appendix 13C). With the most recent rate setting period for July 1, 2016, through June 30, 2017,

Milliman has used the most recent historical cost trends along with expected inflation factors to project

the expected inpatient rates as shown in their letter dated November 29, 2016 (see Appendix 13D). The

assumption is it would not be reasonable to expect a 10 percent inpatient savings on a continuing basis.



It is not an appropriate expectation for a new CCO to have immediate results on day one of a contract.

The value‐based purchasing model, measures and targets have to take this into consideration.

An example of value‐based purchasing that DOM’s CCOs are utilizing with some of its primary care

physicians (PCP) is evidenced in its Participating Provider Agreements, which incorporate quality metrics

such as Inpatient Care Transition, Emergency Room Visit Transition and High Risk Patient Monitoring for

incentive payment arrangements.

DOM has worked with its fiscal agent and CCOs on a number of collaborative items already including

potentially preventable readmissions, potential preventable complications, and a prenatal care task

force.

Navigant Finding 14: There is limited inpatient utilization available to assess program performance.

Navigant Recommendation 14: DOM should collect inpatient data and conduct further analysis to

understand the impact of including inpatient services within MississippiCAN.

DOM Initial Response: DOM currently collects inpatient data in MMIS and conducts analysis on data to

understand the impact of including inpatient services with MississippiCAN. Both CCOs have received

Inpatient Hospital Services Discrepancy Reports for review and response (see Appendix 14A, Appendix

14B). Also, beginning December 2015 through 2016, the CCOs were sending weekly Inpatient Reports to

view trends associated with this new process.

Provider Outreach was also conducted by DOM Nurses regarding complaints about the application of

clinical criteria for Inpatient Hospital Services. The information obtained from the hospitals was very

useful and was provided to CCO for provider education.

DOM Detailed Response: Hospital Programs and Services (HPS) assists in the validation of encounter

data for accuracy as mandated by 42 C.F.R. § 438.818. This is done by ensuring the CCOs implement

system changes for reimbursing providers using DOM’s policy. HPS also reviews encounter data to

ensure the information received in the Medicaid Management Information System (MMIS) is complete.

HPS creates and conducts reviews for monthly management reports to monitor encounter claims.

Attached is a copy of the monthly report review for inpatient utilization (see Appendix 14C, Appendix

14D). The CCOs also send weekly inpatient payment validation reports for review (see Appendix 14E,

Appendix 14F).

Navigant Finding 15: CCOs have not consistently demonstrated effective quality improvement initiatives.

Navigant Recommendation 15: DOM should implement continuous and stronger monitoring of CCO

quality initiatives.



DOM Initial Response: DOM disagrees with this finding. The 2016 EQRO review commended the CCOs

on improvements to performance improvement projects. Navigant based this finding off of one report

which does not substantiate this finding. Both CCOs have demonstrated improvement each year,

despite frequent changes to services and enrollment.


is required.

Navigant Finding 16: The 2015 EQR indicates provider access for MississippiCAN beneficiaries is not

improving.

Navigant Recommendation 16: DOM should increase monitoring of CCO provider networks.

DOM Initial Response: Both CCOs contract with vendors to conduct access and availability studies. Both

EQR and DOM have directed CCOs to utilize these vendors to update provider files with more accurate

information, and both have implemented measures to update directory and PCP information.

DOM Detailed Response: DOM shares Navigant’s concern over provider access for MississippiCAN

beneficiaries and all Medicaid beneficiaries. This problem impacts Medicaid and Mississippi statewide,

due to Mississippi having the lowest physician to population ratio in the union. This issue is exacerbated

by the fact that Mississippi has a higher acuity (sicker) patient caseload than all other states in the union.

Navigant Finding 17: MississippiCAN providers contracting with United have low satisfaction rates.

Navigant Recommendation 17: DOM should collaborate with CCOs to improve provider satisfaction.

DOM Initial Response: DOM began conducting Provider Services meetings from mid‐2015 to mid‐2016

with each CCO regarding contractual requirements and provider issues. Simultaneously, DOM began

meeting with CCOs regarding Inpatient Hospital Services implementation.

DOM Detailed Response: DOM began conducting Provider Services meetings mid‐2015 with each CCO

regarding contractual requirements and provider issues. Simultaneously, DOM began meeting with

CCOs regarding inpatient hospital services implementation.

In specific regard to UHC, DOM has met regularly with management of UHC to review and discuss

resolutions to provider issues such as those from North Mississippi Medical Center.

DOM is active with both CCOs to improve provider satisfaction by:

Scheduling nine provider workshops to provide education and policy updates

Tracking denials in total and by specific payment categories



Reviewing call center details to track the volume and types of calls, and to follow up on the

timing and resolution activities of the CCOs

Navigant Finding 18: There is limited beneficiary satisfaction data available.

Navigant Recommendation 18: DOM should collect beneficiary satisfaction data from CCOs and assess

CCO performance.

DOM Initial Response: Both CCO CAHPS surveys for 2016 have been received. All years are available.

Both CCOs have implemented measures to improve beneficiary satisfaction. DOM is presently reviewing

2017 CAHPS survey for implementation.


is required.

MississippiCAN:Cost‐Effectiveness

Navigant Finding 19: There has been no independent assessment of the cost‐effectiveness of the

MississippiCAN program.

Navigant Recommendation 19: The State Legislature should commission a study to evaluate the cost‐

effectiveness of the MississippiCAN program.

DOM Initial Response: DOM has provided to the legislature the study evaluating the cost –effectiveness

of the MississippiCAN program. The study evaluated the program from inception January 1, 2011

through June 30, 2016, the last state fiscal year end. The report indicates that the state has saved

$210.5 million through the use of Medicaid managed care. A copy of this report prepared by Milliman

will be included in the DOM formal response to this report.

DOM Detailed Response: As Navigant acknowledged in their January 15, 2017, Project Update and

Summary of Interview Findings on this project, the MississippiCAN program has avoided $210.5 million

since its inception in 2011. However, Navigant recommends another study due to a finding that there

has been no independent assessment of the cost effectiveness of the program. The current study was

performed by Milliman (See Appendix 19). DOM offers that a more “cost‐effective” approach to

determining the success of MississippiCAN’s cost effectiveness is to continue to utilize and rely upon

information provided by Milliman.

Milliman is a highly reputable, national actuarial firm recognized by CMS to provide actuarially sound

rates and opinions. In Navigant’s findings, there is no mention of the Milliman report issued in

December 2016; instead nine measures are listed for evaluating cost effectiveness in a follow‐up study.

DOM contends that Milliman took five of these measures into consideration when preparing their



findings. One measure considered is “the necessity and/or benefit of DOM increasing current SFY

payments to CCOs following a legislative session that funded DOM at approximately $75 million below

spending projections.” CMS requires that the payments to CCOs be based on actuarially sound rates

determined to cover the approved program. State law outlines what services DOM covers and the

payment level. Therefore, to meet the requirements of CMS and state law, DOM does not have the

discretion with CCO payment rates as implied.

However, Navigant also recommends a comparison of MississippiCAN per beneficiary per month and

non‐claims costs to peer states and other benchmarks that include the potential for distortion, including

likely differences in provider reimbursement changes over time. For example, factor in the impact

MHAP has on per member per month rates for comparison. Other states may or may not have similar

payments of a different amount built into their rates. There would be a significant difference for

comparison. Navigant also recommends the comparisons of annual growth in spending to national

indexes, which DOM has provided to the Legislature. Additionally, Navigant recommends studying the

impact of duplicative or unnecessary services, emergency department visits, and inpatient stays, all for

which CCOs have built‐in controls to minimize misuse.

Somewhat different from the Navigant recommendation to review potentially preventable admissions,

the Conduent Payment Method Development has analyzed potentially preventable readmissions and

complications in the inpatient setting for DOM. This information has provided a baseline for evaluating

coordinated care performance for future periods, which we will do. Lastly, Navigant did not recommend

a study of the impact of the premium tax on cost‐effectiveness. The premium tax continues to be a

significant, positive component of the cost‐effectiveness of coordinated care.

DOM disagrees with the recommendation to spend valuable resources for a study that is thoughtfully

prepared currently by national experts with minimal additional expense.

MississippiCAN:ProgramIntegrity

Navigant Finding 20: DOM maintains a clear and comprehensive SOP to coordinate CCO Fraud and

Abuse activities.

Navigant Recommendation 20: DOM should continue to use and refine the SOP to reflect additional

terms and conditions in the new CCO contract.

DOM Initial Response: DOM agrees that it should continue to maintain a clear and comprehensive SOP

to coordinate fraud and abuse activities.


is required.



Navigant Finding 21: DOM uses strong templates for exchange of data between DOM and CCOs.

Navigant Recommendation 21: DOM should continue to use and refine the CCO reporting templates.

DOM Initial Response: DOM agrees that it uses strong templates for exchange of data between DOM

and CCOs.


is required.

Navigant Finding 22: OPI approval and coordination of CCO program integrity activities on a case‐by‐case

basis may require additional staff resources.

Navigant Recommendation 22: DOM should review procedures related to the CCO reports and fraud

complaints to determine the optimal allocation of staff and resources between FFS and managed care

activities.

DOM Initial Response: As a point of clarification, the Offices of Policy and Appeals are not in the Office of

Program Integrity. At this time, the Office of Program Integrity is adequately staffed to conduct the

necessary reviews and investigations for FFS and managed care. When changes occur, DOM will address

additional staffing needs at that time.


is required.

Navigant Finding 23: Inconsistent and non‐CCO specific information related to program integrity in the

Annual Report makes it challenging to evaluate program performance year over year and assess trends.

Navigant Recommendation 23: DOM should develop consistent and complete annual reporting related

to program integrity for trending and analysis.

DOM Initial Response: Information contained in the Annual Report mirrors that required by State law,

specifically Miss. Code Annotated Section 43‐13‐129. If more information is requested, DOM can

certainly provide that information and include it in future reports.


is required.

Navigant Finding 24: DOM has limited documentation available to assess program integrity activities and

performance.



Navigant Recommendation 24: DOM should perform a full assessment of OPI and CCO program

integrity.

DOM Initial Response: DOM will continue to review the Office of Program Integrity and its role with the

CCOs. Further, each Medicaid State Agency is organized very differently and has options as how to

operate the Medicaid program. Without a thorough review of the State Plans and managed care

programs of the other “comparison states,” it is inaccurate to classify these states as comparisons to

Mississippi, especially considering the recovery options available to the States.

DOM Detailed Response: DOM has further reviewed Navigant’s report and would like to reiterate

Navigant’s points that the dollar figures of recovery reported by the Office of Program Integrity (PI) are

only representative of a portion of activities performed by PI. The office has a variety of functions which

include, but are not limited to: Conducting regularly scheduled meetings to discuss issues related with

fraud, waste and abuse with both CCOs, DOM’s Medicaid‐Medicare partner AdvanceMed, and the

Medicaid Fraud Control Unit of the attorney general’s office; providing oversight of the CCOs’ program

integrity activities; performing provider and beneficiary surveillance utilization reviews; performing

collaborative audits with the Medicaid Integrity Contractor; managing the audit activities of the

Recovery Auditor Contractor; educating providers and beneficiaries about fraud, waste, and abuse at

events and conferences; performing new provider inspections and post payment audits on providers;

performing identification card abuse investigations regarding beneficiaries; terminating providers

excluded by the Office of Inspector General, U.S. Department of Health and Human Services;

terminating providers revoked by Medicare or debarred by other states; and terminating providers that

have been terminated for cause by other states’ Medicaid programs. All of these activities are aimed at

recovering overpayments, referring cases for prosecution and implementing cost‐avoidance procedures

in attempts to eliminate unnecessary expenditures of Medicaid funds.

Unfortunately, the timing of Navigant’s review of DOM was also a busy time for PI as it was in the midst

of procuring a new Recovery Audit Contractor. PI was unable to devote adequate staff time and

resources to create documents requested by Navigant, which were deemed low priority requests by

Navigant, under the strict deadline.

DOMOperations:StakeholderCommunication

Navigant Finding 25: DOM reports to the State Legislature lack clarity.

Navigant Recommendation 25: DOM should redesign reports sent to the State Legislature.

DOM Initial Response: DOM provides the information monthly to the Legislature in the format and

including the information requested. DOM provides information to the Legislature in a number of

formats. We continually strive to improve the information provided to the Legislature to assist them in

their decision‐making. We are, at all times, careful to provide correct and meaningful information.



DOM Detailed Response: Section 11 of our appropriations bill, House Bill 1650 of the 2016 session,

describes the monthly report required for submission to the Legislative Budget Office (LBO) and the

monthly cash flow projection to be made available upon request. Section 7 describes the format of the

budget request required for submission to LBO. The requirements read as follows:

SECTION 11. The division shall provide statistical and financial reports on a monthly basis to the

Legislative Budget Office. These reports shall include, but are not limited to, an accounting of all

funds spent and participant statistics medical program, the CHIP program, the Dialysis

Transportation program, and each of the Home‐ and Community‐Based Waiver programs, and

an accounting of all funds spent in the administrative program.

The Division of Medicaid shall perform its cash flow projections on a predetermined monthly

schedule and make this and any other information requested available, upon request, to the

Chair of the Senate Public Health and Welfare Committee, the House Public Health and Human

Services Committee, the House Medicaid Committee, the House and Senate Appropriations

Committees as well as the Legislative Budget Office.

SECTION 7. It is the intention of the Legislature that the Governor's Office ‐ Division of Medicaid

shall maintain complete accounting and personnel records related to the expenditure of all

funds appropriated under this act and that such records shall be in the same format and level of

detail as maintained for Fiscal Year 2016. It is further the intention of the Legislature that the

agency's budget request for Fiscal Year 2018 shall be submitted to the Joint Legislative Budget

Committee in a format and level of detail comparable to the format and level of detail provided

during the Fiscal Year 2017 budget request process with the Children's Health Insurance

Program (CHIP) being separated from the Medical Services Program and submitted as a separate

program. In addition, the performance measures reported for the Medical Services Program

shall include an unduplicated case count of individuals served by eligibility status, and the

number and the costs of emergency room visits.

DOM complies with the content and timeline requirements in law for reports. The most recent monthly

LBO report for the month of January 2017 is attached (see Appendix 25), and provides high level

information. Throughout the past, DOM has worked with LBO to adjust the information and format of

the report. Due to the many changes that have occurred in the coordinated care program over the last

few years, the medical services graphs were removed so as not to provide information that could appear

misleading without a thorough review. Much of the information suggested by Navigant for inclusion in

the monthly reports is included in the annual budget submission to LBO. DOM is available at any time to

meet and discuss possible additions to improve the value of the report to the LBO and legislative leaders

(they also receive the report monthly).

Navigant listed five bullets indicating information not included in the report in the findings section and

four different bullets for what DOM should add in the recommendations section. DOM tracks

MississippiCAN enrollment levels, as suggested, and tracks the enrollment by category of eligibility and



coordinated care plan. DOM tracks expenditure data by beneficiary count (as suggested by Navigant);

those who are enrolled in coordinated care, as well as other populations.

In addition, DOM tracks comparisons of a number of components to prior year and budget monthly and

year‐to‐date and tracks trends in expenditures and enrollment. DOM would have appreciated more

specific recommendations for data and format presentations. For example, Navigant states in their

finding that “the reader cannot easily understand how expenditures or number of participants have

increased or decreased from the previous year.” The DOM monthly LBO report shows both current data

and prior year enrollment and expenditure data, along with count and percentage changes,

accompanied by notes. The finding is vague and subjective because it does not offer a clear explanation

or suggestion for the recommendation.

Navigant also notes that the LBO report does not break down MississippiCAN program expenditures.

Because of the inherent delay in receiving encounter data in the DOM data warehouse, the information

is not obtainable for the month within the 25 days allowed for submitting the report. This is a normal

characteristic of Medicaid coordinated care programs. Other recommendations for the LBO monthly

report, including “supporting program data” and “actions DOM and CCO’s are taking for identified risk

areas or issues” are outside of the historical scope of the report.

While DOM emphasizes willingness to amend the content and format of the report, DOM disagrees with

Navigant’s representation as a finding ‐ the vague statement of omission, the inclusion of information

that is not possible to present in a monthly report, and the information outside the scope of the

legislation. DOM is disappointed with the lack of meaningful suggestions in the recommendations,

because Navigant failed to provide example metrics DOM might consider using or what could be

considered "key”, and did not present suggestions for “graphics, taglines and call outs to facilitate

review of the data presented.”

Navigant Finding 26: DOM conducts proactive outreach to providers and beneficiaries.

Navigant Recommendation 26: DOM should continue outreach and work with CCOs more closely to

improve provider response times and rates.

DOM Initial Response: DOM will continue to conduct proactive outreach and continuing education to

providers and beneficiaries, and identify ways to work more closely with the CCOs.

DOM Detailed Response: The Office of Provider Beneficiary Relations (PBR) oversees provider and

beneficiary outreach and education. PBR handles inquiries from Medicaid providers, beneficiaries, and

the general public received through the main DOM switchboard, external website and other inquiries

that do not qualify as official requests for information (RFI). PBR employees are also dedicated to

conducting provider visits, speaking on behalf of DOM at community events, providing information at

health fairs, and coordinating the production of the quarterly printed Provider Bulletin.



PBR’s outreach team and provider field representatives work in an integrated partnership with DOM’s

fiscal agent and the Office of Coordinated Care coordinating regional provider and beneficiary

workshops to educate stakeholders. These workshops offer updated policy education, a hands‐on

resolution component for issues on claims submission and reimbursement for the providers, as well as a

face‐to‐face educational setting on covered services and programs for beneficiaries.

To ensure transparent lines communications, PBR monitors the activities of the CCOs by participating in

monthly management meetings (headed by the Office of Coordinated Care) with each CCO.

On a monthly basis, PBR tracks the following activities:

Number of calls received through the DOM switchboard and those directed to provider relations

and beneficiary relations representatives

The call abandonment rate, response time for answering calls and other related call concerns for

the DOM switchboard and fiscal agent call center

Number of outreach and education events, as well as speaking requests for PBR and offices

agency wide

Number of provider visits (regular provider visits for claims concerns, unannounced provider site

visits and newly enrolled providers)

Number of RFIs completed by PBR staff

Number of unannounced walk‐in visitors to the central office

Number of direct provider contact that the provider representatives receive per email or direct

phone call (voice messages)

Provider Relations also monitors and works reports to aid providers in receiving payments for claims

that have not processed correctly.

Additionally, PBR staff monitors the calls received through the fiscal agent’s agency call center. PBR

receives a monthly report from our fiscal agent on the statistics of calls received and random samples of

calls received are reviewed by supervisors.

An example of DOM being proactive are the reports from both CCOs of the “2016 Summary of Top 10

Categories of Calls, Issues, Complaints” reports (see Appendix 26A, Appendix 26B), which were recently

presented to DOM at a monthly management review meeting. These reports, which include both

providers and beneficiaries, indicates to the CCOs that DOM expects their oversight of these issues, the

agency is tracking their results, and DOM is interested in the details of the issues down to the names,

dates, places and events.

This level of reporting gives DOM insight into what actions the CCOs are taking to address issues, what is

going on with providers and beneficiaries to establish a baseline of information and experience for

future year comparisons, and how the CCOs respond to issues over time. For example, if DOM

continually identifies an issue with access to PCPs, DOM can look more closely at availability of PCPs.



Navigant Finding 27a: DOM lacks a comprehensive communication strategy.

Navigant Recommendation 27a: DOM should create a stakeholder communication plan.

DOM Initial Response: DOM has a comprehensive communication strategy plan, and would have

provided it upon request.

DOM Detailed Response: The Office of Communications is responsible for the messaging to our internal

and external audiences. This includes the design, writing, layout, editing, and distribution process for the

external DOM website, publications, collateral materials, and digital media. This area also handles public

relations, issues official statements and is the contact for news media requests.

Communications houses the Office of PBR, official Requests for Information process, the Office of

Project Coordination, Disaster Management, Operations and Property Management. As previously

stated, PBR is responsible for outreach and educational events for providers and beneficiaries about

Medicaid programs and services. Additionally, Communications is in charge of Health Insurance

Portability and Accountability Act of 1996 (HIPAA) compliance and houses the privacy officer.

DOM is deliberate about making strategic plans. Each year, the Communications team conducts a

situational analysis of the agency, and then creates a strategic communications plan targeting various

stakeholder groups for the following year. Often times, employees are spread thin and juggle multiple

projects simultaneously to fulfill daily duties and responsibilities. Strategic planning is a valuable road

map for success and assures employees that leaders are forward thinking.

DOM has quarterly stakeholder meetings with MHA, the University of Mississippi Medical Center

(UMMC) and periodic meetings with other provider groups. When invited to meetings, professional

groups and community events across the state, agency employees participate as Medicaid

representatives and speakers.

Navigant Recommendation 27b: DOM should develop report dashboard summary reports to share with

stakeholders.

DOM Initial Response: Currently, MedeAnalytics supplies DOM with dashboard summaries. See below

for a sample dashboard report:

• Top 1000 by total costs

• Top 1000 by total emergency room visits

• Top 1000 by total readmissions

• Quality measures

• Pregnancy

• EPSDT reports

Reports are shared with stakeholders as warranted or requested.




is required.

Navigant Recommendation 27c: DOM should enhance DOM’s website to improve transparency.

DOM Initial Response: DOM will continue to update DOM’s website. We will continue to post additional

information and ensure compliance with all CMS regulations; the regulations referenced go into effect

July 1, 2017, and July 1, 2018.

DOM Detailed Response: DOM strives to reasonably accommodate all our target audiences through our

communications tools, including the external website at http://medicaid.ms.gov. Since the site is built

within a content management system there are a number of benefits such as improved workflow

management, consistent brand and navigation, remote access, and mobile‐ready responsive design. The

website was also developed with a variety of stakeholders in mind and includes tools for font size

increase/decrease, language translation, prominent search features, and a site map. To ensure

adherence to web standard guidelines, Web Content Accessibility Guidelines checks are routinely

performed to identify and mitigate potential issues.

The DOM website is reviewed, maintained and updated on a regular basis. The Office of

Communications utilizes a web governance suite to monitor quality assurance, accessibility, analytics,

and response time. External website change requests are submitted from program areas throughout the

agency and monitored daily. Due to federal regulations, the timeliness of postings for items such as

public notices for waivers and state plan amendments is paramount. Postings that correlate with a

federal timeline or are considered breaking news for providers and/or the public are made available on

the homepage for ease of access and transparency. Two internal staff members are responsible for

handling external website requests and they are dedicated to responding to each one expediently.

DOMOperations:StaffTurnover

Navigant Finding 28: DOM maintains a low turnover rate in comparison to benchmark states; however,

staff turnover is still costly and can lead to the loss of institutional knowledge.

Navigant Recommendation 28: DOM should develop SOPs and a training program to retain institutional

knowledge.

DOM Initial Response: Each office created SOP’s beginning in August 2014 and has updated them

annually. DOM has several training program that include but are not limited to employee engagement

and onboarding of new employees.

DOM Detailed Response: DOM recognizes that staff turnover is costly and can lead to the loss of

institutional knowledge. Turnover can have significant negative impacts on any organization and its



ability to achieve its mission. Research indicates the cost of turnover is one half to three times an

employee’s annual salary. The cost of turnover includes:

Lowered productivity

Overworking remaining staff (job satisfaction and morale go down, and the possibility of

additional turnover increases because existing staff has to pick up slack)

Loss of institutional knowledge

Recruiting and interviewing costs

Training costs including time

If DOM’s turnover is calculated at being equal to the annual salary of the departing employee, the SFY

2015 cost of turnover alone was over $4.2 million ($4,269,104).

Because of the substantial impact that unwanted turnover can have, and has had, DOM has deliberately

worked to reduce agency turnover by utilizing the tools available to advance targeted groups of

employees resulting in higher pay and job satisfaction. In addition, DOM’s executive director rolled out

an employee engagement project designed to improve communication, trust, individual growth, and

employee recognition. Lastly, DOM has recently implemented a new onboarding process to educate

newly hired employees on the internal workings of DOM and to curtail turnover among those

employees who have worked for DOM less than one year.

Because of these efforts DOM turnover within key identified job classes has decreased 35 percent when

compared to the same periods of time from previous years.

Regarding SOPs, each office of DOM is required to have SOPs on file for every relevant function.

DOMOperations:Training

Navigant Finding 29: Navigant did not identify a career‐building Medicaid training program.

Navigant Recommendation 29: DOM should develop a long‐term training program to address DOM’s

goals and objectives.

DOM Initial Response: Each year, employees complete a written Individual Action Plan, jointly

developed by the employee and the reviewing supervisor to foster individual performance growth. The

Office of Workforce Development within HR identifies training needs based on legal compliance and

DOM strategic needs DOM has developed highly successful internal training programs. In 2016 DOM

implemented two internal training programs, the Leadership Development Series and the Office

Administration Development Program. In addition, DOM is implementing a new internal development

program we’re calling, “The Launching Pad”.

DOM Detailed Response: While DOM cannot be sure of Navigant’s definition of “career‐building

Medicaid training program”, we submit the following in response.



DOM utilizes a robust, three‐pronged approach to address training needs.

1. Each year, employees complete a written Individual Action Plan, jointly developed by the

employee and the reviewing supervisor to foster individual performance growth. Together, they

identify development needs and coordinate with Human Resources to schedule employees for

the needed training.

2. The Office of Workforce Development within Human Resources identifies training needs based

on legal compliance and DOM strategic needs (e.g., orientation, Health Insurance Portability and

Accountability Act (HIPAA) compliance, sexual harassment, cardiac pulmonary resuscitation

(CPR), technical writing, etc.).

3. DOM has developed highly successful internal training programs. In 2016, DOM graduated 59

employees from its prestigious Leadership Development Series. Employees in administrative

positions participate in the Office Administration Development program with 70 graduates in

2016. In addition, DOM is launching a new internal development program focused on Medicaid

specialist training in the first half of 2017 and most Medicaid specialist employees will be eligible

(nearly 50 percent of total agency employees) to participate. DOM recognizes that the most

effective succession planning strategy includes developing talented employees, creating bench

strength at all levels of the organization. The overarching goal of The Launching Pad is to assure

a steady pipeline of potential leaders to secure DOM’s commitment to service well into the

future.

*Note: Nurses, social workers, certified public accountants, attorneys and others holding professional

licenses/certification are typically required to accrue a designated number of continuing education

credits per year to maintain their license/certification.

ContactInformationIf you have questions or need more information, please contact:

Wil Ervin

Director of Government Relations

Phone: 601‐359‐6140

Toll‐free: 800‐421‐2408

Fax: 601‐576‐6342

Email: [email protected]

Website: medicaid.ms.gov

Mississippi Division of Medicaid

Walter Sillers Building

550 High Street, Suite 1000

Jackson, MS 39201



Appendices

Medicaid’sDetailedResponse

toNavigant’sOperationalandPerformanceAssessmentReport

DEPARTMENT OF HEALTH & HUMAN SERVICESCenten for Medicare & Medicaid Services7500 Security Boulevard, Mail Stop 00-00-00Baltimore, Maryland 21244-l 850

Division of Medicaid and Children's Health Operations

March25,2016

David J. Dzielak, Ph.D.Executive DirectorMississippi Division of Medicaid550 High Street, Suite 1000Jackson, MS 39201-1399

Dear Dr. Dzielak:

In accordance with 42 CFR 438.6 the Centers for Medicare & Medicaid Services (CMS) hasreviewed and is approving Mississippi's submission of Coordinated Care Organization (CCO)capitation mtes for the period July 1, 2015 to June 30, 2016 and the contracts for inpatient hospitalservices. The contract and rate certifications were received by the CMS Regional Office onDecember 16, 2015.

Specifically, Amendment 3 is the development ofJuly 1, 2015 - June 30,2016 Coordinated CareOrganization (CCO) capitation rates for the original population and non-newbom children populationof Mississippi Coordinated Access Network (MississippiCAN). Amendment 5 removes the carve-out for inpatient hospital sewices and implements the Mississippi Hospital Access Payments(MHAP) program in accordance with state law.

While the rates have been approved, the review noted that the Health Insurance Providers Fee is notincluded in the capitation rates. CMS looks forward to receipt of the amendment to these rates toaccount for the Health Insurance Fee and the state should provide revised rates and rate ranges oncethe amounts ofthe fees are known.

It was also noted that the Adminishative expenses lack detail and supporting documentation.CMS recommends the state provide more detail on the development of administrative expenses infuture rate development.

Lastly, the state implemented the Mississippi Hospital Access Program (MHAP) effective December1, 2015. This program incorporates state directed pass-though payments to specific hospitals into itsmanaged care rate development for the period covered under this review. As outlined in a separatecommunication to the state on MHAP, dated March 21, 2016, these payments violate 42 cFR 438.60.In future rate development and consistent with the 2016 Medicaid Managed Care Rate DevelopmentGuide, CMS requires that the state more clearly document the existence and extent ofthese pass-through payments. CMS also requires the state to develop a corrective action plan, within 120 daysof this correspondence, outlining the state's timeline, key metrics and milestones to move from a

(crvrs

Appendix 1A

pass-through payment structue that is divorced ftom actual utilization to a payment structure withclear linkages between payment and the utilization, quality, or outcomes ofdelivered services.

Mississippi's current MCO contracts expire on June 30,2017. The contract and rates are approvedfor the purpose offederal financial participation effective March 25,2016.

Ifyou have questions concerning this letter, please feel liee to contact Caletha Henry at (404)562-7506 or Tandra Hodges at (404)562-7409, Division of Medicaid and Children's Health Operations.

Sincerely,-n

taxlr.z- plz(-4 .. ^.Jacl(re ulazeAssociate Regional AdministratorDivision of Medicaid & Children's Health Operations

Appendix 1APage 2

O F F I C E O F T H E G O V E R N O R

Walter Sillers Building | 550 High Street, Suite 1000 | Jackson, Mississippi 39201

Toll-free 800-421-2408 | Phone 601-359-6050 | Fax 601-359-6294 | medicaid.ms.gov

October 27, 2016

Ms. Jackie L. Glaze Associate Regional Administrator Department of Health & Human Services Centers for Medicare & Medicaid Services Division of Medicaid & Children’s Health Operations 7500 Security Boulevard, Mail Stop 00-00-00 Baltimore, Maryland 21244-1850

Re: Mississippi Hospital Access Program Corrective Action Plan Demonstration

We have prepared the attached demonstration to show that our proposed Mississippi Hospital

Access Program (MHAP) funding pool is compliant with federal Medicaid managed care regulations

at 42 CFR 438.

Overview:

Effective December 1, 2015 the Mississippi Division of Medicaid (DOM) transitioned our inpatient

hospital program into managed care. Our outpatient hospital program was transitioned into

managed care a few years earlier.

It is our intention to enroll all Medicaid recipients into our managed care program with a few

exceptions. These include:

Dually Eligible Beneficiaries: Medicaid beneficiaries who are eligible to participate in bothMedicare and Medicaid. Since the Medicare program will be the primary payer for inpatient

and outpatient hospitals services utilized by these individuals we expect little or no claims

within our fee-for-service (FFS) program after the transition to inpatient hospital managed

care.

Beneficiaries in long term care including all waivers, and

Beneficiaries with hemophilia

In summary, it is our expectation that, after the transition to inpatient hospital managed care, only a

relatively small portion of our inpatient and outpatient hospital Medicaid volume will be paid under

the FFS program. The majority of the residual FFS claims will be associated with new Medicaid

beneficiaries’ inpatient or outpatient hospital services occurring prior to their enrollment in one of

our managed care plans.

Appendix 1B

MHAP Limit Demonstration:

Since it is our expectation that almost all of our inpatient and outpatient hospital services will be

associated with Medicaid beneficiaries who are, or will be, enrolled within our managed care

organization (MCO) program, we have approached our limit demonstration using historical

inpatient hospital FFS volume, and outpatient hospital FFS and managed care paid claims volumes

combined. The limit demonstrations show that our total payments (FFS and MCO) will be at or

below our calculated limit (Medicare Upper Payment Limit (UPL) analysis), including our requested

MHAP funding pool.

The most recent data we have available for the demonstration is information for each hospital that

corresponds with their cost reporting period ending in calendar 2014. Using this base-year data we

have prepared a 2016 MHAP limit demonstration.

Our inpatient hospital demonstration uses a Medicare payment based UPL analysis. This analysis

compared our expected FFS Medicaid payment per discharge, using our 2016 Diagnosis Related

Groups (DRG) payment simulation, to Medicare payments per discharge calculated using cost

report information. After adjusting Medicare payments per discharge for the acuity differences

between Medicare and Medicaid, the net difference per discharge is then multiplied by Medicaid

discharges to calculate the limit (or UPL). For those hospitals where a Medicare DRG weight is not available (Psychiatric hospitals and Critical Access Hospitals primarily) we used a cost-based UPL

methodology. This is essentially the same UPL analysis we have been using for the past 10 plus

years to demonstrate our compliance with the Medicare inpatient hospital UPL. Our analysis shows

that prior to making any MHAP payments, our inpatient hospital program has available funding of

$521 million from UPL.

We believe this approach is appropriate for calculating the inpatient hospital limit, since a condition

in Mississippi state law and within our MCO contracts mandates that MCO’s pay no less than our

FFS DRG inpatient hospital rates. We expect this contractual requirement will result in virtually all

of our MCO inpatient hospital payments to be identical to what would have been paid under our

FFS program.

We also prepared a cost-based limit (UPL) analysis for our outpatient hospital program. Using the

same 2014 cost report base-year data we inflated cost from 2014 to 2016 using the Medicare

without capital hospital prospective market basket index. We then subtracted expected Medicaid

payments using our 2016 Ambulatory Payment Classification (APC) payment simulation and

managed care payments. The analysis shows that we expect outpatient payments to provide $72

million from the calculated UPL limit.

In addition to the hospitals included in our limit demonstrations, there are several out-of-state

hospitals that have, and will continue, to provide inpatient and outpatient hospital services to

Mississippi Medicaid beneficiaries covered by our managed care program. We have not included

those entities, or their Mississippi Medicaid MCO volume, in our limit demonstrations. They have

been excluded from the analyses, since we did not have ready access to all of the data needed to

include them at this time. The room under our limit would have been even higher had we included

Appendix 1BPage 2

these out-of-state hospitals, which is yet another reason why we believe our MHAP request is

completely reasonable.

Summary:

Our Medicaid FFS and MCO programs are expected to make payments that are below the

approximately $593 million equivalent of the Medicare UPL ($521M inpatient and $72M

outpatient). We are seeking approval of $533 million in MHAP program authority. This would still

leave us approximately $60M below our inpatient and outpatient limit (UPL) combined funding

limitation. The MHAP program will be phased out over the next ten years, in accordance with

federal regulations, as we transition the MHAP funding towards payments based on volume and

quality improvement programs.

We have provided detailed narratives, and the actual limit analyses for both our inpatient and

outpatient hospital demonstrations. Please see Attachments A and B.

We are available to discuss these analyses with you at your convenience.

Sincerely,

David J. Dzielak, Ph.D.

Executive Director

Attachments

DJD: Mississippi MHAP limit Demonstration

cc: Karson Luther, DOM

Margaret King, DOM

Tara Clark, DOM

Sharon Jones, DOM

Keith Heartsill, DOM

Appendix 1BPage 3

Mississippi Medicaid 2016 Demonstration Year

Medicaid and Managed Care MHAP Limit Demonstration

Prepared September 22, 2016

The following document and related materials demonstrate Mississippi Medicaid’s MHAP Limit for Medicaid and Managed Care services. This demonstration is showing that Mississippi’s proposed MHAP funding pool is compliant with federal Medicaid managed care regulations at 42 CFR 438.

INPATIENT Limit DEMONSTRATION (UPPER PAYMENT LIMIT)

42 CFR 447.272 requires that a Medicaid agency’s payments for inpatient hospital services are no greater than a reasonable estimate of what would have been paid using Medicare payment principles. This requirement is frequently referred to as the Medicare upper payment limit (UPL). The steps below describe the 2016 Inpatient Limit demonstration (UPL calculation) for Mississippi.

1. The inpatient Medicaid UPL is calculated in the worksheet titled “2016Mississippi Medicaid IP UPL (MCO Limit).” For each Mississippi hospital, theaverage Medicaid payment per discharge was calculated. Total Medicaiddischarges and Estimated Medicaid IP DRG FFS Payments were obtained fromthe FY 16 APR-DRG simulation using paid claims data from July 1, 2013 throughJune 30, 2014 and applying them to the period that corresponds to each hospitalsMedicare cost report (CMS 2552-10) period ending in calendar year 2014. Thisdata was used to determine the average APR-DRG payment per stay. Estimatedmedical education payments were also calculated for the five MS hospitals thathave an approved medical education program by multiplying the medicaleducation add-on per case times the Medicaid discharges. The paymentsimulation estimates actual 2016 payments, therefore, inflation adjustments arenot necessary.

2. Medicare payments were obtained from each provider’s Medicare cost reportWorksheet E, Part A and Worksheet E-3.

3. Medicare Discharges were obtained from each provider’s Medicare cost reportWorksheet S-3.

4. The Medicare average payment per discharge was determined by dividing thetotal Medicare inpatient payments (Step 2) by total Medicare discharges (Step 3).Medicare payments were inflated from the midpoint of the cost report period tothe midpoint of the limit demonstration year. The inflation index utilized was theCMS Hospital Prospective Market Basket (as published by IHS Global Insight).

Appendix 1BAttachment A

5. The Medicare average inpatient payment per discharge was adjusted for the acuitydifference between Medicare and Medicaid. A simple average Medicare DRGweight (CMI) was calculated for all Non-CAH and Non-Psych Hospitals usingMedicaid paid claims data. For the limit analysis we used the most recent CMIcalculations available. For the hospitals where a Medicare DRG weight (CMI) isnot available (Psychiatric hospitals and CAH primarily) a cost based UPLmethodology was used.

6. The available limit room was then determined by subtracting the Medicaidaverage payment per discharge (Step 1) from the acuity adjusted Medicareaverage per discharge (Step 5) and then multiplying the difference by Medicaiddischarges. For critical access hospitals and psychiatric hospitals the UPLcontribution for those providers was set at 101 percent of their Medicaid costs,less expected Medicaid payments. The total UPL is calculated for each ownershipclass of hospitals according to their ownership type: non-state governmental(GNS), privately-owned (P), and state-owned (S).

OUTPATIENT UPPER PAYMENT LIMIT

A cost based Outpatient limit (UPL) is displayed on the “Outpatient Hospital UPL (MCO Limit)” worksheet of the demonstration. This involved calculating the outpatient costs of hospital services provided to Medicaid FFS and managed care patients, and then reducing this amount by any payments the hospitals received from the Medicaid FFS and managed care entities. Paid claims listings were used as data sources for both FFS and MCO. The calculation steps are outlined as follows:

1. The most recent cost and charge data from 2014 cost reports and correspondingMedicaid and managed care Provider Statistical & Reimbursement (PS&R)reports were used to arrive at the outpatient facility costs. Costs were calculatedby multiplying ancillary charges by corresponding cost-to-charge ratios (costreport mechanics).

2. The cost was then inflated from the midpoint of the cost reporting period to themidpoint of the limit demonstration year. The inflation index utilized was theCMS Hospital Prospective Market Basket (as published by IHS Global Insight).

3. Managed care payments were obtained from PS&R data and inflated with thesame methodology used in inflating the cost (step 2). Medicaid payments werecalculated from paid claims data for the period that corresponds to each hospitalsMedicare cost report (CMS 2552-10) period ending in calendar year 2014 in theFY 2016 OP simulation. The payment simulation estimates actual 2016payments, therefore, inflation adjustments are not necessary.

4. Remaining outpatient limit (UPL) was then calculated by taking inflatedoutpatient hospital costs less expected APC payments and managed carepayments (step 3).

Appendix 1BAttachment APage 2

2016 Mississippi Medicaid IP UPL (MCO Limit)

Facility Name Medicaid # Medicare #Ownership

Class

ESTIMATED MEDICAID IP DRG FFS PAYMENTS

MEDICAID DISCHARGES (See M'Care &

M'Caid CMI Data)

MEDICAID AVERAGE PER

DISCHARGE

Gross MEDICARE PAYMENTS

MEDICARE DISCHARGES

Inflated Medicare Average Per Discharge

MEDICARE ACUITY

MEASURE

Inflated Medicaid Cost Per

Discharge (101% for CAH)

ACUITY ADJUSTED MEDICARE

AVERAGE PER DISCHARGE


DISCHARGE

ADJUSTED DIFFERENCE M'Care less M'Caid, or Cost

less M'Caid AVAILABLE IP UPL (a) (b) (c) (d) (i) (j) (k) (l) (m) (n) (o) (p) (q)

Source: 2016 IP Simulation2016 IP

SimulationCalc. ((b)

/ (c)Sum ((e) thru

(h)) (cost report)Calc. ((i) / (j)) *

1+Inflation(CMI

Trending)

M'Caid Cost * 101% *

(1+Inflation) Calc. (k)*(l) = (d) Calc. ((n) - (0)) Calc. ((o) * (c))

1 3 5 7 8 9 14 15 16 17 18 19 20 21 22

1 CALHOUN HEALTH SERVICES GNS 58,144 19 3,060 2,076,441 271 7,981 - 3,781 - 3,060 720 13,688 2 CHOCTAW REGIONAL MEDICAL CENTER -1 GNS 48,045 12 4,004 1,070,729 114 9,800 - 16,791 - 4,004 12,787 153,446 3 CLAIBORNE COUNTY HOSPITAL GNS 882,509 252 3,502 2,713,239 402 6,991 - 6,657 - 3,502 3,155 795,028 4 COVINGTON COUNTY HOSPITAL GNS 100,211 30 3,340 2,361,884 235 10,469 - 4,251 - 3,340 911 27,316 5 DELTA REGIONAL MEDICAL CENTER GNS 14,223,326 2,796 5,087 25,646,960 3,187 8,383 0.9464 - 7,933 5,087 2,846 7,958,364 6 FIELD MEMORIAL COMMUNITY HOSPITAL GNS 243,678 61 3,995 2,056,196 345 6,208 - 5,883 - 3,995 1,888 115,169 7 FORREST GENERAL HOSPITAL GNS 39,521,501 6,458 6,120 91,964,161 9,543 10,038 0.8631 - 8,664 6,120 2,544 16,431,289 8 FRANKLIN COUNTY MEMORIAL HOSPITAL GNS 32,137 7 4,591 1,179,624 179 6,950 - 14,429 - 4,591 9,838 68,864 9 GEORGE COUNTY HOSPITAL GNS 1,574,873 482 3,267 3,091,210 559 5,760 1.2030 - 6,930 3,267 3,662 1,765,218

10 GREENE COUNTY HOSPITAL GNS - - - 214,205 17 13,125 - - - - - - 11 GREENWOOD LEFLORE HOSPITAL GNS 10,573,829 2,353 4,494 24,651,637 3,088 8,316 0.9534 - 7,928 4,494 3,434 8,081,136 12 HANCOCK MEDICAL CENTER GNS 2,477,885 629 3,939 3,919,955 747 5,466 1.0096 - 5,519 3,939 1,579 993,392 13 HARDY WILSON MEMORIAL HOSPITAL GNS 312,910 83 3,770 1,373,986 306 4,651 - 3,541 - 3,770 (229) (19,039) 14 HIGHLAND COMMUNITY HOSPITAL GNS 2,668,046 790 3,377 5,082,944 698 7,586 1.4198 - 10,770 3,377 7,393 5,840,259 15 JASPER GENERAL HOSPITAL GNS - - - 40,714 5 8,482 - - - - - - 16 JEFFERSON COUNTY HOSPITAL GNS 152,467 46 3,314 4,235,191 451 9,782 0.8813 - 8,621 3,314 5,306 244,091 17 JEFFERSON DAVIS COMMUNITY HOSPITAL GNS 177,861 44 4,042 1,997,647 236 8,817 - 6,658 - 4,042 2,615 115,069 18 SOUTH MISSISSIPPI REGIONAL MEDICAL GNS 58,929 20 2,946 1,818,694 291 6,510 - 5,142 - 2,946 2,196 43,914 19 MAGNOLIA REGIONAL HEALTH CENTER GNS 7,801,536 1,903 4,100 36,156,636 4,162 9,049 0.8935 - 8,086 4,100 3,986 7,585,260 20 FORREST COUNTY GENERAL HOSPITAL GNS 474,250 108 4,391 7,250,607 603 12,525 0.9524 - 11,929 4,391 7,538 814,085 21 MEMORIAL HOSPITAL AT GULFPORT GNS 23,208,509 3,703 6,267 64,444,178 6,308 10,642 0.9068 - 9,650 6,267 3,383 12,525,862 22 NESHOBA COUNTY GENERAL HOSPITAL-NUR GNS 1,051,052 360 2,920 4,429,115 791 5,833 0.9121 - 5,320 2,920 2,400 864,149 23 NORTH SUNFLOWER MEDICAL CENTER GNS 267,077 62 4,308 6,869,071 691 10,355 - 13,751 - 4,308 9,444 585,509 24 NOXUBEE GENERAL CRITICAL ACCESS HOS GNS 294,031 82 3,586 1,825,090 453 4,197 - 3,614 - 3,586 29 2,351 25 OKTIBBEHA COUNTY HOSPITAL GNS 4,863,224 1,546 3,146 5,433,976 734 7,712 1.1920 - 9,192 3,146 6,047 9,348,158 26 PEARL RIVER COUNTY HOSPITAL GNS 8,827 3 2,942 174,883 27 6,747 - 5,483 - 2,942 2,541 7,622 27 SHARKEY-ISSAQUENA COMMUNITY HOSPITA GNS 221,901 70 3,170 1,941,805 316 6,401 1.0041 - 6,427 3,170 3,257 228,006 28 SINGING RIVER HEALTH SYSTEM GNS 17,438,661 3,779 4,615 59,558,134 6,172 10,052 0.8964 - 9,010 4,615 4,396 16,611,785 29 SOUTH CENTRAL REGIONAL MEDICAL CENT GNS 10,324,985 2,670 3,867 24,631,902 3,196 8,028 1.0168 - 8,163 3,867 4,296 11,470,517 30 SOUTH SUNFLOWER COUNTY HOSPITAL GNS 2,014,038 622 3,238 2,559,154 414 6,439 1.0841 - 6,981 3,238 3,743 2,327,911 31 SW MS REGIONAL MEDICAL CENTER GNS 9,815,613 2,222 4,417 16,477,181 2,305 7,446 0.9710 - 7,230 4,417 2,813 6,250,254 32 TALLAHATCHIE GENERAL HOSPITAL GNS 87,252 25 3,490 1,284,571 145 9,228 - 8,752 - 3,490 5,262 131,542 33 TIPPAH COUNTY HOSPITAL GNS 74,750 20 3,738 1,798,603 307 6,103 0.9162 - 5,591 3,738 1,854 37,077 34 TYLER HOLMES MEMORIAL HOSPITAL GNS 215,035 60 3,584 1,363,107 294 4,830 - 5,437 - 3,584 1,853 111,203 35 WALTHALL GENERAL HOSPITAL GNS 191,810 52 3,689 1,640,345 208 8,215 - 9,425 - 3,689 5,736 298,271 36 WAYNE GENERAL HOSPITAL GNS 2,026,034 582 3,481 3,583,790 689 5,418 1.1426 - 6,191 3,481 2,710 1,577,009 37 YALOBUSHA GENERAL HOSPITAL GNS 55,440 15 3,696 838,191 192 4,547 0.9243 - 4,203 3,696 507 7,608

153,540,378 31,966 113,411,385

38 ALLEGIANCE SPECIALTY HOSPITAL OF PR - - - - - - - - - - - - 39 ALLIANCE HEALTH CENTER PR 8,651,204 1,435 6,029 5,479,841 2,218 2,559 1.2965 - 3,318 6,029 (2,711) (3,890,372) 40 ALLIANCE HEALTHCARE SYSTEM PR 208,689 60 3,478 2,972,192 417 7,382 0.9063 - 6,691 3,478 3,212 192,746 41 ANDERSON REGIONAL MEDICAL CENTER SO PR 380,093 27 14,078 6,536,846 454 14,998 0.8579 - 12,867 14,078 (1,210) (32,683) 42 JEFF ANDERSON REGIONAL MEDICAL CENT PR 12,912,614 2,618 4,932 39,512,749 5,310 7,751 1.0729 - 8,316 4,932 3,384 8,859,496 43 MONTFORT JONES MEMORIAL HOSPITAL PR 328,329 96 3,420 2,778,875 503 5,755 0.8788 - 5,057 3,420 1,637 157,173 44 KING'S DAUGHTERS HOSPITAL PR 359,438 100 3,594 2,063,557 371 5,794 - 5,289 - 3,594 1,695 169,466 45 BAPTIST MEDICAL CENTER-LEAKE INC PR 214,408 65 3,299 1,395,906 354 4,114 - 3,804 - 3,299 505 32,846 46 BAPT MEM HOSP-BOONEVILLE PR 435,158 99 4,396 7,351,943 984 7,783 0.9104 - 7,085 4,396 2,690 266,303 47 BMH DESOTO PR 18,639,403 4,056 4,596 62,652,835 6,160 10,595 0.8907 - 9,437 4,596 4,841 19,635,872 48 BMH GOLDEN TRIANGLE PR 9,144,914 2,074 4,409 35,666,426 3,565 10,421 0.8810 - 9,181 4,409 4,772 9,897,133 49 BAPTIST MEMORIAL HOSPITAL NORTH MS PR 8,387,123 1,859 4,512 36,347,171 3,711 10,203 0.9337 - 9,526 4,512 5,014 9,321,929 50 BAPTIST MEMORIAL HOSP-UNION COUNTY PR 7,084,156 2,327 3,044 7,895,822 1,235 6,660 1.2310 - 8,198 3,044 5,154 11,993,004 51 BEACHAM MEMORIAL HOSPITAL PR 325,976 76 4,289 1,942,007 315 6,422 1.0796 - 6,933 4,289 2,644 200,945 52 PHC-CLEVELAND INC PR 4,812,470 1,345 3,578 12,425,145 1,512 8,666 0.9959 - 8,631 3,578 5,053 6,795,914 53 BRENTWOOD ACQUISITION INC PR 10,801,272 1,739 6,211 - 195 - - 4,872 - 6,211 (1,339) (2,329,023) 54 CLAY COUNTY MEDICAL CORPORATION PR 2,362,826 742 3,184 3,918,837 740 5,516 1.4147 - 7,804 3,184 4,620 3,427,762 55 DIAMOND GROVE CENTER PR 4,435,055 680 6,522 - - - - 5,141 - 6,522 (1,381) (938,865) 56 GPCH-GP INC PR 4,436,534 1,036 4,282 15,477,862 1,579 10,153 0.9103 - 9,242 4,282 4,960 5,138,165 57 RUSH MEDICAL FOUNDATION PR 103,167 30 3,439 967,713 185 5,418 - 8,029 - 3,439 4,590 137,694 58 KEMPER CAH, INC. PR 27,588 7 3,941 679,044 97 7,251 - 9,034 - 3,941 5,093 35,649 59 KING'S DAUGHTERS MEDICAL CENTER PR 5,516,404 1,442 3,826 8,190,751 978 8,724 1.0241 - 8,934 3,826 5,109 7,366,727 60 LAIRD HOSPITAL INC PR 138,934 40 3,473 1,139,713 181 6,522 - 4,912 - 3,473 1,439 57,564 61 LTAC HOSPITAL OF GREENWOOD, LLC PR - - - - - - - - - - - - 62 MAGEE GENERAL HOSPITAL PR 1,637,555 585 2,799 3,432,226 617 5,762 1.5528 - 8,947 2,799 6,147 3,596,209 63 ALLIANCE HEALTH PARTNERS LLC PR 5,181,322 1,178 4,398 8,364,910 1,076 8,052 1.1575 - 9,320 4,398 4,922 5,797,792 64 BILOXI REGIONAL MEDICAL CENTER PR 9,631,636 2,171 4,436 20,444,238 2,259 9,427 1.0073 - 9,496 4,436 5,060 10,984,262

Page 1 of 2

Appendix 1BAttachment B


Class



M'Caid CMI Data)


DISCHARGE


MEDICARE DISCHARGES


MEDICARE ACUITY

MEASURE






DISCHARGE





/ (c)Sum ((e) thru


1+Inflation(CMI

Trending)



1 3 5 7 8 9 14 15 16 17 18 19 20 21 22

65 CENTRAL MISSISSIPPI MEDICAL CENTER PR 19,387,262 3,111 6,232 30,447,010 2,378 13,503 0.8555 - 11,551 6,232 5,320 16,549,329 66 AMORY HMA INC PR 4,327,837 1,136 3,810 7,903,016 1,132 7,231 1.2843 - 9,287 3,810 5,477 6,221,940 67 MADISON REGIONAL MEDICAL CENTER PR 3,474,950 1,045 3,325 3,658,372 453 8,365 1.2169 - 10,179 3,325 6,853 7,161,896 68 NATCHEZ HOSPITAL COMPANY LLC PR 2,095,164 586 3,575 9,120,923 1,156 8,219 1.2342 - 10,144 3,575 6,568 3,849,031 69 NORTHWEST MS REGIONAL MEDICAL CENTE PR 8,875,447 2,076 4,275 15,446,023 1,635 9,785 1.1419 - 11,173 4,275 6,898 14,320,192 70 BRANDON HMA PR 962,386 185 5,202 12,020,912 1,401 8,887 0.9043 - 8,036 5,202 2,834 524,356 71 RIVER OAKS HOSPITAL PR 10,392,227 1,921 5,410 12,739,318 1,067 12,406 1.0322 - 12,806 5,410 7,396 14,207,976 72 RIVER REGION HEALTH SYSTEM PR 15,040,156 3,022 4,977 31,574,175 3,176 10,424 0.8628 - 8,994 4,977 4,017 12,138,804 73 WESLEY MEDICAL CENTER PR 11,667,337 2,531 4,610 29,519,345 2,779 11,202 0.9782 - 10,958 4,610 6,348 16,067,271 74 WOMANS HOSPITAL PR 2,970,617 854 3,478 933,029 12 80,532 1.5004 - 120,829 3,478 117,351 100,217,772 75 METHODIST HEALTHCARE-OLIVE BRANCH PR 706,224 190 3,717 4,954,697 617 8,317 - 10,874 - 3,717 7,157 1,359,905 76 MISSISSIPPI BAPTIST MEDICAL CENTER PR 16,036,768 2,270 7,065 91,460,705 9,134 10,448 0.9129 - 9,538 7,065 2,473 5,613,426 77 MS METHODIST REHAB CENTER PR 2,294,816 128 17,928 9,980,823 529 19,783 1.3233 - 26,179 17,928 8,250 1,056,039 78 NATCHEZ COMMUNITY HOSPITAL PR 3,618,731 1,041 3,476 10,153,073 1,373 7,703 1.0700 - 8,242 3,476 4,766 4,961,330 79 NORTH MS MED CTR PR 30,968,955 4,605 6,725 127,289,172 12,205 10,864 0.8467 - 9,198 6,725 2,473 11,389,663 80 NORTH OAK REGIONAL MEDICAL CENTER PR 703,475 183 3,844 3,271,386 479 7,202 0.9679 - 6,971 3,844 3,127 572,265 81 PARKWOOD BEHAVIORAL HLTH SYSTEM PR 5,047,529 741 6,812 - 413 - - 4,959 - 6,812 (1,853) (1,373,162) 82 PATIENTS CHOICE MEDICAL CENTER PR - - - 1,619,625 150 11,183 - - - - - - 83 PERRY COUNTY GENERAL HOSPITAL PR 77,298 22 3,514 - - - - - - 3,514 (3,514) (77,298) 84 PIONEER COMM HOSPITAL OF ABERDEEN PR 6,209 2 3,105 2,254,950 285 8,195 - 27,583 - 3,105 24,478 48,956 85 PIONEER HEALTH SERVICES OF NEWTON C PR 488,081 183 2,667 2,638,323 255 10,716 - 2,761 - 2,667 94 17,191 86 PONTOTOC HEALTH SERVICES INC PR 16,286 5 3,257 729,880 146 5,207 - 3,457 - 3,257 200 999 87 PROMISE HOSPITAL VICKSBURG PR - - - - - - - - - - - - 88 QUITMAN COUNTY HOSPITAL, LLC PR 194,438 60 3,241 1,956,991 287 7,063 - 5,228 - 3,241 1,988 119,263 89 REGENCY HOSPITAL OF JACKSON, LLC PR - - - - - - - - - - - - 90 REGENCY HOSPITAL OF MERIDIAN LLC PR - - - - - - - - - - - - 91 REGENCY HOSPITAL OF HATTIESBURG LLC PR - - - - - - - - - - - - 92 RESTORATIVE CARE HOSP AT BAPTIST PR - - - - - - - - - - - - 93 RUSH FOUNDATION HOSPITAL PR 9,362,647 1,871 5,004 24,175,712 2,748 9,112 1.0400 - 9,476 5,004 4,472 8,367,881 94 S E LACKEY MEMORIAL HOSPITAL PR 715,315 268 2,669 2,663,528 385 7,236 - 3,783 - 2,669 1,113 298,397 95 SCOTT REGIONAL MEDICAL CENTER PR 224,253 67 3,347 1,363,077 210 6,723 - 5,029 - 3,347 1,682 112,700 96 Select Specialty Hospital of Gulfport 0 PR - - - - - - - - - - - - 97 SELECT SPECIALTY HOSPITAL - JACKSON PR - - - - - - - - - - - - 98 SIMPSON GENERAL HOSPITAL PR 294,676 89 3,311 2,346,757 365 6,659 - 3,055 - 3,311 (256) (22,787) 99 SPECIALTY HOSP OF MERIDIAN-HOSPITAL PR - - - - 582 - - - - - - -

100 ST DOMINIC-JACKSON MEMORIAL HOSPITA PR 27,602,944 4,856 5,684 89,182,457 9,055 10,201 0.9030 - 9,212 5,684 3,527 17,128,139 101 STONE COUNTY HOSPITAL INC PR 218,712 65 3,365 1,330,044 235 5,862 - 4,820 - 3,365 1,455 94,606 102 TISHOMINGO HEALTH SERVICES INC PR 170,485 48 3,552 2,291,215 420 5,683 0.9208 - 5,233 3,552 1,681 80,676 103 TRACE REGIONAL HOSPITAL PR 134,064 41 3,270 3,309,962 455 7,628 0.7486 - 5,710 3,270 2,440 100,047 104 WEBSTER HEALTH SERVICES INC PR 434,565 112 3,880 3,773,350 772 5,091 0.8469 - 4,312 3,880 432 48,370 105 WINSTON MEDICAL CENTER PR 117,510 29 4,052 1,514,902 212 7,401 0.8192 - 6,063 4,052 2,011 58,318 106 REGIONAL MEDICAL CENTER AT MEMPHIS PR 6,458,366 326 19,811 39,316,536 1,236 33,353 1.0037 - 33,476 19,811 13,665 4,454,907

301,241,994 59,556 342,542,105

107 EAST MISSISSIPPI STATE HOSPITAL 0 S - - - - - - - - - - - - 108 NORTH MISSISSIPPI STATE HOSPITAL S - - - - - - - - - - - - 109 SOUTH MISSISSIPPI STATE HOSPITAL S - - - - - - - - - - - - 110 HOLMES COUNTY HOSPITAL AND CLINICS S 288,100 71 4,058 1,135,882 173 6,884 - 8,131 - 4,058 4,074 289,234 111 MISSISSIPPI STATE HOSPITAL WHITFIEL S 2,664,320 193 13,805 - - - - 35,837 - 13,805 22,032 4,252,179 112 STATE OF MISSISSIPPI-UNIVERSITY OF S 170,577,768 12,061 14,143 131,594,263 6,502 21,221 0.8826 - 18,730 14,143 4,587 55,321,045 113 University of MS Med Ctr Grenada S 3,081,575 917 3,360 13,911,265 1,732 8,346 1.0910 - 9,106 3,360 5,745 5,268,273 114 WHITFIELD MED SURGICAL HOSP S 64,769 14 4,626 305,040 47 6,805 0.9963 - 6,780 4,626 2,154 30,150

176,676,532 13,256 65,160,881

Summary by classGovernment Non-State 153,540,378 31,966 113,411,385 Private 301,241,994 59,556 342,542,105 State Owned 176,676,532 13,256 65,160,881

631,458,904 104,778 521,114,371

Page 2 of 2

Appendix 1BAttachment BPage 2

Mississippi Medicaid 2016 Demonstration Year

Medicaid and Managed Care MHAP Limit Demonstration

Prepared February 28, 2017

The following document and related materials demonstrate Mississippi Medicaid’s MHAP Limit for Medicaid and Managed Care services. This demonstration is showing that Mississippi’s proposed MHAP funding pool is compliant with federal Medicaid managed care regulations at 42 CFR 438.

INPATIENT Limit DEMONSTRATION (UPPER PAYMENT LIMIT)

42 CFR 447.272 requires that a Medicaid agency’s payments for inpatient hospital services are no greater than a reasonable estimate of what would have been paid using Medicare payment principles. This requirement is frequently referred to as the Medicare upper payment limit (UPL). The steps below describe the 2016 Inpatient Limit demonstration (UPL calculation) for Mississippi.

1. The inpatient Medicaid UPL is calculated in the worksheet titled “2016Mississippi Medicaid IP UPL (MCO Limit).” For each Mississippi hospital, theaverage Medicaid payment per discharge was calculated. Total Medicaiddischarges and Estimated Medicaid IP DRG FFS Payments were obtained fromthe FY 16 APR-DRG simulation using paid claims data from July 1, 2013 throughJune 30, 2014 and applying them to the period that corresponds to each hospitalsMedicare cost report (CMS 2552-10) period ending in calendar year 2014. Thisdata was used to determine the average APR-DRG payment per stay. Estimatedmedical education payments were also calculated for the five MS hospitals thathave an approved medical education program by multiplying the medicaleducation add-on per case times the Medicaid discharges. The paymentsimulation estimates actual 2016 payments, therefore, inflation adjustments arenot necessary. The FY 2016 IP Simulation tab is the source of this data.

2. Medicare payments were obtained from each provider’s Medicare cost reportWorksheet E, Part A and Worksheet E-3. The Hosp. CR Data tab is the source ofthis data.

3. Medicare Discharges were obtained from each provider’s Medicare cost reportWorksheet S-3. The Hosp. CR Data tab is the source of this data.

4. The Medicare average payment per discharge was determined by dividing thetotal Medicare inpatient payments (Step 2) by total Medicare discharges (Step 3).Medicare payments were inflated from the midpoint of the cost report period tothe midpoint of the limit demonstration year. The inflation index utilized was theCMS Hospital Prospective Market Basket (as published by IHS Global Insight).

Appendix 1CAttachment A

The Hosp. CR Data tab is the source of the Medicare data and the Inflation Table tab is the source of the inflation index.

5. The Medicare average inpatient payment per discharge was adjusted for the acuitydifference between Medicare and Medicaid. A simple average Medicare DRGweight (CMI) was calculated for all Non-CAH and Non-Psych Hospitals usingMedicaid paid claims data. For the limit analysis we used the most recent CMIcalculations available. For the hospitals where a Medicare DRG weight (CMI) isnot available (Psychiatric hospitals and CAH primarily) a cost based UPLmethodology was used. The M’care & M’caid CMI Data tab is the source of theacuity measure.

6. The available limit room was then determined by subtracting the Medicaidaverage payment per discharge (Step 1) from the acuity adjusted Medicareaverage per discharge (Step 5) and then multiplying the difference by Medicaiddischarges. For critical access hospitals and psychiatric hospitals the UPLcontribution for those providers was set at 101 percent of their Medicaid costs,less expected Medicaid payments. The total UPL is calculated for each ownershipclass of hospitals according to their ownership type: non-state governmental(GNS), privately-owned (P), and state-owned (S).

Tabs Utilized in the Inpatient Limit Demonstration

1. FY 2016 IP Simulation – Medicaid claims data corresponding to each hospitals2014 cost reporting period was modeled to reflect expected total DRG paymentsfor the 2016 state fiscal year.

2. Hosp. CR Data – This tab includes data that has been extracted from eachhospitals Medicare cost report and includes Medicare payment and discharge datanecessary for calculating the Medicare payment per discharge.

3. Inflation Table – This tab demonstrates how the published market basketinflation factors were calculated from the midpoint of the cost reporting period tothe midpoint of the 2016 state fiscal year for each individual hospital.

4. M’care & M’caid CMI Data – This tab shows the calculation of the necessaryacuity adjustment for each Non-CAH and Non-Psych hospital in thedemonstration.


OUTPATIENT UPPER PAYMENT LIMIT

A cost based Outpatient limit (UPL) is displayed on the “Outpatient Hospital UPL (MCO Limit)” worksheet of the demonstration. This involved calculating the outpatient costs of hospital services provided to Medicaid FFS and managed care patients, and then reducing this amount by any payments the hospitals received from the Medicaid FFS and managed

Appendix 1CAttachment APage 2

care entities. Paid claims listings were used as data sources for both FFS and MCO. The calculation steps are outlined as follows:

1. The most recent cost and charge data from 2014 cost reports and correspondingMedicaid and managed care Provider Statistical & Reimbursement (PS&R)reports were used to arrive at the outpatient facility costs. Costs were calculatedby multiplying ancillary charges by corresponding cost-to-charge ratios (costreport mechanics). The Survey Data tab is the source of this data.

2. The cost was then inflated from the midpoint of the cost reporting period to themidpoint of the limit demonstration year. The inflation index utilized was theCMS Hospital Prospective Market Basket (as published by IHS Global Insight).The Inflation Table tab is the source of this data.

3. Managed care payments were obtained from PS&R data and inflated with thesame methodology used in inflating the cost (step 2). Medicaid payments werecalculated from paid claims data for the period that corresponds to each hospitalsMedicare cost report (CMS 2552-10) period ending in calendar year 2014 in theFY 2016 OP simulation. The payment simulation estimates actual 2016payments, therefore, inflation adjustments are not necessary. The FY 2016 OPSimulation tab was the source of the Medicaid payments and the Survey Data tabwas the sourced of the managed care payments.

4. Remaining outpatient limit (UPL) was then calculated by taking inflatedoutpatient hospital costs less expected APC payments and managed carepayments (step 3).

Tabs Utilized in the Outpatient Limit

1. Survey Data – All hospitals in the state of Mississippi complete a Survey toolthat includes cost report information and Medicaid and managed care MMIS datato calculate and summarize Medicaid and managed care costs and payments.


3. FY 2016 OP Simulation – Medicaid claims data corresponding to each hospitals2014 cost reporting period was modeled to reflect expected APC payments for the2016 state fiscal year.

Appendix 1CAttachment APage 3

2016 Mississippi Medicaid IP UPL (MCO CAP)


Class



M'Caid CMI Data)


DISCHARGE


MEDICARE DISCHARGES


MEDICARE ACUITY

MEASURE






DISCHARGE





/ (c)Sum ((e) thru


1+Inflation

(M'Care & M'Caid CMI

Data)



1 3 5 7 8 9 14 15 16 17 18 19 20 21 22

1 CALHOUN HEALTH SERVICES GNS 58,144 19 3,060 2,076,441 271 7,981 - 3,781 - 3,060 720 13,688 2 CHOCTAW REGIONAL MEDICAL CENTER GNS 48,045 12 4,004 1,070,729 114 9,800 - 16,791 - 4,004 12,787 153,446 3 CLAIBORNE COUNTY HOSPITAL GNS 882,509 252 3,502 2,713,239 402 6,991 - 6,657 - 3,502 3,155 795,028 4 COVINGTON COUNTY HOSPITAL GNS 100,211 30 3,340 2,361,884 235 10,469 - 4,251 - 3,340 911 27,316 5 DELTA REGIONAL MEDICAL CENTER GNS 14,223,326 2,796 5,087 25,646,960 3,187 8,383 0.9464 - 7,933 5,087 2,846 7,958,364 6 FIELD MEMORIAL COMMUNITY HOSPITAL GNS 243,678 61 3,995 2,056,196 345 6,208 - 5,883 - 3,995 1,888 115,169 7 FORREST GENERAL HOSPITAL GNS 39,521,501 6,458 6,120 91,964,161 9,543 10,038 0.8631 - 8,664 6,120 2,544 16,431,289 8 FRANKLIN COUNTY MEMORIAL HOSPITAL GNS 32,137 7 4,591 1,179,624 179 6,950 - 14,429 - 4,591 9,838 68,864 9 GEORGE COUNTY HOSPITAL GNS 1,574,873 482 3,267 3,091,210 559 5,760 1.2030 - 6,930 3,267 3,662 1,765,218

10 GREENE COUNTY HOSPITAL GNS - - - 214,205 17 13,125 - - - - - - 11 GREENWOOD LEFLORE HOSPITAL GNS 10,573,829 2,353 4,494 24,651,637 3,088 8,316 0.9534 - 7,928 4,494 3,434 8,081,136 12 HANCOCK MEDICAL CENTER GNS 2,477,885 629 3,939 3,919,955 747 5,466 1.0096 - 5,519 3,939 1,579 993,392 13 HARDY WILSON MEMORIAL HOSPITAL GNS 312,910 83 3,770 1,373,986 306 4,651 - 3,541 - 3,770 (229) (19,039) 14 HIGHLAND COMMUNITY HOSPITAL GNS 2,668,046 790 3,377 5,082,944 698 7,586 1.4198 - 10,770 3,377 7,393 5,840,259 15 JASPER GENERAL HOSPITAL GNS - - - 40,714 5 8,482 - - - - - - 16 JEFFERSON COUNTY HOSPITAL GNS 152,467 46 3,314 4,235,191 451 9,782 0.8813 - 8,621 3,314 5,306 244,091 17 JEFFERSON DAVIS COMMUNITY HOSPITAL GNS 177,861 44 4,042 1,997,647 236 8,817 - 6,658 - 4,042 2,615 115,069 18 SOUTH MISSISSIPPI REGIONAL MEDICAL GNS 58,929 20 2,946 1,818,694 291 6,510 - 5,142 - 2,946 2,196 43,914 19 MAGNOLIA REGIONAL HEALTH CENTER GNS 7,801,536 1,903 4,100 36,156,636 4,162 9,049 0.8935 - 8,086 4,100 3,986 7,585,260 20 FORREST COUNTY GENERAL HOSPITAL GNS 474,250 108 4,391 7,250,607 603 12,525 0.9524 - 11,929 4,391 7,538 814,085 21 MEMORIAL HOSPITAL AT GULFPORT GNS 23,208,509 3,703 6,267 64,444,178 6,308 10,642 0.9068 - 9,650 6,267 3,383 12,525,862 22 NESHOBA COUNTY GENERAL HOSPITAL-NUR GNS 1,051,052 360 2,920 4,429,115 791 5,833 0.9121 - 5,320 2,920 2,400 864,149 23 NORTH SUNFLOWER MEDICAL CENTER GNS 267,077 62 4,308 6,869,071 691 10,355 - 13,751 - 4,308 9,444 585,509 24 NOXUBEE GENERAL CRITICAL ACCESS HOS GNS 294,031 82 3,586 1,825,090 453 4,197 - 3,614 - 3,586 29 2,351 25 OKTIBBEHA COUNTY HOSPITAL GNS 4,863,224 1,546 3,146 5,433,976 734 7,712 1.1920 - 9,192 3,146 6,047 9,348,158 26 PEARL RIVER COUNTY HOSPITAL GNS 8,827 3 2,942 174,883 27 6,747 - 5,483 - 2,942 2,541 7,622 27 SHARKEY-ISSAQUENA COMMUNITY HOSPITA GNS 221,901 70 3,170 1,941,805 316 6,401 1.0041 - 6,427 3,170 3,257 228,006 28 SINGING RIVER HEALTH SYSTEM GNS 17,438,661 3,779 4,615 59,558,134 6,172 10,052 0.8964 - 9,010 4,615 4,396 16,611,785 29 SOUTH CENTRAL REGIONAL MEDICAL CENT GNS 10,324,985 2,670 3,867 24,631,902 3,196 8,028 1.0168 - 8,163 3,867 4,296 11,470,517 30 SOUTH SUNFLOWER COUNTY HOSPITAL GNS 2,014,038 622 3,238 2,559,154 414 6,439 1.0841 - 6,981 3,238 3,743 2,327,911 31 SW MS REGIONAL MEDICAL CENTER GNS 9,815,613 2,222 4,417 16,477,181 2,305 7,446 0.9710 - 7,230 4,417 2,813 6,250,254 32 TALLAHATCHIE GENERAL HOSPITAL GNS 87,252 25 3,490 1,284,571 145 9,228 - 8,752 - 3,490 5,262 131,542 33 TIPPAH COUNTY HOSPITAL GNS 74,750 20 3,738 1,798,603 307 6,103 0.9162 - 5,591 3,738 1,854 37,077 34 TYLER HOLMES MEMORIAL HOSPITAL GNS 215,035 60 3,584 1,363,107 294 4,830 - 5,437 - 3,584 1,853 111,203 35 WALTHALL GENERAL HOSPITAL GNS 191,810 52 3,689 1,640,345 208 8,215 - 9,425 - 3,689 5,736 298,271 36 WAYNE GENERAL HOSPITAL GNS 2,026,034 582 3,481 3,583,790 689 5,418 1.1426 - 6,191 3,481 2,710 1,577,009 37 YALOBUSHA GENERAL HOSPITAL GNS 55,440 15 3,696 838,191 192 4,547 0.9243 - 4,203 3,696 507 7,608

153,540,378 31,966 113,411,385

38 ALLEGIANCE SPECIALTY HOSPITAL OF PR - - - - - - - - - - - - 39 ALLIANCE HEALTH CENTER PR 8,651,204 1,435 6,029 5,479,841 2,218 2,559 1.2965 - 3,318 6,029 (2,711) (3,890,372) 40 ALLIANCE HEALTHCARE SYSTEM PR 208,689 60 3,478 2,972,192 417 7,382 0.9063 - 6,691 3,478 3,212 192,746 41 ANDERSON REGIONAL MEDICAL CENTER SO PR 380,093 27 14,078 6,536,846 454 14,998 0.8579 - 12,867 14,078 (1,210) (32,683) 42 JEFF ANDERSON REGIONAL MEDICAL CENT PR 12,912,614 2,618 4,932 39,512,749 5,310 7,751 1.0729 - 8,316 4,932 3,384 8,859,496 43 MONTFORT JONES MEMORIAL HOSPITAL PR 328,329 96 3,420 2,778,875 503 5,755 0.8788 - 5,057 3,420 1,637 157,173 44 KING'S DAUGHTERS HOSPITAL PR 359,438 100 3,594 2,063,557 371 5,794 - 5,289 - 3,594 1,695 169,466 45 BAPTIST MEDICAL CENTER-LEAKE INC PR 214,408 65 3,299 1,395,906 354 4,114 - 3,804 - 3,299 505 32,846 46 BAPT MEM HOSP-BOONEVILLE PR 435,158 99 4,396 7,351,943 984 7,783 0.9104 - 7,085 4,396 2,690 266,303 47 BMH DESOTO PR 18,639,403 4,056 4,596 62,652,835 6,160 10,595 0.8907 - 9,437 4,596 4,841 19,635,872 48 BMH GOLDEN TRIANGLE PR 9,144,914 2,074 4,409 35,666,426 3,565 10,421 0.8810 - 9,181 4,409 4,772 9,897,133 49 BAPTIST MEMORIAL HOSPITAL NORTH MS PR 8,387,123 1,859 4,512 36,347,171 3,711 10,203 0.9337 - 9,526 4,512 5,014 9,321,929 50 BAPTIST MEMORIAL HOSP-UNION COUNTY PR 7,084,156 2,327 3,044 7,895,822 1,235 6,660 1.2310 - 8,198 3,044 5,154 11,993,004 51 BEACHAM MEMORIAL HOSPITAL PR 325,976 76 4,289 1,942,007 315 6,422 1.0796 - 6,933 4,289 2,644 200,945 52 PHC-CLEVELAND INC PR 4,812,470 1,345 3,578 12,425,145 1,512 8,666 0.9959 - 8,631 3,578 5,053 6,795,914 53 BRENTWOOD ACQUISITION INC PR 10,801,272 1,739 6,211 - 195 - - 4,872 - 6,211 (1,339) (2,329,023) 54 CLAY COUNTY MEDICAL CORPORATION PR 2,362,826 742 3,184 3,918,837 740 5,516 1.4147 - 7,804 3,184 4,620 3,427,762 55 DIAMOND GROVE CENTER PR 4,435,055 680 6,522 - - - - 5,141 - 6,522 (1,381) (938,865) 56 GPCH-GP INC PR 4,436,534 1,036 4,282 15,477,862 1,579 10,153 0.9103 - 9,242 4,282 4,960 5,138,165 57 RUSH MEDICAL FOUNDATION PR 103,167 30 3,439 967,713 185 5,418 - 8,029 - 3,439 4,590 137,694 58 KEMPER CAH, INC. PR 27,588 7 3,941 679,044 97 7,251 - 9,034 - 3,941 5,093 35,649 59 KING'S DAUGHTERS MEDICAL CENTER PR 5,516,404 1,442 3,826 8,190,751 978 8,724 1.0241 - 8,934 3,826 5,109 7,366,727 60 LAIRD HOSPITAL INC PR 138,934 40 3,473 1,139,713 181 6,522 - 4,912 - 3,473 1,439 57,564 61 LTAC HOSPITAL OF GREENWOOD, LLC PR - - - - - - - - - - - - 62 MAGEE GENERAL HOSPITAL PR 1,637,555 585 2,799 3,432,226 617 5,762 1.5528 - 8,947 2,799 6,147 3,596,209 63 ALLIANCE HEALTH PARTNERS LLC PR 5,181,322 1,178 4,398 8,364,910 1,076 8,052 1.1575 - 9,320 4,398 4,922 5,797,792 64 BILOXI REGIONAL MEDICAL CENTER PR 9,631,636 2,171 4,436 20,444,238 2,259 9,427 1.0073 - 9,496 4,436 5,060 10,984,262

Page 1 of 2

Appendix 1CAttachment B


Class



M'Caid CMI Data)


DISCHARGE


MEDICARE DISCHARGES


MEDICARE ACUITY

MEASURE






DISCHARGE





/ (c)Sum ((e) thru


1+Inflation

(M'Care & M'Caid CMI

Data)



1 3 5 7 8 9 14 15 16 17 18 19 20 21 22

65 CENTRAL MISSISSIPPI MEDICAL CENTER PR 19,387,262 3,111 6,232 30,447,010 2,378 13,503 0.8555 - 11,551 6,232 5,320 16,549,329 66 AMORY HMA INC PR 4,327,837 1,136 3,810 7,903,016 1,132 7,231 1.2843 - 9,287 3,810 5,477 6,221,940 67 MADISON REGIONAL MEDICAL CENTER PR 3,474,950 1,045 3,325 3,658,372 453 8,365 1.2169 - 10,179 3,325 6,853 7,161,896 68 NATCHEZ HOSPITAL COMPANY LLC PR 2,095,164 586 3,575 9,120,923 1,156 8,219 1.2342 - 10,144 3,575 6,568 3,849,031 69 NORTHWEST MS REGIONAL MEDICAL CENTE PR 8,875,447 2,076 4,275 15,446,023 1,635 9,785 1.1419 - 11,173 4,275 6,898 14,320,192 70 BRANDON HMA PR 962,386 185 5,202 12,020,912 1,401 8,887 0.9043 - 8,036 5,202 2,834 524,356 71 RIVER OAKS HOSPITAL PR 10,392,227 1,921 5,410 12,739,318 1,067 12,406 1.0322 - 12,806 5,410 7,396 14,207,976 72 RIVER REGION HEALTH SYSTEM PR 15,040,156 3,022 4,977 31,574,175 3,176 10,424 0.8628 - 8,994 4,977 4,017 12,138,804 73 WESLEY MEDICAL CENTER PR 11,667,337 2,531 4,610 29,519,345 2,779 11,202 0.9782 - 10,958 4,610 6,348 16,067,271 74 WOMANS HOSPITAL PR 2,970,617 854 3,478 933,029 12 80,532 1.5004 - 120,829 3,478 117,351 100,217,772 75 METHODIST HEALTHCARE-OLIVE BRANCH PR 706,224 190 3,717 4,954,697 617 8,317 - 10,874 - 3,717 7,157 1,359,905 76 MISSISSIPPI BAPTIST MEDICAL CENTER PR 16,036,768 2,270 7,065 91,460,705 9,134 10,448 0.9129 - 9,538 7,065 2,473 5,613,426 77 MS METHODIST REHAB CENTER PR 2,294,816 128 17,928 9,980,823 529 19,783 1.3233 - 26,179 17,928 8,250 1,056,039 78 NATCHEZ COMMUNITY HOSPITAL PR 3,618,731 1,041 3,476 10,153,073 1,373 7,703 1.0700 - 8,242 3,476 4,766 4,961,330 79 NORTH MS MED CTR PR 30,968,955 4,605 6,725 127,289,172 12,205 10,864 0.8467 - 9,198 6,725 2,473 11,389,663 80 NORTH OAK REGIONAL MEDICAL CENTER PR 703,475 183 3,844 3,271,386 479 7,202 0.9679 - 6,971 3,844 3,127 572,265 81 PARKWOOD BEHAVIORAL HLTH SYSTEM PR 5,047,529 741 6,812 - 413 - - 4,959 - 6,812 (1,853) (1,373,162) 82 PATIENTS CHOICE MEDICAL CENTER PR - - - 1,619,625 150 11,183 - - - - - - 83 PERRY COUNTY GENERAL HOSPITAL PR 77,298 22 3,514 - - - - - - 3,514 (3,514) (77,298) 84 PIONEER COMM HOSPITAL OF ABERDEEN PR 6,209 2 3,105 2,254,950 285 8,195 - 27,583 - 3,105 24,478 48,956 85 PIONEER HEALTH SERVICES OF NEWTON C PR 488,081 183 2,667 2,638,323 255 10,716 - 2,761 - 2,667 94 17,191 86 PONTOTOC HEALTH SERVICES INC PR 16,286 5 3,257 729,880 146 5,207 - 3,457 - 3,257 200 999 87 PROMISE HOSPITAL VICKSBURG PR - - - - - - - - - - - - 88 QUITMAN COUNTY HOSPITAL, LLC PR 194,438 60 3,241 1,956,991 287 7,063 - 5,228 - 3,241 1,988 119,263 89 REGENCY HOSPITAL OF JACKSON, LLC PR - - - - - - - - - - - - 90 REGENCY HOSPITAL OF MERIDIAN LLC PR - - - - - - - - - - - - 91 REGENCY HOSPITAL OF HATTIESBURG LLC PR - - - - - - - - - - - - 92 RESTORATIVE CARE HOSP AT BAPTIST PR - - - - - - - - - - - - 93 RUSH FOUNDATION HOSPITAL PR 9,362,647 1,871 5,004 24,175,712 2,748 9,112 1.0400 - 9,476 5,004 4,472 8,367,881 94 S E LACKEY MEMORIAL HOSPITAL PR 715,315 268 2,669 2,663,528 385 7,236 - 3,783 - 2,669 1,113 298,397 95 SCOTT REGIONAL MEDICAL CENTER PR 224,253 67 3,347 1,363,077 210 6,723 - 5,029 - 3,347 1,682 112,700 96 Select Specialty Hospital of Gulfport 0 PR - - - - - - - - - - - - 97 SELECT SPECIALTY HOSPITAL - JACKSON PR - - - - - - - - - - - - 98 SIMPSON GENERAL HOSPITAL PR 294,676 89 3,311 2,346,757 365 6,659 - 3,055 - 3,311 (256) (22,787) 99 SPECIALTY HOSP OF MERIDIAN-HOSPITAL PR - - - - 582 - - - - - - -

100 ST DOMINIC-JACKSON MEMORIAL HOSPITA PR 27,602,944 4,856 5,684 89,182,457 9,055 10,201 0.9030 - 9,212 5,684 3,527 17,128,139 101 STONE COUNTY HOSPITAL INC PR 218,712 65 3,365 1,330,044 235 5,862 - 4,820 - 3,365 1,455 94,606 102 TISHOMINGO HEALTH SERVICES INC PR 170,485 48 3,552 2,291,215 420 5,683 0.9208 - 5,233 3,552 1,681 80,676 103 TRACE REGIONAL HOSPITAL PR 134,064 41 3,270 3,309,962 455 7,628 0.7486 - 5,710 3,270 2,440 100,047 104 WEBSTER HEALTH SERVICES INC PR 434,565 112 3,880 3,773,350 772 5,091 0.8469 - 4,312 3,880 432 48,370 105 WINSTON MEDICAL CENTER PR 117,510 29 4,052 1,514,902 212 7,401 0.8192 - 6,063 4,052 2,011 58,318 106 REGIONAL MEDICAL CENTER AT MEMPHIS PR 6,458,366 326 19,811 39,316,536 1,236 33,353 1.0037 - 33,476 19,811 13,665 4,454,907

301,241,994 59,556 342,542,105

107 EAST MISSISSIPPI STATE HOSPITAL 0 S - - - - - - - - - - - - 108 NORTH MISSISSIPPI STATE HOSPITAL S - - - - - - - - - - - - 109 SOUTH MISSISSIPPI STATE HOSPITAL S - - - - - - - - - - - - 110 HOLMES COUNTY HOSPITAL AND CLINICS S 288,100 71 4,058 1,135,882 173 6,884 - 8,131 - 4,058 4,074 289,234 111 MISSISSIPPI STATE HOSPITAL WHITFIEL S 2,664,320 193 13,805 - - - - 35,837 - 13,805 22,032 4,252,179 112 STATE OF MISSISSIPPI-UNIVERSITY OF S 170,577,768 12,061 14,143 131,594,263 6,502 21,221 0.8826 - 18,730 14,143 4,587 55,321,045 113 University of MS Med Ctr Grenada S 3,081,575 917 3,360 13,911,265 1,732 8,346 1.0910 - 9,106 3,360 5,745 5,268,273 114 WHITFIELD MED SURGICAL HOSP S 64,769 14 4,626 305,040 47 6,805 0.9963 - 6,780 4,626 2,154 30,150

176,676,532 13,256 65,160,881

Summary by classGovernment Non-State 153,540,378 31,966 113,411,385 Private 301,241,994 59,556 342,542,105 State Owned 176,676,532 13,256 65,160,881

631,458,904 104,778 521,114,371

Page 2 of 2

Appendix 1CAttachment BPage 2

DEPARTMENT OF HEAL TH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, GA 3030

fcMS CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILREN'S HEAL TH OPERATIONS

January 17, 2017

David J. Dzielak, Executive Director Mississippi Division of Medicaid 550 High Street, Suite l 000 Jackson, Mississippi 39201

Dear Mr. Dzielak:

I am writing in response to your letter dated October 27, 2016 that outlines the Mississippi's Hospital Access Program (MHAP) corrective action plan. The Center's for Medicare and Medicaid Services has reviewed the MHAP corrective action plan and continues to support the state's intended goal of integrating inpatient hospital services into its managed care program.

CMS is requesting the state to include timelines, key metrics and milestones that the state will follow to meet the requirements to move from a pass-through payment structure to a payment structure with clear linkages between the utilization, quality, or outcomes of delivered services. This should include dates in which steps will be implemented as well as risks to not meeting the timelines proposed. It is necessary for the state to develop a stakeholder engagement strategy that includes milestones and a tracking system to monitor the progress of the key activities the stakeholders agree necessary to achieve accepted outcomes.

In addition, the excel work sheet for the inpatient hospital upper payment limit (UPL) titled "2016 Mississippi Medicaid IP UPL (MCO Limit) and the outpatient hospital UPL titled "Outpatient Hospital UPL (MCO Limit) did not include formulas or supporting documentation (tabs on the excel worksheets). CMS is requesting that the state revise the inpatient and outpatient UPL spreadsheets to include formulas and supporting documentation as tabs on the excel work sheet with detailed descriptions of process and data used. The supporting documentation should include a detailed analysis that demonstrates how the state will remain within the UPL limit year over year as the projections the state provided appear to project forward the total pass-through payment amount as opposed to recalculating the base amount each year. The state must track the total amount of pass through payments in the base amount permitted through the transitional period.

Technical assistance is available to the state as it develops an acceptable corrective action plan. We appreciate our partnership with the state in its efforts to move towards a value-based payment system.

Appendix 1D

Mr. David Dzielak Page 2

CMS looks forward to continuing our dialogue with the state regarding the program. If you have questions, please contact myself at ( 404) 562-7417 or Davida Kimble at ( 404) 562-7496.

Operations

cc: Jim Golden, CMS Debbie Anderson, CMS

Sincerely,

Jackie Glaze Associate Regional Administrator Division of Medicaid & Children's Health

Appendix 1DPage 2

O F F I C E O F T H E G O V E R N O R

Walter Sillers Building | 550 High Street, Suite 1000 | Jackson, Mississippi 39201

Toll-free 800-421-2408 | Phone 601-359-6050 | Fax 601-359-6294 | medicaid.ms.gov

November 20, 2015

Dr. James Golden, Ph.D. Director Division of Managed Care Plans Center for Medicaid and CHIP Services 7500 Security Blvd. S2-26-12 Woodlawn, MD 21244

Via E-mail: [email protected]

Dear Dr. Golden:

We appreciate the opportunity to meet with you and other Centers for Medicare and Medicaid Services (CMS) representatives during the Fall 2015 Conference of the National Association of Medicaid Directors. At that meeting, you asked us to provide detailed information regarding the Mississippi Hospital Access Program (MHAP) being proposed, along with the inclusion of inpatient hospital services into our managed care program, MississippiCAN. This letter provides the information requested and includes justification for implementing MHAP.

The Mississippi Division of Medicaid (DOM), at the direction of our state legislature and with the support of the state’s hospital association, is in the process of moving inpatient hospital services into MississippiCAN, effective Dec. 1, 2015. This transition would allow our MississippiCAN coordinated care organizations (CCOs) to effectively manage the healthcare continuum for their plan members, while still ensuring access to quality health coverage for all Mississippi Medicaid beneficiaries. We believe this change is consistent with federal Medicaid program goals and desires.

DOM has carefully studied our state health plan, historical funding mechanisms for hospital reimbursement, payment models used in other states’ Medicaid programs and, perhaps most importantly, the many factors influencing market stability and service access unique to Mississippi.

Over the last several years, Mississippi has methodically expanded its managed care program, aiming to improve quality of care while reducing costs and minimizing disruption to the overall delivery system. Intentionally, inpatient hospital services represent the last major service category to be included in our managed care program. While we recognize that our Medicaid program for the state as a whole is over-bedded, underserved areas of our state are critically dependent on the operation of smaller, rural hospitals to serve our patient population.

Under the fee-for-service (FFS) program, these hospitals depend on Medicare upper payment limit (UPL) payments to maintain financial solvency, as the total volume of patients they serve is lower than other Mississippi hospitals with significantly fewer commercially covered patients. Although our peer states have been able to support their

Appendix 1E

Dr. James Golden, Ph.D., Director November 20, 2015 Page 2

critical access providers through the disproportionate share hospital (DSH) program, funding for Mississippi does not meet this need. The following table reflects this reality:

State name FY 2016

FMAP

FY 2016 DSH Allotment (Federal

Share)

Medicaid Beneficiaries

(as of June 2015)

Federal DSH Allotment per

Beneficiary Alabama 69.87% $ 334,186,261 1,004,776 $ 332.60

Louisiana 62.21% $ 745,902,374 1,392,207 $ 535.77 Mississippi 74.17% $ 165,734,650 740,937 $ 223.68

Historically, DOM has been able to address this inequity in the DSH allotment process through the use of the UPL funding flexibility allowed under federal Medicaid law. Using this funding approach, DOM increased Medicaid program payments for inpatient hospital services beyond our rate-based payments by approximately $533 million annually. While recognizing that CMS does not have authority under federal law to address the inequity of the DSH allotments, your past support of the UPL program has been an integral part of our program. For this transition, DOM needs your approval and support of MHAP in order to mitigate this funding disparity and ensure access to quality hospital care.

Funding our program at these historic levels is crucial. Our 2016 DSH payment model, which calculates uncompensated-care cost for hospital services (costs for inpatient and outpatient hospital services provided to Medicaid-eligible and uninsured patients, less payments received for those service), shows that our hospitals would incur the following financial losses after distribution of the full DSH allotment without the supplemental UPL program or MHAP funding.

Hospital Ownership Class Net Gain / (Loss) after 2016 DSH Payments

Government Non-State Owned & Operated ( $162,556,595) Privately Owned & Operated ( 471,311,691)

State Owned & Operated ( 91,332,613) Total ( $725,200,899)1

When calculated on a per patient day basis, all hospitals in Mississippi except two will experience a loss, with net impacts ranging from ($2,940) to $38. The hospital industry in Mississippi cannot sustain payment shortfalls of this magnitude. Access to quality hospital services would be gravely impacted without the continuation of UPL payment level funding.

1The $725M loss is based on FFS levels of payment before any efficiencies or changes in payment due to influences of managed care are experienced by the hospitals.

Appendix 1EPage 2


In determining how Mississippi might move inpatient hospital service into managed care and maintain UPL level funding, the state considered the resulting impacts of simply increasing the All Patient Refined Diagnosis Related Group (APR DRG) base rate for hospital services or otherwise providing a uniform dollar or percent increase across all providers of a particular service. However, under the most recent UPL model, FY 2015 supplemental reimbursement per patient day varied significantly across hospitals, with net impacts varying from $0 to $1,881. Larger impacts typically correspond to small, rural hospitals, which would be at risk of closing if they were to receive the average supplemental payment rate. Further, if the full variation of supplemental reimbursement was recognized in base reimbursement rates, there would be very significant revenue volatility for small hospitals as their admissions fluctuate across years. Again, this model would create significant risk of hospital closures and a strong incentive for hospitals to increase admissions as a result, contrary to the goal of this program.

Recognizing this fact, the state legislature has indicated that shifting inpatient hospital services under managed care must not happen at the expense of these critical access providers. Please see the attached MHAP Statutory Summary that details the law relevant to this proposed program.

To ensure stability of our delivery system, while taking a critical next step to expand managed care, Mississippi proposes the MHAP for your consideration. DOM actuaries have certified rates effective Dec. 1, 2015 that include the proposed MHAP payment pool of $533,110,956. DOM anticipates signing contracts with our CCOs that include distributing the entire payment pool to hospitals in addition to the APR DRG payments. In the short term, this payment methodology will allow our CCOs to more effectively manage members across the care continuum while ensuring continued access in our underserved areas. Additionally, as the MHAP is not folded into an APR DRG-based model, one hundred percent of the funding is distributed directly to the provider community without any administrative withhold by the CCOs. The CCOs have agreed that the medical loss ratio (MLR) will not apply to the MHAP portion of the capitation rates. Therefore, the administration ratios applied to previously determined and future capitation rates will not be impacted by increasing the base rates for MHAP.

In the long term, this methodology has three key advantages:

1) Providers in Mississippi have expressed an interest in moving toward value-basedpayment. However, across public and private payers, the market for value-basedpayment in Mississippi is still in its infancy. Moving inpatient hospital servicesunder managed care will afford Mississippi the opportunity to collect significanttotal medical expense data under a more holistic capitation model. This data willallow our CCOs and health systems to explore value-based payment options in amanner that is data and experience driven, which DOM strongly believes will

Appendix 1EPage 3


improve their success rate long term. 2) MHAP funding will be capped at the FY 2015 UPL funding level of $533,110,956 in

perpetuity. Under the current FFS structure, UPL funding has grown year after year.The proposed funding cap, therefore, will provide a timely incentive to beginrestructuring our payment and delivery system at a pace that is manageable acrossour hospital network.

3) The proposed MHAP program leaves inpatient hospital APR DRG rates at theircurrent levels in the near term, leaving open the possibility of adjusting these ratesupward based on experience and outcomes in the future. As noted previously,infusion of UPL level funding is critical to our current delivery system. The stepwiseprogram adjustments made possible under MHAP will allow Mississippi tothoughtfully move toward value-based payment and care in the future withoutsacrificing access to services for our population today.

As discussed above, the state legislature has significant concerns regarding the loss of UPL funding under managed care. As such, it is possible that the state legislature could prevent the transition of inpatient hospital services to managed care if the MHAP is not approved by CMS. We believe that continuation of FFS payment for inpatient hospital services would significantly delay progress toward improving quality and health outcomes for our population. The MHAP strikes an appropriate balance for our state by supporting movement toward value-based care at a pace that maintains stability for our critical access providers today while allowing for additional, data driven payment innovation in the future. Based on these considerations, DOM requests that CMS approve the MHAP model for Mississippi managed care.

Sincerely,

David J. Dzielak, Ph.D. Executive Director

Enclosure: MHAP Statutory Summary

Cc: Vikki Wachino, Deputy Administrator and Director Center for Medicaid and Children’s Health Insurance Program (CHIP) Services

Kristin Fan, Director, Financial Management Group, CMCS Center for Medicaid and Children’s Health Insurance Program (CHIP) Services

Jackie Glaze, Associate Regional Administrator Atlanta Regional Office (Region 4)

Appendix 1EPage 4

StandardOperatingProcedures

MSDivisionofMedicaid

AreaofFinancialOversightofCCOcontracts

SOPsubmissiondate01/25/2017

Revisiondate

ImplementationDate

Page#LastReviewed/UpdateDate

SOPOwner MargaretKing Approval

1. Purpose

To ensure financial oversight of MSCAN and MSCHIP contracts.

2. Definitions

3. Responsibilities

Deputy Director for Finance. Chief Financial Officer. Office of Financial Reporting. Office of

Recovery. Office of Financial and Performance Review. Contractors including Keith Heartsill, Gary

Owens, Samantha Hand, Myers and Stauffer, Milliman, PCG.

4. Procedures

Provide the steps and procedures required to perform all of your area’s responsibilities. Include a

process flowchart. (Answer: who, what, when, where, why, how).

* Review and approve all payments and recoupments issued to the CCO’s

* Review and approve all agency contracts and CCO provider agreements

* Perform CMS Protocol 4 Activities

* Review and approve MHAP distribution totals; provide beneficiary count for its use and

reconciliations

* Attend monthly management meetings

* Calculate and review all Kick Payments, HIF payments.

* Attend monthly meetings with Milliman, the contractor for capitation rate development and

budgets

* Contact other states for best practice information and apply it

* Attend training as available and keep abreast of information through various sources, such as e‐

mail updates, CMS e‐mails, etc.

* Assist, as needed, with any related work, projects, meetings and trainings

Appendix 4


* Ensure the financial health of the coordinated care program; communicate concerns to executive

director and deputies and office directors, as appropriate

* Staff direct, Monitor and approve contractual work

* Monitor trends and legislation with financial implications for Medicaid

* Participate in RFP and model contract development

* Assist in the development, review and measuring data of reporting dashboards and CCO reports

* Assist with the development and updates of the reporting manual

* Review reports assigned and upload comments according to the agency timeline

* Serve as the lead contact with CCO CFO’s

* Assist in the development of capitation rates and review them

* Assist in the development of the budget and budget updates and review them

* Monitor the monthly and year‐to‐date activity using established benchmarks

* Other duties determined necessary to ensure complete financial oversight of the CCO programs.

5. Other Notes

Other notes go here. All applicable MS Code and federal regulations related to Medicaid and

sometimes Medicare, along with MS Code related to accounting requirements are relevant.

Additionally federal regulations related to financial and programmatic compliance for grantee

agencies apply.

ForYourInformation

The following standards apply agency wide, to all areas, and is just for your information. Please keep

these items in mind when writing your SOP.

Request for Information (RFI) Procedure

All requests for information submitted by email or in writing are to be processed through RFI, unless it

can be easily answered by readily available information, or is received directly by your program area and

is specific to your daily operations.

Submit RFI inquiries to [email protected].

Upon receipt of the request, RFI will coordinate the response with the appropriate area(s) responsible

for the subject matter. Requests will be processed within federal, state and agency guidelines. If you

have questions about the RFI process, visit the RFI webpage or contact the Public Information Officer by

email at [email protected].

Requests including or handling protected health information (PHI) in accordance with the Health

Insurance Portability and Accountability Act (HIPAA)

All DOM use or disclosure of beneficiary information must be in compliance with federal law (HIPAA),

state law and DOM policies and procedures regarding the safeguarding of beneficiary information,

Appendix 4 Page 2


including but not limited to Division of Medicaid Employee Manual sections 2.9, 3.6, 3.7, 6.0, 6.1, 7.0,

7.1, 8.0, and Appendix P.

When using or disclosing beneficiary information, DOM workforce members shall follow these policies

and procedures, including but not limited to:

Responding to and documenting requests, inquires or complaints regarding beneficiary

information;

Applying the minimum necessary standard to all applicable tasks;

Maintaining accountings of disclosures;

Accurately de‐identifying information when necessary;

Applying appropriate safeguards to all use, disclosure, storage and destruction of

beneficiary information (e.g., encryption, password protection, confidentiality statements,

certified mail, confidential print, cross‐cut shredding, etc.);

Obtaining required authorizations;

Verifying the identities of persons or entities in receipt of beneficiary information;

Following the appropriate document retention schedule;

Coordinating with RFI, Legal, iTech, Executive and other offices as necessary to obtain the

appropriate documentation and information (e.g., Nondisclosure Agreement, Business

Associate Agreement, Data Use Agreement, etc.);

Mitigating and reporting to the Privacy Officer and appropriate supervisor privacy or

security violations and breaches; and

Learning and applying DOM privacy and security policies and procedures.

Appendix 4Page 3

Mississippi Managed Care Services:

Myers and Stauffer is conducting managed care consulting, auditing, and financial services on behalf of the Division of Medicaid. Mississippi currently has two plans operating its MississippiCAN (Medicaid) and MississippiCHIP programs. Together, these two plans incurred medical expenses in excess of three billion dollars ($3,000,000,000) over the last two years. Mississippi is required by establish actuarially sound rates for these two plans, based on the medical spend. Each plan is required to spend at least eighty-five percent (85%) of its monthly capitation payments from the state on medical expenses.

New federal regulations, established May 6, 2016, require each state operating Medicaid managed care to comply with certain regulations. Most of the tasks performed under this contract assist the Division of Medicaid’s ability to meet those federal oversight requirements required to continue to receive federal financial participation for managed care expenses. The following list below summarizes some of the services currently being provided to the Division of Medicaid. This list isn’t intended to be comprehensive but rather to capture major tasks currently being performed.

Service Perform a bi-monthly reconciliation of the cash disbursement journals to the

encounters submitted by the health plans and their delegated vendors to the Division’sMMIS vendor, Conduent, to ensure completeness and accuracy. Work with fiscalintermediary (Conduent) to obtain the encounter data on a monthly basis and toidentify issues with accurately storing and reporting health plan submitted encounterdata.

Perform CMS External Quality Review (EQR) Protocol 4 activities which includesgaining an understanding and assessment of each CCO’s encounter submissionprocess and capabilities, validating claim data elements to the submitted encounterdata, performing a few Healthcare Effectiveness Data and Information Set (HEDIS)assessments, and reviewing medical claims sample for accuracy and completeness.

Benefit Mississippi is required through the new federal regulations to provide accurate

financial and encounter data to its actuary as well as to CMS as part of theTransformed Medicaid Statistical Information System (T-MSIS) project. This datamust be audited no less than once every three years. The methods utilized arespecifically cited as an acceptable method for meeting the requirement. Encounterdata serves as a leading tool for stakeholders to make informed decisions aboutMedical Management, Care Coordination, Program Integrity Issues, QualityImprovement, Financial and Actuarial calculations, and Performance Evaluations.This regulation was established by CMS because many states did not maintain acomplete and accurate encounter data set to be utilized for these purposes. Sinceinitiating this service, Mississippi health plans have increased their requiredcompletion percentages from significantly below contract required levels to at or nearcontract required levels. With monitoring, DOM can both identify issues for

Appendix 5

correction and assess liquidated damages as appropriate. Encounter data is an area in which many state Medicaid programs struggle. This was noted as a reason for including the audit requirement in the final rule. By initiating encounter data validation in advance of the federal requirement, Mississippi serves as a leader among its peers in this area and as an example for other states to follow on this requirement.

Service Perform examinations of Medical Loss Ratio and Administrative Expense reports

submitted by each CCO. This includes requesting supporting documentation fromeach CCO, including trial balance, claim lag reports and other claim and financialinformation and performing analyses to ensure the definitions and assignments ofmedical and administration expenses are appropriate.

Benefit Mississippi is required through the new federal regulations to audit the financial

information provided to its actuary. Each health plan is required to have a medicalloss ratio that exceeds eighty-five (85%) but remains actuarially sound. Anyaggregate medical expenditure that in the reporting period does not exceed eighty-five (85%) of the total capitation payments receive, must rebate the amount beloweighty-five (85%). While audits are federally mandated, they also ensure accuratereporting by the health plans and rebates are accurately calculated. As a result of thework currently completed and/or in-process, Mississippi will benefit from bothincreased rebates and increased cost avoidance due to identified reportable errors.

Service Identify members that currently have more than one member number assigned to

them for which the CCOs have received multiple capitation payments.

Benefit Under a capitation model, health plans are paid a per-member per-month fee.

Duplicate members identified on the enrollment files results in overpayments to thehealth plans. Correcting these errors results in the reduction in monthly payments andthe opportunity to recover overpayments. As a result of the work completed and/orin-process, Mississippi has identified erroneous capitation payments and will benefitfrom both significant recoveries and cost avoidance.

Service Review claims with Third Party Liability (TPL) coverage indicated to ensure that

they are being either being properly cost avoided or that recoveries are initiated andreported to DOM to ensure that the capitation rates reflect this information.

Benefit Third party liability recoveries are factored into the actuarially sound rates. Federal

regulations require the state to establish a sound rate. Inaccurate information can lead

Appendix 5 Page 2

to an incorrect rate. Inability to collect TPL by a health plan will result in increased cost to Mississippi DOM.

Service Provide other consulting services as requested by the Division. The Division

requested best practice recommendations in: 1) Creating a robust Monthly DenialsReport; 2) Reviewing their actuary’s Health Insurance Provider Fee (HIPF)reimbursement calculator to ensure proper payment to the Coordinated CareOrganizations; and 3) Review portions of the CCO contract and makerecommendations regarding best practices utilizing our library of state MedicaidMCO contracts.

Benefit The Monthly Denials Report generated as a result of this process is a best practices

model likely to be shared with other state Medicaid agencies. It is a robust andcomprehensive report designed to provide detailed monitoring of the CoordinatedCare’s Organizations denials to assess denial reasons as well as ensure compliancewith contract requirements. This will help ensure that Mississippi beneficiaries arenot being taken advantage of and denied medical services inappropriately. Thereview of the HIPF reimbursement calculator identified an adjustment to thecalculation that resulted in significant financial savings. Suggested changes to theCCO contracts were recently implemented and are being used to better improve CCOperformance.

Appendix 5 Page 3

Appendix 13A

Appendix 13APage 2

Appendix 13APage 3

Appendix 13APage 4

Appendix 13APage 5

Appendix 13APage 6

Appendix 13APage 7

Appendix 13APage 8

Appendix 13APage 9

Appendix 13APage 10

Appendix 13B

Appendix 13BPage 2

Appendix 13BPage 3

Appendix 13BPage 4

Appendix 13BPage 5

Appendix 13BPage 6

Appendix 13BPage 7

Appendix 13BPage 8

Appendix 13BPage 9

Appendix 13BPage 10

Appendix 13BPage 11

Appendix 13BPage 12

Appendix 13C

Appendix 13CPage 2

Appendix 13D

Appendix 13DPage 2

Appendix 13DPage 3

O F F I C E O F T H E G O V E R N O R | M I S S I S S I P P I D I V I S I O N O F M E D I C A I D

To: Aaron Sisk, JD President and CEO Magnolia Health Plan

From: Tara Clark, JD, CHP Executive Administrator

Date: December 29, 2016

Re: Notice of Inpatient Encounter Claims Discrepancies

In September 2016, the Mississippi Division of Medicaid (DOM) conducted a review of

Magnolia Health Plan, Inc.’s (Magnolia) Inpatient encounter claims for 12/01/2015 –

12/31/2015. The following discrepancies were discovered as a result of DOM’s review:

1. Failure to reimburse some providers’ claims at a rate equal to the Medicaid APR-

DRG rate;

2. Failure to submit some encounter records on or before the last calendar day of the

third month after the payment/adjudication calendar month in which Magnolia

paid/adjudicated the claims;

3. Failure to close (pay or deny) any suspended claim held for additional requested

information within 60 days of receipt of the encounter claim; and

4. Failure to appropriately deny encounter claims.

The attached spreadsheet contains specific information and claims detail related to the

discrepancies identified.

Miss. Code Ann. §43-13-117 (H)(1) states in part that DOM “shall require that no program

may: (a) Pay providers at a rate that is less than Medicaid All-Patient Refined-Diagnosis

Related Groups (APR-DRG) reimbursement rate.”

Item 3(Encounter Submissions) of Section 10.R (Encounter Data) of the MississippiCAN

Contract between DOM and Magnolia states that “[a]ll Encounter Records must be

submitted by the Contractor and determined acceptable by the Division’s Agent on or

before the last calendar day of the third month after the payment/adjudication calendar

month in which the Contractor paid/adjudicated the Claim.”

M E M O R A N D U M

Appendix 14A

2

Section 17.A (Claims Payment) states in part that “the Contractor must pay at least ninety

percent (90%) of all clean claims (as defined by Miss. Code Ann. § 83-9-5) for covered

services, within thirty (30) calendar days of receipt” and “[c]laims pending or suspended

for additional information must be processed (paid or denied) by the thirtieth (30th)

calendar day following the receipt of information requested, otherwise the Contractor must

close (pay or deny) any other suspended claim if all requested information is not received

prior to the expiration of the thirty (30) calendar day period.”

Item 2 (Provider Claims) of Section 10.R (Encounter Data) states that “Providers shall be

provided. . . a maximum of six (6)months to submit claims from the date of service.”

DOM request that Magnolia review the deficiencies identified and provide a response, no

later than, January 27, 2017, to the findings as noted in the enclosed document.

cc: Terrica Miller, Vice President of Compliance, Magnolia Health Plan Dorthy Young, Ph.D., Deputy Administrator, Mississippi Division of Medicaid Zeddie Parker, Office of Hospital Programs & Services, Mississippi Division of Medicaid Sharon Jones, Office of Coordinated Care, Mississippi Division of Medicaid Stephanie J. Evans, JD, Office of Contract Compliance, Mississippi Division of Medicaid

Appendix 14APage 2

O F F I C E O F T H E G O V E R N O R | M I S S I S S I P P I D I V I S I O N O F M E D I C A I D

To: Jocelyn Chisolm-Carter, JD President and CEO UnitedHealthcare

From: Tara Clark, JD, CHP Executive Administrator

Date: December 29, 2016

Re: Notice of Inpatient Encounter Claims Discrepancies

In September 2016, the Mississippi Division of Medicaid (DOM) conducted a review of

United Healthcare of Mississippi, Inc.’s (United) Inpatient encounter claims for

12/01/2015 – 12/31/2015. The following discrepancies were discovered as a result of

DOM’s review:

1. Failure to reimburse some providers’ claims at a rate equal to the Medicaid APR-

DRG rate;

2. Failure to submit some encounter records on or before the last calendar day of the

third month after the payment/adjudication calendar month in which United

paid/adjudicated the claims;

3. Failure to close (pay or deny) any suspended claim held for additional requested

information within 60 days of receipt of the encounter claim; and

4. Failure to appropriately deny encounter claims.

The attached spreadsheet contains specific information and claims detail related to the

discrepancies identified.

Miss. Code Ann. §43-13-117 (H)(1) states in part that DOM “shall require that no program

may: (a) Pay providers at a rate that is less than Medicaid All-Patient Refined-Diagnosis

Related Groups (APR-DRG) reimbursement rate.”

Item 3 (Encounter Submissions) of Section 10.R (Encounter Data) of the MississippiCAN

Contract between DOM and United states that “[a]ll Encounter Records must be submitted

by the Contractor and determined acceptable by the Division’s Agent on or before the last

M E M O R A N D U M

Appendix 14B

2

calendar day of the third month after the payment/adjudication calendar month in which

the Contractor paid/adjudicated the Claim.”

Section 17.A (Claims Payment) states in part that “the Contractor must pay at least ninety

percent (90%) of all clean claims (as defined by Miss. Code Ann. § 83-9-5) for covered

services, within thirty (30) calendar days of receipt” and “[c]laims pending or suspended

for additional information must be processed (paid or denied) by the thirtieth (30th)

calendar day following the receipt of information requested, otherwise the Contractor must

close (pay or deny) any other suspended claim if all requested information is not received

prior to the expiration of the thirty (30) calendar day period.”

Item 2 (Provider Claims) of Section 10.R (Encounter Data) states that “Providers shall be

provided. . . a maximum of six (6)months to submit claims from the date of service.”

DOM request that United review the deficiencies identified and provide a response, no later

than, January 27, 2017, to the findings as noted in the enclosed document.

cc: Terence Christopher, Compliance Officer, United Healthcare Dorthy Young, Ph.D., Deputy Administrator, Mississippi Division of Medicaid Zeddie Parker, Office of Hospital Programs & Services, Mississippi Division of Medicaid Sharon Jones, Office of Coordinated Care, Mississippi Division of Medicaid Stephanie Evans, JD, Office of Contract Compliance, Mississippi Division of Medicaid

Appendix 14BPage 2

Mississippi Division of MedicaidManaged Care Monitoring ReportMC IP Less Than Allowed Amt Monitoring Report-Magnolia Date of Service Range: Dec 1, 2015 through Dec 31, 2015

TCN MC Claim Number Prov ID Prov Name DOM DRG Code DRG Base Pymt DRG Rt Chng MC TPL DRG Pymt Amt MC Pd Amt Diff DOM/MC Pd MC Clm Rcvd MC Clm Pd DOM Comment MC Response

UNIVERSITY OF MISS MED CENTER 723-2 $3,038.98 2,704.12 $5,743.10 $2,005.41 ($3,737.69) 12/9/15 12/31/15 Claim paid less than DOM





UNIVERSITY OF MISS MED CENTER 640-1 $973.73 2,704.12 $3,677.85 $2,754.62 ($923.23) 12/15/15 1/21/16 Claim paid less than DOM



UNIVERSITY OF MISS MED CENTER 640-1 $973.73 2,704.12 $3,677.85 $2,453.58 ($1,224.27) 12/28/15 1/21/16 Claim paid less than DOM

UNIVERSITY OF MISS MED CENTER 113-3 $4,298.37 2,704.12 $7,002.49 $6,225.31 ($777.18) 12/10/15 1/21/16 Claim paid less than DOM








































UNIVERSITY OF MISS MED CENTER 563-2 $3,248.49 2,704.12 $5,952.61 $4,376.69 ($1,575.92) 1/5/16 3/24/16Claim paid less than DOM / Claim

adjudicated/pd over 60 days of receipt



Appendix 14C

Mississippi Division of MedicaidManaged Care Monitoring ReportMC IP Less Than Allowed Amt Monitoring Report-Magnolia Date of Service Range: Dec 1, 2015 through Dec 31, 2015

TCN MC Claim Number Prov ID Prov Name DOM DRG Code DRG Base Pymt DRG Rt Chng MC TPL DRG Pymt Amt MC Pd Amt Diff DOM/MC Pd MC Clm Rcvd MC Clm Pd DOM Comment MC Response














UNIVERSITY OF MISS MED CENTER 639-1 $3,056.75 2,704.12 $5,760.87 $5,760.86 ($0.01) 12/29/15 5/5/16Claim adjudicated/pd over 60 days of

receipt

Appendix 14CPage 2

Mississippi Division of MedicaidManaged Care Monitoring ReportMC IP Less Than Allowed Amt Monitoring Report-United Date of Service Range: Dec 1, 2015 through Dec 31, 2015

TCN MC Claim # Prov ID Prov Name DOM DRG Code DRG Base Pymt DRG Rt Chng MC TPL DRG Pymt Amt MC Pd Amt Diff DOM/MC Pd Mc Clm Rcvd MC Clm Pd DOM Comment MCO Response



UNIVERSITY OF MISS MED CENTER 224-3 $16,139.82 2,704.12 $18,843.94 $171.53 ($18,672.41) 1/12/16 2/6/16 Claim paid less than DOM
































UNIVERSITY OF MISS MED CENTER 640-1 $973.73 2,704.12 $3,677.85 $973.70 ($2,704.15) 12/24/15 12/31/15 Claim paid less than DOM














Appendix 14D

Metric12/14 -

12/17/201512/18 -

12/24/201512/25 -

12/31/201501/01/16 - 01/07/2016

01/08/16 - 01/14/2016

01/15 - 01/21/16

1/22 - 1/28/16 1/29 - 2/4/16 2/5 - 2/11/16

2/12 - 2/18/16

2/19 - 2/25/2016

2/26 - 03/03/2016

03/04/ - 03/10/2016

03/11/- 03/17/2016

03/18/ - 03/24/2016

Inpatient PA Total Volume 492 557 604 748 840 681 793 778 742 729 776 718 716 754 804

Inpatient PA Approval Volume 448 506 529 677 787 597 724 726 696 675 696 563 650 694 729

Inpatient PA Denial Volume 2 1 1 1 1 3 1 5 0 0 4 0 2 3 1

Inpatient PA Pend/Suspend Volume 42 50 74 70 52 81 68 50 46 54 76 155 64 57 74

Inpatient Claim Total Volume 272 447 377 668 768 765 755 805 908 747 703 821 739 832 950

Inpatient Claim Approval Volume 145 228 194 293 378 408 358 397 446 415 360 396 349 423 475

Inpatient Claim Pend/Suspend Volume 26 77 89 90 81 74 78 98 62 90 89 112 159 77 111

Inpatient Claim Denial Volume 101 142 94 285 309 283 319 310 400 242 254 313 231 332 364

Inpatient Reconsideration Total Volume 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Inpatient Appeal Total Volume 0 0 0 3 11 6 6 1 2 0 3 2 0 0 0

Magnolia Health Plan CCO Provider Inpatient Payment Validation Weekly Update

Appendix 14E

Friday Update_03.25.2016 Friday, March 25, 2016 9:07 AM

Prior Authorization:

MS IP Authorizations Report

Volume Percentage Denial Reason

Auth Volume Elective 36

Elective Volume and % Approved 20 55.56%

Elective Volume and % Denied 1 2.78%

Elective Volume and % Pended 15 41.67%

Elective Top Denial Reasons 1 Inappropriate Level of Care

Auth Volume Urgent 598

Urgent Volume and % Approved 417 69.73%

Urgent Volume and % Denied 48 8.03%

Urgent Volume and % Pended 133 22.24%

Urgent Top Denial Reasons 37 Medical review - MD

5 Inappropriate Level of Care

1 Clinical Review

1 Lack of Notification

1 Med Denial - Insufficient Info

Auth Volume Urgent/Emergent Elective BH MH and SA

1

BH, MA, SA Volume and % Approved 1 100.00%

BH, MA, SA Volume and % Denied 0 0.00%

BH, MA, SA Volume and % Pended 0 0.00%

BH, MA, SA Top Denial Reasons

Claim:

Inpatient Claim Approval Volume = 8039

Appendix 14F

Inpatient Claim Denial Volume = 1793 Inpatient Claim Pend/Suspend Volume = 52 Inpatient Claim Total Volume = 9780

Other Claim:

Inpatient Reconsideration: Open Items Volume = 39 Inpatient Reconsideration: Closed Items Volume = 290 Inpatient Reconsideration: Total Volume = 329

Inpatient Appeal: Open Items Volume = 30 Inpatient Appeal: Closed Items Volume = 123 Inpatient Appeal: Total Volume = 153

Appendix 14FPage 2

Appendix 19

Appendix 19 Page 2

Appendix 19 Page 3

Legislative Budget Office (LBO) Report

January 2017

550 High Street, Suite 1000 | Jackson, Mississippi 39201Phone (601) 359-6050

Website: www.medicaid.ms.gov

Office of the Governor, Division of Medicaid

Appendix 25

http://www.medicaid.ms.gov/

http://www.medicaid.ms.gov/

Medical Service Expenditures (Note 1)* SFY-17 SFY-16 $ Change % ChangeJan-17 Jan-16

Totals - MTD $386,864,435 $372,518,898 $14,345,537 3.9% (Note 2)*July - Jan. 2017 July - Jan. 2016

Totals - YTD $2,782,513,369 $2,697,021,050 $85,492,319 3.2% (Note 3)*

Other Medical Service Type Expenditures SFY-17 SFY-16 $ Change % ChangeJan-17 Jan-16

Totals - MTD $40,697,736 $41,918,256 ($1,220,520) -2.9%July - Jan. 2017 July - Jan. 2016

Totals - YTD $275,196,175 $263,599,309 $11,596,866 4.4%

DSH/MHAP/UPL Supplemental Payments (Note 4)* SFY-17 SFY-16 $ Change % ChangeJan-17 Jan-16


Totals - YTD $409,640,388 $255,250,441 $154,389,947 60.5%

Administrative Expenditures (Note 5)* SFY-17 SFY-16 $ Change % ChangeJan-17 Jan-16


Totals - YTD $95,327,644 $100,471,962 ($5,144,318) -5.1%

Health Information Technology Payments SFY-17 SFY-16 $ Change % ChangeJan-17 Jan-16

Totals - MTD $229,500 $170,900 $58,600 34.3% (Note 6)*July - Jan. 2017 July - Jan. 2016

Totals - YTD $14,703,226 $6,983,034 $7,720,192 110.6% (Note 6)*

*See Monthly Legislative Report Notes on following page.

Office of the Governor - Division of MedicaidMonthly Legislative Report - Medicaid Expenditure Summary

Month Ended January 31, 2017

Appendix 25Page 2

(Note 6) The Health Information Technology (HIT) grant provides 100% federal funding for incentive payments made to Medicaid providers that have adopted or meaningfully used certified electronic health record (EHR) technology. MTD and YTD totals will differ between years based on the timing of provider applications and approvals, CMS program changes, and reporting cycles established by CMS.

(Note 5) Administrative expenditures include agency salaries, fringe, travel, commodities, and equipment. They also include contractual services, which account for approximately 65% of total administrative expenditures. The majority of these contracts are related to the administration and monitoring of the agency's medical service claims payments. Specific planning and implementation administrative expenditures are paid with 90% federal funds. Administrative expenditures related to claims processing, survey and certification activities of long term care facilities, quality improvement organizations, skilled professional medical personnel, and MMIS personnel are paid with 75% federal funds. The remainder of DOM administrative expenditures are paid with 50% federal funds. Also, the YTD amounts reflected above were paid from either the SFY16 or SFY17 budget depending upon when goods and services were received.

Office of the Governor - Division of MedicaidMonthly Legislative Report NotesMonth Ended January 31, 2017

The expenditure amounts included in this report are presented on a cash basis. Medical service and administrative expenditures reflect the date of payment rather than the date of service or the date goods or services are received. The report reflects all payments made during the reporting period, and will include funds spent from both SFY-16 and SFY-17 budgets.

(Note 4) Beginning 12/1/15, Inpatient Hospital Services were rolled into Managed Care. Due to regulations related to this change, eligible hospitals will receive Mississippi Hospital Access Payments (MHAP) and will no longer receive Upper Payment Limit (UPL) payments. The annual amount of MHAP in SFY16 and SFY17 will be approximately the same as SFY15 UPL payments. MHAP will be made on a monthly basis. (These monthly payments began in December during SFY16 and began in July during SFY17.) Eligible hospitals will still receive DSH payments in December, March, and June. Also, eligible nursing facilities and physicians will receive UPL payments.

(Note 1) Inpatient Hospital services were rolled into Managed Care on December 1, 2015. Also, approximately 300,000 children were rolled into Managed Care during May, June, and July '15. These additional Managed Care services and enrollees resulted in a decrease for most medical service categories and an increase in capitated payments to our Managed Care vendors. It is normal to experience an increase in payments during the transition to managed care services since managed care capitation payments are made at the start of the covered month while fee-for-service claims may be submitted up to one year after the date of service.

(Note 2) January '17 MTD totals for Medical Service Expenditures include one more weekly pay period than January '16 MTD totals. If the non-monthly expenditures for an average weekly pay period in January '17 were subtracted from January '17 MTD totals, the MTD% change in Medical Service Expenditures for January '17 MTD compared to January '16 MTD totals will reflect a decrease of 2.6% rather than an increase of 3.9%.

(Note 3) FY'17 YTD totals for Medical Service Expenditures include one more weekly pay period than FY'16 YTD totals. If the non-monthly expenditures for an average weekly pay period in FY'17 were subtracted from FY'17 YTD totals, the YTD% change in Medical Service Expenditures for FY'17 YTD compared to FY'16 YTD totals will reflect an increase of 2.3% rather than an increase of 3.2%.

Appendix 25Page 3

Office of the Governor - Division of MedicaidMonthly Medical Services Comparison

January 2017 vs January 2016Service Jan-17 Jan-16 $ Change % Change

TOTAL Expenditures $386,864,435 $372,518,898 $14,345,537 3.9%

Inpatient Hospital $12,941,828 $25,108,792 ($12,166,964) -48.5%Outpatient Hospital $7,906,717 $6,824,990 $1,081,727 15.8%Lab and X-Ray $508,485 $358,226 $150,259 41.9%Nursing Facility $68,897,543 $62,063,429 $6,834,114 11.0%Physician $5,755,249 $5,724,471 $30,777 0.5%Home and Comm. Based $36,072,959 $29,132,380 $6,940,579 23.8%Home Health Services $136,223 $100,094 $36,129 36.1%Swing Bed Skilled $3,326 $5,331 ($2,004) -37.6%Mental Health Clinic $3,155,527 $2,488,726 $666,800 26.8%EPSDT Screening $468,660 $463,834 $4,826 1.0%Transportation $552,428 $494,770 $57,658 11.7%Non-Emergency Transport $0 $2,892,015 ($2,892,015) -100.0%Dental Services $424,277 $321,012 $103,265 32.2%Eyeglass Services $229,521 $184,635 $44,886 24.3%Pharmacy $11,956,243 $12,207,282 ($251,039) -2.1%Dental Screening $896,970 $708,693 $188,277 26.6%Eyeglass Screening $162,131 $163,242 ($1,111) -0.7%Hearing Screening $15,218 $12,275 $2,943 24.0%ICF IID Facility $20,347,826 $21,681,067 ($1,333,241) -6.1%Swing Bed Intermediate $12,523 $27,196 ($14,673) -54.0%Rural Health Clinic $946,938 $930,259 $16,678 1.8%Federally Qualified Hlth Ctr $310,827 $311,747 ($920) -0.3%Medical Supply (DME) $2,136,706 $1,312,636 $824,070 62.8%Therapy Services $340,118 $202,268 $137,850 68.2%Inpt. Residential Psych. $3,728,903 $3,955,426 ($226,523) -5.7%Inpt. Free Standing Psych. $354,453 $508,777 ($154,323) -30.3%Nurse Services $2,408,028 $1,791,947 $616,082 34.4%Ambulatory Surg. Center $161,481 $111,137 $50,344 45.3%Personal Care Services $625,907 $534,745 $91,162 17.0%Hospice $3,745,026 $2,883,260 $861,766 29.9%Outpat. Free Stand. Psych $0 $0 $0 N/AMental Health Priv. Serv. $413,331 $134,473 $278,859 207.4%Fam. Planning Drugs $201,402 $161,945 $39,458 24.4%Free Standing Dialysis $238,927 $233,971 $4,956 2.1%Managed Care* (see note below) $177,971,970 $172,643,456 $5,328,514 3.1%Crossover Part A $5,259,537 $3,488,744 $1,770,793 50.8%Crossover Part B $15,823,551 $10,452,310 $5,371,241 51.4%NET Accommodation Prov $0 $0 $0 N/AMYPAC $1,453,901 $1,931,347 ($477,446) -24.7%Inpatient Pediatric LTC Hosp. $0 $0 $0 N/AOutpatient Pediatric LTC Hosp. $0 $0 $0 N/ACrossover Part A-Pediatric LTC Hosp. $0 $0 $0 N/APrescribed Ped. Ext. Care Center $350,541 $104,111 $246,430 236.7%Other ($50,764) ($136,119) $85,355 -62.7%

Note: Inpatient Hospital services were rolled into Managed Care on December 1, 2015. Also, approximately 300,000 children were rolled into Managed Care during May, June, and July '15. These additional Managed Care services and enrollees resulted in a decrease for most medical service categories and an increase in capitated payments to our Managed Care vendors.

Appendix 25Page 4

Office of the Governor - Division of MedicaidMedical Services Comparison Fiscal Year to Date (FYTD)

FYTD 2017 vs 2016Service FYTD 2017 FYTD 2016 $ Change % Change

TOTAL Expenditures $2,782,513,369 $2,697,021,050 $85,492,320 3.2%

Inpatient Hospital $93,804,238 $333,848,273 ($240,044,035) -71.9%Outpatient Hospital $51,854,849 $49,477,600 $2,377,249 4.8%Lab and X-Ray $3,557,177 $3,393,413 $163,764 4.8%Nursing Facility $443,404,658 $432,510,219 $10,894,439 2.5%Physician $39,381,290 $50,132,267 ($10,750,977) -21.4%Home and Comm. Based $235,707,229 $198,583,818 $37,123,411 18.7%Home Health Services $907,365 $1,040,984 ($133,619) -12.8%Swing Bed Skilled $100,484 $65,412 $35,073 53.6%Mental Health Clinic $23,500,920 $23,519,909 ($18,989) -0.1%EPSDT Screening $2,841,208 $2,723,628 $117,580 4.3%Transportation $3,739,445 $4,340,302 ($600,857) -13.8%Non-Emergency Transport $17,264,537 $18,030,660 ($766,123) -4.2%Dental Services $2,944,584 $2,862,132 $82,452 2.9%Eyeglass Services $1,619,116 $1,553,535 $65,581 4.2%Pharmacy $76,755,297 $88,468,128 ($11,712,831) -13.2%Dental Screening $6,415,682 $8,399,461 ($1,983,779) -23.6%Eyeglass Screening $1,390,372 $1,713,258 ($322,886) -18.8%Hearing Screening $119,871 $140,031 ($20,160) -14.4%ICF IID Facility $149,219,203 $147,810,351 $1,408,853 1.0%Swing Bed Intermediate $337,979 $306,749 $31,230 10.2%Rural Health Clinic $6,313,369 $7,164,949 ($851,580) -11.9%Federally Qualified Hlth Ctr $2,175,962 $2,404,862 ($228,900) -9.5%Medical Supply (DME) $13,535,756 $10,737,361 $2,798,394 26.1%Therapy Services $1,943,062 $1,850,608 $92,455 5.0%Inpt. Residential Psych. $29,510,977 $27,981,523 $1,529,454 5.5%Inpt. Free Standing Psych. $3,003,913 $14,514,719 ($11,510,806) -79.3%Nurse Services $15,865,926 $12,813,755 $3,052,172 23.8%Ambulatory Surg. Center $991,490 $1,079,215 ($87,725) -8.1%Personal Care Services $4,283,260 $3,672,957 $610,303 16.6%Hospice $22,972,863 $22,586,895 $385,968 1.7%Outpat. Free Stand. Psych $0 $0 $0 N/AMental Health Priv. Serv. $4,968,169 $1,017,165 $3,951,004 388.4%Fam. Planning Drugs $1,208,955 $1,187,044 $21,912 1.8%Free Standing Dialysis $1,508,550 $2,057,975 ($549,425) -26.7%Managed Care $1,380,939,005 $1,090,985,872 $289,953,133 26.6%Crossover Part A $31,877,421 $29,500,401 $2,377,021 8.1%Crossover Part B $94,115,219 $85,167,770 $8,947,449 10.5%NET Accomodation Prov $0 $0 $0 N/AMYPAC $11,035,180 $10,936,074 $99,106 0.9%Inpatient Pediatric LTC Hosp. $0 $12,119 ($12,119) -100.0%Outpatient Pediatric LTC Hosp. $0 $0 $0 N/ACrossover Part A-Pediatric LTC Hosp. $0 $0 $0 N/APrescribed Ped. Ext. Care Center $1,808,639 $355,186 $1,453,453 409.2%Other ($409,857) $2,074,467 ($2,484,324) -119.8%

Note: Inpatient Hospital services were rolled into Managed Care on December 1, 2015. Also, approximately 300,000 children were rolled into Managed Care during May, June, and July '15. These additional Managed Care services and enrollees resulted in a decrease for most medical service categories and an increase in capitated payments to our Managed Care vendors.

Appendix 25Page 5

MS Medicaid Beneficiaries SFY-17 SFY-16 Change % ChangeJan-17 Jan-16

As of Last Day of the Month 713,065 726,638 (13,573) -1.9%July - Jan. 2017 July - Jan. 2016

Average for the Period 716,253 729,063 (12,810) -1.8%

CHIP Beneficiaries SFY-17 SFY-16 Change % ChangeJan-17 Jan-16

50,524 47,909 2,615 5.5%

Home and Comm Based Waiver Participants * SFY-17 SFY-16 Change % ChangeJan-17 Jan-16

As of Last Day of the Month 22,267 21,596 671 3.1%

Dialysis Transport Participants SFY-17 SFY-16 Change % ChangeJan-17 Jan-16

66 90 (24) -26.7%

* Home and Community Based Waiver Participants are also included in the MS Medicaid Beneficiaries total.

Office of the Governor - Division of MedicaidMonthly Legislative Report - Participant Counts


As of the First Day of the Month

Participants Covered by MonthlyPayment

Appendix 25Page 6

OFFICE OF THE GOVERNOR - DIVISION OF MEDICAIDOther Medical Services Comparison Fiscal Year to Date (FYTD)

FYTD 2017 vs 2016

Service MTD 1/31/2017 MTD 1/31/2016 FYTD 2017 FYTD 2016 $ Change % Change

TOTAL Expenditures $40,697,736 $41,918,256 $275,196,175 $263,599,309 $11,596,866 4.4%

CHIP (Note 1) $12,473,137 $15,988,630 $89,966,547 $100,084,855 ($10,118,309) -10.1%Part A & B Premiums (Note 2) $22,867,568 $20,966,201 $151,145,279 $132,253,468 $18,891,810 14.3%Clawback $4,307,812 $3,891,019 $30,247,211 $27,813,674 $2,433,537 8.7%Dialysis Transport (Note 3) $33,167 $59,273 $258,797 $460,254 ($201,457) -43.8%State Funded Subsidies $1,016,052 $1,013,132 $3,578,342 $2,987,057 $591,285 19.8%

(Note 3): A comparison of monthly payment amounts for Dialysis Transport services between fiscal years can be misleading due to timing issues with the monthly invoice payments. Eligibility for the state funded Dialysis Transport program is limited to beneficiaries that were enrolled in a specific eligibility category (PLAD) on 12/31/05 that need dialysis transportation and are not eligible for the Medicaid program. The population that is eligible for this program will continue to decline through qualification for Medicaid services or death.

(Note 2): On January 1, 2017, Part A monthly premiums increased from $411 to $413 and Part B monthly premiums increased from $121.80 to $134.00. Part B payments make up approximately 90% of the total Part A and Part B payments.

(Note 1): SFY 17 monthly CHIP premium payments are $256.95 per CHIP beneficiary, which is a decrease from the SFY 16 monthly premium amount of$270.46.

Appendix 25Page 7

Jan-17 Jan-17 Jan-17 Jan-17

Waiver ServicesState Plan Services Total (Note 1)

Participants (Notes 2 & 3)

$1,069,002 $233,016 $1,302,018 625

$20,154,611 $2,846,749 $23,001,360 15,792

$5,107,834 $676,221 $5,784,055 2,465

$8,354,387 $893,201 $9,247,588 2,544

$2,034,515 $502,870 $2,537,385 841

N/A $1,453,901 $1,453,901 0

Waiver for Elderly and Disabled Individuals

Office of the Governor - Division of MedicaidHome and Community Based Expenditures


Assisted Living Waiver for Elderly and Disabled Adults

(Note 4): Beginning 10/1/14, MYPAC is a state plan service. Therefore, there is no waiver participant count.

(Note 3): Participant count does not include pending applications during the month.

Independent Living Waiver

Waiver for Intellectual Disabilities / Developmentally Disabled

Waiver for Individuals With A Traumatic Brain or Spinal Cord

MYPAC (MS Youth Programs Around the Clock)

(Note 1): Home and Community Based Waiver expenditures are also included in Medical Service Expenditure totals cited in this report.

(Note 2): The expenditure totals above reflect claims payments made during January, 2017. Claims payments could be related to dates of service for periods up to 2 years prior to the claims payment date. Therefore, any comparison of expenditures and participants noted above will not provide accurate results. The number enrolled and the amount of paid claims must be viewed independent of one another.

Appendix 25Page 8

MTD YTDJan-17 July '16-Jan. '17

1. PERSONAL SERVICES - SALARIES 4,310,215$ 29,649,891$ 2. PERSONAL SERVICES - TRAVEL 46,661$ 509,044$ 3. CONTRACTUAL SERVICES 8,774,377$ 64,152,004$ 4. COMMODITIES 69,007$ 638,512$ 5. CAPITAL OUTLAY - EQUIP 14,379$ 378,193$

TOTAL ADMINISTRATIVE EXPENSE 13,214,639$ 95,327,644$

Office of the Governor - Division of MedicaidAdministrative Expenditures Detail


Appendix 25Page 9

2016 MississippiCAN Call Summary

Analysis

Member Services An analysis of the 2016 Call Center Statistics indicates we have answered 124,547 Member calls with an average Service Level of 96.02%. The average speed of answer for calls was five seconds to which the average talk time is 4:53. A listing of the top ten calls is listed below and it validates that our members are consistently in contact with the Plan to update their demographic information. We educated the members to contact the proper entity to ensure the information is updated at the entity that is supplying information to DOM so all the systems will be updated accordingly. Our second primary reason for calls is updating the Health Risk Survey which is a tool the Plan uses to ensure we evaluate the member’s medical needs annually. The Plan continues to review calls and look for opportunities to improve the member’s experience.

The top ten call categories are as followed: 1. Member Information Update2. Member Activity (Health Risk Survey)3. Benefits Inquiry4. PCP Change5. CentAccount Card Inquiry6. Follow-Up Inquiry7. Member material request8. Eligibility9. Practitioner/Provider Lookup10. Authorizations

Areas of Focus • Continue to inform members of the need to notify the entity that established eligibility of their

demographic changes• Continue to educate providers of what is needed for authorizations and ask them to inform their

members• Continue to verify each member has a PCP when we speak to them and assist members with

selecting a PCP for those who do not have one

Appendix 26A


Provider Services For 2016 the Magnolia MSCAN the call center took 78,312 Provider calls with an average Service Level of 94.66%. The average speed of answer for calls was five seconds to which the average talk time is 5:47. The primary reason for Provider calls is to receive claims status. All providers are educated on how to use the portal to retrieve claims information and to review members’ eligibility. The Plan has reorganized the call center to allow agents to specialize in member or provider. This allows the agent to become more knowledgeable of claims filing, claims processing and claims appeals. Learning these skills will allow an agent to better service the Providers and reduce the need for providers to make multiple calls or be transferred to other departments.

The top ten call categories are as followed: 1. Claims status Inquiry2. Provider Education Eligibility3. Provider Education Authorizations4. Internal Health Plan transfer5. Authorization Status Inquiry6. Authorizations Clinical review7. Benefit Inquiry Benefit/Limits Copay8. Eligibility Inquiry9. Claims Appeals10. Pharmacy Benefits

Areas of Focus • Continue to educate Providers on the how to review claims status on the web• Continue to educate providers using fax blasts, emails and Provider Orientations• Continue to develop Provider Services to provide a higher level of service to Providers from the

Call Center

Appendix 26APage 2


2016 CHIP Call Summary Analysis Member Services Although the CHIP population is significantly less than MSCAN research indicates the calls are similar in nature. For 2016 the Magnolia MSCHIP call center took 7,844 Member calls with an average Service Level of 96.38%. The average speed of answer for calls was five seconds to which the average talk time is 5:25.

The top ten call categories are as followed: 1. Member Activity (Health Risk Survey)2. Member Information Update3. Practitioner/Provider Lookup4. Benefits Inquiry5. Follow-Up Inquiry6. PCP Change7. Member material request8. CentAccount Card Inquiry9. Eligibility10. Billing

Areas of Focus • Continue to inform members of the need to notify the entity that established eligibility of their

demographic changes• Continue to educate providers of what is needed for authorizations and ask them to inform their

members• Continue to verify each member has a PCP when we speak to them and assist members with

selecting a PCP for those who do not have one

Appendix 26APage 3


Provider Services For 2016 the Magnolia MSCHIP call center took 4,405 Provider calls with an average Service Level of 95.39%. The average speed of answer for calls was six seconds to which the average talk time is 5:40. The Call Center will take the same approach for MSCHIP calls as MSCAN calls.

The top ten call categories are as followed: 1. Claims status Inquiry2. Provider Education Eligibility3. Eligibility Inquiry4. Benefit Inquiry Benefit/Limits Copay5. Provider Education Authorizations6. Internal Health Plan transfer7. Authorization Status Inquiry8. Authorizations Clinical review9. Claims Appeals10. Prior Authorization Inquiry

Areas of Focus • Continue to educate Providers on the how to review claims status on the web• Continue to educate providers using fax blasts, emails and Provider Orientations• Continue to develop Provider Services to provide a higher level of service to Providers from the

Call Center

Appendix 26APage 4

MississippiCAN Appeals – 2016

Analysis Findings from a root-cause analysis of 100% of the appeals received in the Benefit Denial or Limitation category, determined that most appeals received were due to a lack of clinical information submitted during the prior authorization process. During this analysis, it was identified that when the additional clinical information was submitted to Magnolia with the appeal, the initial determination was overturned. This analysis showed that during 2016, 447 appeals were received; 332 appeals (76%) were overturned (including partial); 107 (24%) were upheld, and 1 was withdrawn. Magnolia identified that the largest category of appeals within Benefit Denial or Limitation were pharmacy appeals (259) with 229 overturned. Reasons for denial were providers were requesting non-formulary medications without documentation of trial and failure of PDL medication, and. providers were requesting administration of a medication in a manner that is not aligned with Food and Drug Administration (FDA) approved guidelines. Imaging was the second highest category for appeals, at 55 with 25 overturned Imaging was the second category for appeals at 55 with 25 overturned after additional information was submitted which supported medical necessity.

Barriers • Providers not using medications on the Preferred Drug List• Providers not providing medical necessity information during the prior authorization process

Appendix 26APage 5

• Providers prescribing medications for off brand label use

Interventions • Educated providers on the prior authorization requirements• Educated providers on the Universal Preferred Drug List (UPDL)• Held quarterly Joint Oversight Committee meetings with US Script to monitor performance• Educated providers on what information to provide for medical necessity

CHIP Appeals – 2016 In 2016 there was a total of 28 CHIP Appeals in four (4) service categories, Pharmacy, Speech Therapy, Dental and Radiology. Appeals were received throughout the year with the highest number of appeals in March (5), April (4), May (4) and August (4) with no appeals in June and December. The average turn-around-time from the time the appeal was received to resolution was 3.7 days. The 2 expedited appeals were resolved in 1 day or less.

Appendix 26APage 6

Pharmacy There were six (6) appeals in the Pharmacy Category, five (5) for medications and one (1) for a nutritional supplement. Two (2) were expedited and four (4) were standard appeals. Of the six (6) appeals, five (5) were overturned and one (1) was upheld (the nutritional supplement); two (2) were initiated by parents and four (4) appeals were initiated by four (4) different providers.

Speech Therapy There were ten (10) appeals in the Speech Therapy Category with four (4) overturned and six (6) upheld for non-coverage of benefit. Eight (8) of the appeals were received from parents and two (2) from two different Speech Language Pathologists.

Dental There were eleven (11) Appeals in the Dental category and all were standard pre-service. All of the appeals were reviewed by Dental Health and Wellness reviewers and initiated by members/parents, with two (2) overturned, eight (8) upheld, and one (1) partially approved. The Appeals were for: Braces (6), Temporary False Teeth (2), General Anesthesia for an Impacted Tooth (2), and Dental Procedure/Biopsy (1)

Radiology There was one (1) pre-service Radiology Appeal initiated by a Provider for a CT reviewed by NIA Reviewer and overturned after receiving additional clinical information.

Barriers • Providers not submitting correct clinical documentation with prior authorizations

Appendix 26APage 7

• Potential knowledge deficit of providers or providers’ clinic staff of member eligibility andbenefit coverage

Interventions • Identified providers were educated on what clinical documentation is needed for

submission to support medical necessity for prior authorizations• Providers were educated on necessity of confirming member eligibility and benefits

Appendix 26APage 8

Magnolia Health PlanMSCAN Grievance Analysis

2016Specific Reason 2016 Total Description of Grievance Trends and Possible Causes of Grievance Corrective Action / Solution

Payment and Reimbursement Issues

68%

* Member received bill for services* Member did not know service was not covered

* Provider Trends: Baptist, UMMC, Merit Health * Insurance information not correct on file* Office confirms a zero balance - is patient interpreting a statement asa bill?* Office agrees to cease collection efforts is a common resolution *Claim never submitted to Magnolia

* Educate Magnolia Health Plan staff:- Goal is to resolve issue on the initial call, this prevents a grievance -Gather specific information on initial call - who, what, when, why - Document contact information of caller- how to determine if patient received a bill or statement from provider *Educate providers and members on importance of updating insuranceinformation each visit* Educate members on covered services and make information easilyavailable to members and to ask if services are covered by Medicaid *Educate providers about the rules on balance billing MedicaidBeneficiaries *Direct education bythe Provider Realtions team to the providers identified with trends

Access to Service and Providers 6%

* Timeliness of Prior Authorizations*No coverage for specialist in area

* No trends in coverage gaps identified * Specific gaps were related to rheumatology - Jackson, OB GYN -Columbus

* Continue to monitor GeoAccess to ensure there are no gaps incoverage*Work to ensure Provider Finder on website is up to date*Educate members on how to obtain help when looking for a provider

Provider Care and Treatment 0.54%

* Provider would not prescribe pain medications* Provider would not give test results*Professionalism / Rudeness / Attitude of provider orprovider staff*Discharged from hospital to early

* No trends with involved providers identified* Grievances were evenly split between outpatient and inpatientencounters

* Communicate grievances with involved providers and/or vendors*Monitor for trends in providers*Monitor for quality of care and health disparity issues

Benefit Denial and Limitations 1%* Prior Authorization denials due to provider notproviding needed information

* Denials for MRI (3)* Supplies (4) - diabetic x 3, c-pap* Dental coverage (4)

* Educate providers on needed information for Prior Authorization* Educate members on covered benefits and DME*Monitor for trends

CCO Customer Service Issues 1% * Professionalism and Rudeness of Magnolia Healthstaff

* No trends noted except high volume call areas had more complaintsthan other areas

* Educate Magnolia Health staff on importance of customer service* Continue to monitor calls for courtesy and respect

CCO Administrative Issues 1.10%

* CentAccount incentives (5) - Lack of understandingon how to utilize* Denials for service (4)* Nurse Wise (2)could not understand request

* Continue to educate members on covered benefits* Educate members on how to obtain and use of CentAccount rewards

Transportation 22.50%

* Timeliness of service* Driving Habits* Professionalism*Scheduling*Inadequate vehicles

*Trends with involved transport companies identified: Grove, J&D,Aberdeen on Wheels, Universal and Legacy*Member perception

* Re-establish expectations with MTM:- Pick up timneliness- obeying traffic laws- offer a helping hand-treat members with courtesy and respect* Hold MTM accountable during JOC meetings* Educate members on scheduling process and how to obtain help inscheduling transportation *Educate MH staff on how to utilize the MTM webportal to arrange transportation for members *Notified MTM of agencies with the most complaints and grievancesagaist them*Meet with MTM as trends arise and not wait until the quarterly JOC

Appendix 26APage 9

Magnolia Health PlanCHIP Grievance Analysis

2016Specific Reason 2016 Total Description of Grievance Trends and Possible Cause of Grievance Corrective Action / Solution

Payment and Reimbursement Issues

98%

* Member received bill for services * Trends identified with specific involved providers/facilities:St. Dominic, Baptist Hospital, South Central Medical Center * Insurance information not correct on file *Claim never submitted to Magnolia* Member utilizing non network provider or facility*Provider billing UHC instead of Magnolia

* Educate Magnolia Health Plan staff:- Goal is to resolve issue on the initial call, this prevents a grievance-Gather specific information on initial call - who, what, when, why *Educate providers and members on importance of updating insuranceinformation each visit; Educate providers on how to check eligibility * Direct outreach to the facilities trended for one on one education by Provider Relations * Educate members on in network versus out of network coverage and how to obtain that information

Access to Service and Providers 0.50%

Provider Care and Treatment 0.50%

Benefit Denial and Limitations 0.93%

CCO Customer Service Issues 0

CCO Administrative Issues 0

Transportation 0

Appendix 26APage 10

February 21, 2017

2016 TOP 10 CATEGORIES OF CALLS, ISSUES, COMPLAINTS, ETC.

TOP 10 MEMBER CALL DRIVERS 2016

CATEOGRY CALL VOL 1. PCP Inquiry 37734 2. Membership Record 11738 3. Eligibility 9708 4. Address 8082 5. Benefits 6282 6. Provider Related 4715 7. Claims Inquiry 4465 8. COB Information 3863 9. Pharmacy Inquiry 3721 10. ID Cards 3307

Addressing/Resolving Member Issues: The top 10 member call drivers represent the primary reasons why members place inbound phone calls to our call center. In the vast majority of these interactions, the member presents a common question or request, such as “Can I make a change to my assigned PCP?” In this example, the call agent is able to accommodate a specific request involving a particular network PCP, or suggest a network PCP based on proximity to the member’s home address. Call agents are well-equipped to quickly manage all calls represented by the top 10 drivers. In the event that member call agents receive a non-standard member issue that cannot be resolved during the initial call, there is a documented escalation pathway that involves call supervisors and defined Subject Matter Experts to ensure additional resources are engaged as needed and final resolution is achieved.

In order to drive to a higher level of member issue resolution and deliver more comprehensive support to UnitedHealthcare members, the Advocate4Me member services model was deployed in July 2016. Advocate4Me is a customer care approach that provides a single point of contact to address various health needs. By calling a single toll-free number, or using their preferred communication channel, members are connected with an Advocate who provides them with end-to-end support and owns their request until it’s resolved. This approach results in a simpler, more personalized and informed experience for the member.

Advocates can tap into a team of experts specializing in clinical care, emotional health, pharmacy, health care costs and medical plan benefits — to help each consumer navigate the health system and get the information he or she needs. To help UnitedHealthcare anticipate and respond to member questions and concerns, data analytics and technology platforms are used to identify a member’s potential health care situation.

From July through December 2016, Advocate4Me assisted Mississippi members by engaging in over 1,400 conversations about gaps in care once members called for other reasons to provide actionable health education and further scheduled over 200 health care appointments. UnitedHealthcare also implemented a follow-up letter writing campaign in 2016 to provide a more personal touch to our members. We understand that a personal connection can be lost when dealing with a large company and the letter-writing initiative was created with the expressed purpose of creating a personal

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connection with our members. In 2016, nearly 3,000 handwritten members were delivered to members as follow-up to call center interaction.

The Advocate4Me model is where supportive technology and human interaction meet to help clear away member confusion, guide consumers to the care that’s right for them, enable access to care, and provide a higher level of personal service.

TOP 10 PROVIDER CALL DRIVERS 2016

CATEOGRY CALL VOL 1. Claims Inquiry 131003

2. Membership Record/Eligibility 14944

3. Benefits 13654

4. COB Information 11137

5. Authorization Related 4187

6. Appeal/Complaint/Grievance 1841

7. General Inquiry 819

8. PCP Inquiry 2204

9. Provider Related 3802

10. Accumulator 476

TOP 10 PROVIDER CALL ISSUES & RESOLUTION 2016

ISSUE DESCRIPTION & RESOLUTION 1. Claim denials related to manually

priced itemsClaim SOP updates and claim processor education completed late 2015/early 2016. Provider education resources developed and presented to providers to augment individual provider education.

2. Provider calls related to claimadjustments applying multipleprocedure reductions retroactively

Outpatient multiple procedure pricing deployed Q3 2016 with 7/1/15 effective date in follow up to DOM policy. Provider services/provider relations educate providers on state update to outpatient pricing methodology and UHC mechanisms for applying, adjusting claims, etc.

3. Reported issues with newborn claims Claims filed under mother ID. Other examples in which provider clearinghouse creating error related to effective date and DOS being the same. Provider services educate providers to ensure claims filed using newborn own Medicaid ID and to follow up with clearinghouse to resolve any electronic transaction issues.

4. Claims processing to inactive CHIPcoverage when MSCAN coverage isactive resulting in inaccurate denials

Issue detected May 2016. Updated manual SOPs deployed July 2016. Claim adjustments completed October 2016. Additional system upgrades underway.

5. Reported concerns with contractingdelays

Vast majority of contracting delays were found to be related to Disclosure of Ownership form. Revised form/process implemented August 2016 to streamline requirements and drastically reduce provider burden related to disclosure form.

6. Claim denials related to oxygenconcentrators

iCES edit denying claim in error. System updates and claim adjustments completed July 2016 to allow proper reimbursement.

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7. Claim denials related toinvalid/incomplete hysterectomyform

Claim SOPs were built to support outdated form. SOP updates and claim adjustments completed June 2016 to allow proper reimbursement.

8. Call agents not finding eligiblemembers in system

MS Medicaid IDs crosswalk to internal UHC-assigned member IDs. Additional call agent education completed May 2016 to ensure search queries were completed accurately.

9. Provider questions/complaintsrelated to medical records request

Established standing meeting between Provider Relations and Optum Review Team to review process, discuss review triggers, any review any specific provider cases

10. Provider inquiries related to priorauth requirements and differencesamong UHC/MHP/DOM

Review UHC requirements and point providers to location of prior auth materials online. Site of service codes denied incorrectly as needed prior auth. National policy incorrectly applied to MSCAN/CHIP. Configuration updates and claim adjustments completed July 2016.

TOP 10 APPEAL CATEGORIES BY REVIEW OUTCOME

TOP 10 APPEALS BY REVIEW OUTCOME MEMBER APPEALS

PROVIDER APPEALS TOTAL

1. Overturn 165 3446 3611

2. Upheld 367 2511 2878 3. Appeal not submitted within

applicable timeframe 47 1088 2223

4. Partial Overturn 2 147 149

5. Withdrawn 48 53 101

6. Duplicate to Closed Case 4 54 58

7. Duplicate to Case in Process 0 20 20

8. Claim Previously Adjusted 0 15 15

9. Appeal Rights Exhausted 0 7 7 10. Closed for Additional Information -

Provider 0 1 1

TOP 10 APPEALS & GRIEVANCE ISSUES & RESOLUTION 2016

ISSUE DESCRIPTION & RESOLUTION 1. Providers submitting reconsideration

requests as appeals and werereceiving denials for timely filing dueto the timeframe the request wassubmitted

Education provided to UHC staff in regards to the appropriate logging and timeframes for appeals and reconsiderations. Providers are allowed 90 calendar days to submit a reconsideration request. On August 1, 2016, a two-step process was put in place at the case intake level to determine if the reconsideration rights have been exhausted prior to logging the case as an appeal. If the reconsideration rights have not been exhausted, the case is routed to UHC’s reconsideration team. Implementing this process allows the member or provider to have their case reviewed without exhausting their appeal rights. Provider education continues to advise providers of appropriate processes and timeframes for appeals and

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reconsiderations. 2. Providers submitting appeal requests

outside of timely filing requirements(no trending noted for providers orservices.

Provider relations emphasize appeals process and timelines through provider education interactions

3. Initial denial due to missingdata/information that has since beenreceived

Continued education to providers regarding necessary documentation

4. Increase in D8080 denial code for thelast 6 months of 2016. Claim filingerrors and delayed submission ofContinuity of Care documentation dueto provider confusion as to whatinformation was necessary for COCcases.

DBP completed one-on-one training with multiple orthodontia providers. Upon receipt of the corrected COC files, DBP updated claim documentation to allow orthodontia cases to reprocess.

5. Claim review for UHC error was notconsistently completed for casessubmitted past the timely filingdeadline. The appeal requests wereimmediately denied for timely filingwithout regard to any potential UHCerror.

Fall 2016, the appeals process was updated to require a thorough review of the appeal submission and prior determination to identify possible UHC errors before denying for timely filing.

6. Complaints/grievances submittedregarding transportation providerrudeness.

Continue to monitor in collaboration with transportation vendor and work to improve the overall member experience.

7. Complaints/grievances submittedregarding provider care andtreatment.

No specific issue or provider trends. Continue to monitor.

8. Significant appeal volume for singleprovider under FWA investigation.

The Little Chatterbox submitted 814 appeal requests in 2016. The requests were submitted multiple times for the same claims. Appeal resolution letters were edited manually to advise the provider that all appeal rights with the healthplan has been exhausted and their next steps were to request a State Administrative Hearing from DOM.

9. Appeal requests are withdrawn by theHealthplan due to lack of memberconsent when appeals are filed ontheir behalf.

Appeal resolving analysts complete 2 outreach attempts (by phone) after sending the initial consent letter to the member before withdrawing the case and closing.

10. Providers balance billing members Continued education to providers through clinics, workshops, and provider outreach. One-on-one calls/meetings with any trending providers.

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Appendix 26BPage 4

Medicaid’s Detailed Response to...Navigant Recommendation 1: DOM should update the MHAP...

Documents

Transcript of Medicaid’s Detailed Response to...Navigant Recommendation 1: DOM should update the MHAP...