Division Of Medicaid & Medical Assistance
Division of Medicaid & Medical AssistanceDraft2016 Access Monitoring Review PlanJuly 27, 2016
The Mission of the Division of Medicaid and Medical Assistance is to improve health outcomesby ensuring that the highest quality medical services are provided to the vulnerable populationsof Delaware in the most cost effective manner.Page 2
Table of Contents1.Overview . 41.12.3.Background . 41.1.1Medicaid Managed Care and Fee-For-Service Population . 51.1.2Delaware’s Health Professional Shortage Areas . 51.1.3Provider Recruitment and Retention Programs . 81.1.4Telehealth . 91.1.5Delaware’s Oral Health Initiative . 10Methodology . 112.1Recipients access to care . 112.2Provider Participation in FFS . 112.3Rate Analysis . 12Overview of Findings . 133.1Recipients’ Access to Health Care Services . 133.1.1DHSS Divisions Supporting Medicaid Recipients . 133.1.2Delaware 2-1-1 Helpline . 133.1.3DHSS Advisory Councils. 133.1.4Recipient Service Utilization Analysis . 143.2FFS Provider Network Analysis . 143.2.1DMMA Provider Support Services . 143.2.2Delaware Medicaid Provider Enrollment Statistics . 153.33.3.1Medicaid Reimbursement Rate Analysis . 19Comparison of Reimbursement Rates . 194.Ongoing Access Monitoring . 235.Conclusion . 24Page 3
1. OVERVIEWOn November 2, 2015, the Centers for Medicare and Medicaid Services (CMS) issued the final ruleentitled: Methods for Assuring Access to Covered Medicaid Services (CMS-2328-FC). The final rulerequires state Medicaid programs to develop access monitoring review plans (AMRPs) that include ananalysis of access to Medicaid covered services under the state’s fee-for-service (FFS) deliverymethodology consistent with section 1902(a)(30)(A) of the Social Security Act. The rule requires statesto review certain categories of services every three years and additional services should the state reduce(or restructure) provider payment rates.CMS requires AMRPs to: Address the availability of care, providers and how health care needs are met;Review access to Primary Care, Physician Specialists, Behavior Health, Pre/Post-Natal Care, andHome Health services;Document changes in utilization;Compare Medicaid rates and other health care payers; andBe developed with recipient, provider, and stakeholder feedback.The Delaware Division of Medicaid and Medical Assistance (DMMA), within the Department of Healthand Social Services (DHSS), administers Delaware’s Medicaid program and other public medicalassistance program. The mission of DMMA is to improve health outcomes by ensuring that the highestquality medical services are provided to the vulnerable populations of Delaware in the most costeffective manner.In accordance with 42 CFR 447.203, DMMA developed Delaware Medicaid’s AMRP to assess FFSMedicaid recipients’ access to the specified Medicaid services and determine whether reimbursementrates are sufficient to enlist enough providers so that care and services are available as required by theSocial Security Act. DMMA’s AMRP analyzes and evaluates access to care for services covered throughthe Medicaid State Plan and reimbursed on a FFS basis.This AMRP provides information about the extent to which FFS Medicaid recipients’ needs are met, theaccessibility of Medicaid-enrolled providers, changes in utilization of covered services, and comparisonsof Delaware Medicaid FFS reimbursement rates to payment available from other sources. Through thisreport, Delaware addresses access to care by assessing the availability of providers, FFS reimbursementrates, and the utilization of services.DMMA developed the AMRP from April through July 2016 and posted it for public comment in theDelaware Register from August 1, 2016 through August 30, 2016.1.1 BackgroundDelaware is a small, but densely populated state with approximately 946,000 residents, with themajority residing in Delaware’s most populous county, New Castle. Delaware’s other two counties, KentPage 4
and Sussex, have areas that are more rural. Delaware is bordered to the south and west by Maryland, tothe northeast by New Jersey, and to the north by Pennsylvania. As a result, Delaware residents oftenaccess health care in neighboring states and Delaware Medicaid covers treatment provided bynumerous enrolled out-of-state providers.1.1.1Medicaid Managed Care and Fee-For-Service PopulationThe Delaware Medicaid program currently provides health care coverage to approximately 227,377Delaware residents. Since 1996, the majority of Delaware Medicaid recipients have been served under amanaged care service delivery arrangement through the Diamond State Health Plan. In 2012, DMMAmoved additional Medicaid recipients and programs to a managed care arrangement, includingindividuals dually eligible for Medicaid and Medicare, individuals receiving nursing facility care, andindividuals receiving home and community-based services in lieu of nursing facility care. At that time,additional Medicaid services, such as nursing facility, and home and community-based services becamethe responsibility of the Medicaid managed care organizations (MCOs).Currently, the following Medicaid populations remain under the Medicaid FFS delivery methodology: 1,085 individuals receiving services under the Developmental Disabilities Home and CommunityBased Waiver Program administered by the Division of Developmental Disabilities Services(DDDS) 46 women receiving Medicaid under the Breast and Cervical Cancer Program – This programserves previously uninsured women who are identified through the Centers for Disease Control(CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and are in needfor treatment for breast or cervical cancer, including pre-cancerous conditions and early stagecancer.DMMA provides the following Medicaid services under a FFS payment delivery arrangement for allMedicaid recipients, including those served by the Medicaid MCOs: Dental services for 96,333 Medicaid children under the age of 21 Extended behavioral health services for all Medicaid populations to the extent that they areprovided via the FFS delivery system.1.1.2Delaware’s Health Professional Shortage AreasA federally designated Health Professional Shortage Area (HPSA) is a geographic area, population group,or health care facility that the federal government designates as having a shortage of healthprofessionals. The federal Office of Shortage Designation has established three categories of HPSAs:primary care, dental, and mental health professionals. HPSAs are designated using several criteria,including population-to-clinician ratios. This ratio is usually 3,500:1 for primary care, 5,000:1 for dentalcare, and 30,000:1 for mental health care. When there are 3,500 or more people per primary carephysician, an area is eligible to be designated as a primary care HPSA. When there are 5,000 or morePage 5
people per dentist, an area is eligible to be designated as a dental HPSA. When there are 30,000 or morepeople per psychiatrist, an area is eligible to be designated as a mental health HPSA.Since 2007, The Delaware Division of Public Health (DPH) within DHSS has contracted with the Universityof Delaware’s Center for Applied Demography and Survey Research (UD CADSR) to perform healthprofessional shortage area designations. UD CADSR establishes HPSA designations, MedicallyUnderserved Area/Population (MUA/P) designations and Governor’s Exceptional MUP Designations. Thefederal government defines the methodology by which HPSAs and MUA/Ps are designated. For areasthat do not meet HPSA or MUA/P criteria, Exceptional MUP Designations are permitted if “unusual localconditions which are a barrier to access to or the availability of personal health services" exist and aredocumented.For its HPSA analysis, UD CADSR conducts a survey of physicians, dentists, and mental healthprofessionals every three to four years. Before issuing the surveys, it reviews their contents with keystakeholders across the state, and revises them as needed based on stakeholders’ input. UD CADSRjudges the appropriateness of accessing health care services by the ratio of providers to patients in agiven geographic location, wait times for new and existing patients, languages spoken, and otherfactors. UD CADSR uses survey data to estimate the number of active health professionals and theirgeographic distribution. The following maps show Delaware’s HPSA, MUA and MUP areas.Page 6
Figure 1: Primary Care Health ProfessionalShortage Area Designations in Delaware, 2015Figure 2: Dental Health Professional ShortageArea Designations in Delaware, 2015Source: State of Delaware, Office of Primary Care and Rural HealthPage 7
Figure 3: Mental Health Professional Shortage Area Designations in Delaware, 2015Source: State of Delaware, Office of Primary Care and Rural Health1.1.3Provider Recruitment and Retention ProgramsDelaware has a number of programs designed to increase the availability and accessibility of health careprofessionals within the State.State Loan Repayment Program (SLRP) – The SLRP aims to increase the availability and accessibility ofprimary care, dental, and mental health services. The SLRP is a comprehensive statewide effort jointlyadministered by the Delaware Health Care Commission (DHCC), the Delaware Higher Education Office,and DPH. Recently, the Division of Substance Abuse and Mental Health (DSAMH) was added as a keyPage 8
partner as part of a broader mental health focus. Under SLRP, the Delaware Higher EducationCommission is authorized to make awards to primary care clinicians for repayment of outstandinggovernment and commercial loans incurred during undergraduate or graduate education, in exchangefor practicing a minimum of two years in a federally designated HPSA.Conrad State 30/J1 Visa Waiver Program – This program aims to improve access to primary care andneeded specialty care for Delawareans. It places international medical graduates who have completedtheir medical education in the United States in underserved areas of the State. Normally, uponcompletion of their education, these international medical graduates are required to return to theircountry of nationality for at least two years before returning to the United States. However, under theConrad State 30/J-1 Visa Waiver Program, this home residency requirement can be waived for up to 30J-1 physicians annually. In exchange, the J-1 physicians must agree to practice medicine full time at aDelaware pre-approved sponsoring site for at least three years. These practice sites must be located infederally designated HPSAs or a MUA, with the exception of 10 positions that can be placed in areas ofneed that are not in federally designated HPSAs.National Health Service Corps (NHSC) – This program offers financial and other support to primary careproviders and sites in underserved communities. The NHSC Program offers the following incentives tohealth care professionals agreeing to practice in a federally designated HPSA: NHSC Loan Repayment Program: 50,000 (up to the outstanding balance of qualifying studentloans if less than 50,000) provided tax free, to primary care medical clinicians in exchange fortwo years of service at an approved site in a designated HPSA. NHSC Scholar Program: Tuition, required fees, and other education costs (including books,clinical supplies, laboratory expenses, instruments, uniforms and travel for one clinical rotation)provided tax free, for up to four years. Recipients also receive a monthly living stipend, which istaxable. NHSC scholars are committed to completing a primary care residency (family medicine,general pediatrics, general internal medicine, or obstetrics/gynecology), becoming licensed, andserving one year for each year of support (minimum of two years of service) at an approved sitein a high-need HPSA upon graduation.National Rural Recruitment and Retention Network (3RNet) – DPH supports health professionalrecruitment efforts of Delaware’s medical community through membership in the 3RNet. Through thismembership, community health centers, hospitals, private practices, and community-basedorganizations have the opportunity to post job vacancies that can be easily accessed by candidatesseeking employment. This is a free service, providing national exposure for practice sites’ recruitmentefforts. Along with job postings, practice sites may include information about their practices’characteristics and other information.1.1.4TelehealthDelaware Medicaid has reimbursed health care providers for telehealth services since 2012 as animportant access improvement tool. Telehealth assists in addressing health care access issues, whetherPage 9
from shortfalls in critical health care specialties or in underserved geographic locations, as it enablesremote patient monitoring. In 2015, DHSS created the position of Director of Telehealth Planning andDevelopment within the DHSS Secretary’s Office to help fully integrate telehealth into Delaware’s healthcare system. The Mid-Atlantic Telehealth Resources Center and the Delaware Telehealth Coalitionsupport Delaware’s telehealth efforts. The Coalition and more than 85 stakeholders developed aDelaware Telehealth Strategic Action Plan to advance telehealth through advocacy and favorable publicpolicies and legislation.1.1.5Delaware’s Oral Health InitiativeDMMA developed and submitted an Oral Health Action Plan for the CMS Oral Health Initiative. Theobjectives of the Oral Health Action Plan include the following: Improve state Medicaid dental program performance through policy changes Maximize dental provider participation in Medicaid Partner with oral health stakeholders Increase the rate of children ages 1-20 enrolled in Medicaid or CHIP who receive any preventivedental service by 10 percentage points over a 5-year period Increase the rate of children ages 6-9 enrolled in Medicaid or CHIP who receive a dental sealanton a permanent molar tooth by 10 percentage points over a 5-year periodPage 10
2. METHODOLOGYDMMA’s AMRP covers the following categories of services provided via the FFS delivery system to theMedicaid populations identified in the following table. DMMA did not analyze pre- and post-natalobstetric services as no Medicaid FFS recipient utilized these services within the past three years.Table 1: AMRP Categories of Services and Medicaid PopulationCategories of ServiceMedicaid PopulationPrimary care services including thoseprovided by a physician, Federally QualifiedHealth Center (FQHC), and clinic DD HCBS Waiver program recipientsPhysician specialist services (i.e., cardiology,urology, and radiology) DD HCBS Waiver program recipientsHome health services DD HCBS Waiver program recipients Breast and Cervical Cancer program recipients Breast and Cervical Cancer program recipients Breast and Cervical Cancer program recipientsBehavioral health services including mentalhealth and substance use disorder All Medicaid populations to the extent that behavioralhealth services are provided via the FFS deliverysystemDental services All Medicaid children under the age of 21 to the extentthat dental services are provided via the FFS deliverysystemDMMA’s methodologies used in developing the AMRP are described in the following sections.2.1 Recipients access to careGiven Delaware Medicaid’s small FFS population and services, DMMA reviewed Delaware’s supportservices for FFS Medicaid recipients and developed a three-year trend in utilization of services and ineach of the following service categories: primary care, dental, physician specialist, behavioral health,and home health services.2.2 Provider Participation in FFSDMMA reviewed the support provided to FFS providers. In addition, DMMA analyzed providerenrollment data for three-years, for all provider taxonomies that fall under the AMRP’s categories ofservices. DMMA analyzed the enrollment data to identify changes in enrollment of providers inDelaware Medicaid. DMMA also analyzed Medicaid recipients’ utilization of these services over a threeyear period.Page 11
2.3 Rate AnalysisTo conduct the rate comparisons, DMMA queried the top 10 procedure codes by claim volume for thefollowing categories of service: primary care, physician specialists, behavioral health, and home health.DMMA then compared the Delaware Medicaid rate for these procedure codes to the Medicaid rates inthe neighboring states of Maryland, New Jersey, and Pennsylvania, and to the Medicare rates for theseprocedure codes.For our dental services reimbursement rate analysis, DMMA utilized the October 2014 Research Briefproduced by the Health Policy Institute (HPI). HPI is a source for policy knowledge on critical issuesaffecting the U.S. dental care system. HPI generates, synthesizes, and disseminates research for policymakers, oral health advocates, and dental care providers. In October 2014, HPI released a research brieftitled A Ten-Year, State-by-State, Analysis of Medicaid Fee-for-Service Reimbursement Rates forDental Care Services. The entire brief can be found at AnalysisOct2014.pdf.For its analysis, HPI acquired pediatric Medicaid FFS reimbursement rate data for 2003 from previouslypublished research and 2013 reimbursement rate data from state Medicaid program webpages for allstates and DC. HPI constructed an index that measures FFS reimbursement rates in Medicaid relative tocommercial dental insurance charges. HPI based its index for pediatric dental care services on fourteencommon procedures. Within its index, HPI weighted the reimbursement rate for each procedure by itsshar
1.1.1 Medicaid Managed Care and Fee-For-Service Population The Delaware Medicaid program currently provides health care coverage to approximately 227,377 Delaware residents. Since 1996, the majority of Delaware Medicaid recipients have been served under a managed care service delivery arrangement through the Diamond State Health Plan. In 2012, DMMA
The MAX Medicaid policy issue brief series highlights the essential role MAX data can play in analyzing the Medicaid program. MAX is a set of annual, person-level data files on Medicaid eligibility, service utilization, and payments that are derived from state reporting of Medicaid eligibility and claims data into the Medicaid Statistical Infor-
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