MCM Commission NH Department of Health and Human Services July 14, 2016 Legislative Office Building Room 206, Concord, NH Agenda • Step 2 Planning, DSRIP/1115 Waiver, and DHHS Personnel, Enrollment Data – Commissioner Meyers • Prior Authorization Data Update, Quality Summary, and Final Rule – Deb Fournier 2 1
NH Medicaid Enrollment by Program, 7/1/16 Non-MCM/PAP, 8,069 NH Healthy Families, 62,600 MCM, 136,962 Well Sense, 74,362 PAP, 40,381 Notes: Members are open for services as of the point in time as of the source date. Data excludes members without full Medicaid benefits (Family Planning Only & Medicare Savings Plans). Non-MCM/PAP includes members transitioning into MCM or PAP, members exempt from both programs, including members with employer-based insurance purchased by Medicaid through the Health Insurance Premium Program. 3 Source: NH MMIS as of 7/5/16 for most current period; Data subject to revision. MCM Pharmacy Claims, Authorizations & Appeals (Note: logarithmic scale y axis) 892,249 974,270 994,598 968,484 810,536 1,000,000 100,000 10,496 9,543 7,549 6,852 10,000 5,151 4,025 4,030 3,641 3,065 2,679 Counts 1,000 293 279 258 229 200 120 123 116 92 100 53 10 1 CY2015-Q1 CY2015-Q2 CY2015-Q3 CY2015-Q4 CY2016-Q1 Total Claims Total Requests Subject to Service Authorization Denied Authorizations Appeals of Denied Authorizations Upheld Appeals of Denied Authorizations 4 Source: NH MCM Quality Data as of 5/25/16; Data subject to revision. 2
MCM Claims, Authorizations & Appeals Mental Health Drugs (Note: logarithmic scale y axis) 1,000,000 115,287 123,419 121,089 123,499 102,976 100,000 10,000 2,846 2,754 2,015 Counts 1,238 1,102 639 577 1,000 335 350 267 61 100 30 16 17 12 10 9 7 10 6 5 1 CY2015-Q1 CY2015-Q2 CY2015-Q3 CY2015-Q4 CY2016-Q1 Total Claims Total Requests Subject to Service Authorization Denied Authorizations Appeals of Denied Authorizations Upheld Appeals of Denied Authorizations 5 Source: NH MCM Quality Data as of 5/25/16; Data subject to revision. MCM Claims, Authorizations & Appeals PT/OT/ST (Note: logarithmic scale y axis) 100,000 19,725 18,258 16,290 16,339 9,732 10,000 4,081 3,522 3,476 3,152 3,186 1,000 Counts 226 203 179 153 139 100 33 27 21 20 14 13 7 10 6 3 3 1 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1 Total Services Paid Total Requests Subject to Service Authorization Denied Authorizations Appeals of Denied Authorizations Upheld Appeals of Denied Authorizations Source: MCM Quality Data as of 7/6/16; data subject to revision. 6 3
Grievances and Appeals for PT/OT/ST Services Newly Mandatory vs. Total MCM Population Total Appeal of Appeal of Denial Total Grievances Denial Filed Filed (1915b only) Total Grievances (1915b only) May-15 0 - 0 - Jun-15 2 - 1 - Jul-15 10 - 0 - Aug-15 11 - 0 - Sept-15 6 - 0 - Oct-15 8 - 0 - Nov-15 3 - 0 - Dec-15 3 - 0 - Jan-16 13 - 0 - Feb-16 8 0 1 0 Mar-16 12 3 0 0 Apr-16 18 3 0 0 Source: MCM Quality Data as of 6/21/16; data subject to revision. 7 MCM Non-Emergent Medical Transportation Requests, Authorizations, Appeals, & Grievances (Note: logarithmic scale y axis) 1,000,000 160,427 137,282 86,154 93,694 95,440 160,169 136,919 85,953 93,304 95,079 100,000 76,631 91,896 85,614 112,818 130,790 10,000 1,000 100 18 14 12 7 6 6 5 10 4 3 3 3 1 1 1 1 0 0 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1 Total Requests Total Approved Requests Rides Delivered Appeals of Denied Authorizations Upheld Appeals of Denied Authorizations Grievances Filed 8 Source: NH MCM Quality Data as of 7/31/16; Data subject to revision. 4
MCM Non-Emergent Medical Transportation Rides Delivered by Service Type 100,000 87,119 78,619 80,000 60,515 60,000 48,800 43,720 40,000 28,506 24,501 22,557 19,410 19,586 20,000 9,999 8,512 8,394 7,725 7,410 4,989 5,166 4,805 4,070 4,232 0 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1 Mental Health Provider Medical Provider Methadone Treatment Other (eg. Hospital and Pharmacy) 9 Source: NH MCM Quality Data as of 7/31/16; Data subject to revision. Questions? 10 5
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