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Apple Health (Medicaid) MCO and BH-ASO state contracts

HCA is requesting Tribal Consultation on the state’s contracts with the Medicaid managed care organizations (MCOs) and the behavioral health – administrative service organizations (BH-ASOs).

This page provides a collaborative space for Indian Nations and the HCA to review and discuss agreements. 

Current contracts for review

For your tribal government’s review and advice, we have posted these  draft forms of agreement between HCA and the MCOs:

We will post the forms of agreement between HCA and the MCOs for wraparound services as soon as they become available.

Scheduled meetings

Meeting

Date and time

Locations and webinar registration

Roundtable #1

 

January 8, 2020
1-3 p.m.

Health Care Authority
Cherry Street Plaza
Sue Crystal Conference Center
(626 8th Avenue SE, Olympia, WA 98501)

Click here to register for the webinar

Roundtable #2

January 22, 2020
9-10:30 a.m.

Health Care Authority
Cherry Street Plaza
Apple Conference Room
(626 8th Avenue SE, Olympia, WA 98501)

Click here to register for the webinar

Consultation

February 5, 2020
9-11:00 a.m.

Health Care Authority
Cherry Street Plaza
Sue Crystal Conference Center
(626 8th Avenue SE, Olympia, WA 98501)

Click here to register for the webinar

In preparation for the Tribal Consultation, HCA will seek guidance from the Centers for Medicare and Medicaid Services (CMS) on the question of whether and how Tribal 638 Facilities, under the Tribal Clinic designation or the Tribal FQHC designation, may receive the IHS encounter rate for services furnished to AI/AN and non-AI/AN Medicaid beneficiaries enrolled in managed care if the Tribal 638 Facilities do not have a contract with the MCOs.

HCA may seek guidance from CMS on other proposals requested by the American Indian Health Commission for Washington State (the Commission) if those proposals present concerns with compliance with federal Medicaid requirements.

Background

On January 1, 2020, the state completes the statewide implementation of Apple Health (Medicaid) IMC, as directed by Senate Bill 6312 (2014). In Apple Health IMC, MCOs coordinate and pay for all Medicaid-covered physical health, mental health, and substance use disorder treatment services for their managed care plan enrollees – to help provide whole-person care. In each region with Apple Health IMC, there is also a BH-ASO that administers non-Medicaid funds for behavioral health crisis-related programs in the region, such as designated crisis responder (DCR) assessments and crisis hotlines.

Under federal rules, the state may not pay providers for Medicaid-covered services if the beneficiary is enrolled in managed care, as the state has already paid the BHO or MCO to cover those services. Since April 1, 2016, however, the state has paid the Indian Health Service (IHS) and Tribal 638 Facilities for claims submitted directly to the state for mental health and substance use disorder services provided to Medicaid managed care enrollees. The state adopted this exception because of concerns with the BHOs’ ability to accurately pay claims from IHS and Tribal 638 Facilities. With the ending of the BHO program on January 1, 2020, the justification for this exception ends as well. The state has always complied with the federal rules for Medicaid-covered physical health care services furnished to managed care enrollees.

As this could be a significant change for some Tribal 638 Facilities’ administrative processes, HCA began sharing information about this change in autumn 2019. We explained that, beginning January 1, 2020, IHS and Tribal 638 Facilities would need to bill the Apple Health IMC MCO instead of the state’s ProviderOne system for outpatient behavioral health services furnished to Medicaid beneficiaries enrolled in managed care. Most Medicaid beneficiaries who are not AI/AN will be mandatorily enrolled in Apple Health IMC. HCA also stated that “for non-AI/AN clients, contracts with the managed care plans will be required.”

On November 13, 2019, the Commission sent a letter to HCA (enclosed) with an explanation of the federal right to recovery statute (25 U.S.C. § 1621e(a)) and a number of requests. Below is HCA’s summary of these requests of the state:

  1. Prohibit MCOs from requiring Indian Health Care Providers to contract with them in order to pay for services furnished to any managed care enrollees by amending the Tribal Health Program Billing Guide and the state’s contracts with MCOs.
  2. Consider the Commission’s other proposed changes to the state’s contracts with MCOs and BH-ASOs, including proposed language to operationalize MCO payment to non-contracted Tribal 638 Facilities.
  3. Delay changes to any reimbursement process to Indian Health Care Providers until the state has held consultation with the Tribes on the state’s contracts with MCOs.
  4. Make the state’s January 1, 2020 contracts with MCOs and BH-ASOs available to Tribes for review.
  5. Provide a timeline for consultation and engagement on the Commission’s proposed changes to the state’s contracts with MCOs and BH-ASOs.

HCA is requesting Tribal Consultation on the state’s contracts with the Medicaid managed care organizations (MCOs) and the behavioral health – administrative service organizations (BH-ASOs).

HCA is also suspending any changes to the Medicaid reimbursement process for the Indian Health Service (IHS) and Tribal 638 Facilities that submit claims directly to the ProviderOne system for outpatient mental health and outpatient substance use disorder treatment services furnished to individuals enrolled in Medicaid managed care plans until after the Tribal Consultation.

Contact

Jessie Dean, Tribal Affairs administrator
Phone:
 360-725-1649
Email: jessie.dean@hca.wa.gov