Senator Udalls office correspondence with Jemez

From Jemez:

 

 

Fern-

Thank you so much for your response. I have a tendency to be very straight forward, so I apologize if this seems a bit blunt:

1.       We want our tribal people to retain their “right to choose” their health care system and provider, not be mandatorily enrolled with an MCO. We are uncompromising on this point.
2.       What we want to work with the state, though. We see the state’s position and wand to find points of compromise. In fact, the four points, you detailed in your email was an act of compromise. Our original list contained nearly 10 items.
To that end, we are suggesting a demonstration project within Centennial Care as it relates to Native Americans to “test pilot” the initiative before we expose 100% of the Native American population and 100% of the I/T/Us to a system that we are trying to indicate is simply not going to work in Indian Country. Truthfully, we are not confident it will work in rural NM as a whole, but we are focused on our NA population.
3.       From that demonstration project and during the pilot year, we want to develop with the state a tribal specific contract- this could be for tribes to engage the selected state MCO’s or for a tribal specific MCO, which the state identifies as for I/T/Us to work with.

 

There is just a two part clarification that is important in response to your email below:

MCO’s do not align with tribal health systems-

We would be considered a provider by an MCO under Centennial Care, yes, and that is the problem. It is unreasonable to expect an MCO to not act like an MCO when it comes to tribal health centers. It will cycle our claims and care coordination through the same system of scrutiny as it would any claim from any health center. On its face, that seems reasonable. However, when you think about the fact that the MCO has specific standards of care, specific provider manuals, federal and state compliance requirements which MCO’s generally defer responsibility for to the affiliated facility and a myriad of other check points that make an MCO an MCO, you have to acknowledge that this does not align or make sense to align with a tribal health system. Now. Compound that by 5 MCOs- we would have to engage each of them.

Tribal health systems in contrast are working in rural, racially homogenous populations (in general) and with Indian Health Service in the design of shared standards of care, provider credentialing and privileging, etc.

Our systems of care, our health outcomes, our existing managed care coordination and system- all of these were not considered when Centennial Care was created. An MCO overlay on our system is an “accident waiting to happen”.

 

When (emphasis added) MCOs pay, yes, they would pay the OMB rate, but the MCO is then just passing thru the 100% FMAP the state receives from the feds, while the MCO retains the full PMPM (per patient/month) capitated rate for services for the Native American who was automatically enrolled in that MCO. However, that MCO will not be providing any services, because the NA is going to the tribal health centers. The tribal health centers are providing the services. I say this to point out that this is NOT a money saving venture, as proposed by the state.  Our elected officials must understand that.

Bottom line- Organizations of every sector get into business together for mutual benefit. In fact, Jemez is a provider under and MCO that we sought out (Lovelace), because it worked in the best interest of our business model.

From the comments above, it is clear that the benefit is to the MCO, the administrative burden is to the I/T/Us and the risk is to the NA client who can easily fall through the cracks in this system. It is happening today with the existing MCOs that the state is supposed to be managing.

Sorry for the long answer. Please let me know if you need any additional information.

April

 

 

From: Goodhart, Fern (Tom Udall) 
Sent: Tuesday, January 29, 2013 7:17 AM
To: April L. Wilkinson

 

Very helpful April, thanks.

 

Given this points:

 

1.      Eliminate requirement for Native Americans to be automatically or mandatorily enrolled in a Managed Care Organization. This is to ensure that Native American’s retain their right to choose their own health care system, including the choice to “opt in” to an MCO. However, only 15% of current NA Medicaid eligible individuals have chosen to “opt in” to an MCO.

2.      Reject New Mexico’s proposal to eliminate the retroactive eligibility for Medicaid beneficiaries. CMS heard and responded to this concern and has tabled this request from the state. It will not be approved in the waiver this time, but remains a priority issue for I/T/Us.

3.      Preserve the mechanism for payment of Medicaid claims for Fee For Service directly between the IHS/Tribal/Urban (I/T/U) and the State of New Mexico at the existing all inclusive OMB rate. Under the current system, when I/T/Us provide a service to a Medicaid eligible patient, the state’s fiscal intermediary makes payment promptly and in full. This system is working and working well. However, the position of the MCO as a “middle man” will create payment issues and administrative burdens that are likely to delay, limit or even eliminate the I/T/U’s ability to collect the Medicaid revenue owned.

4.      Require that the protection against cost sharing for all Native Americans enrolled in New Mexico’s Medicaid program is clearly written in the state’s waiver; this is regardless of whether they seek care at an IHS or non-IHS facility. Currently, HSD indicates that this issue is “understood” in the application, but the tribes continue to request its clear delineation in the waiver.

 

It’s my impression at the current time that all providers in NM (including tribal providers) would be considered part of an MCO, so that tribal members can continue to go to any provider they choose. That retroactive eligibility is likely. That the OMB rate is the default rate for tribal providers. And we can definitely request that cost sharing for Native Americans be clearly written into the terms and conditions.

 

If CMS approves the Centennial Care waiver, we can also request language to evaluate: the coordination of care under Centennial Care for Native Americans, an assessment of the cultural competence of care coordinators, and prompt payment to assure no negative fiscal impact on tribes under this model.

 

Anything else to include for consideration in terms and conditions?

 

Thank you for your thoughtful review of the application regarding the needs of tribal members.

 

Best,

Fern