SB 1123 - This act directs the Department of Social Services to request the appropriate federal waivers to permit the establishment of both a Coordinated Care pilot program and an Administrative Services Organization (ASO) pilot program for recipients of Medicaid who receive such assistance on the basis of being aged, blind, or disabled. Enrollments for such programs shall be completed by July 1, 2007. Eligibility for the pilot programs shall not include individuals who are under twenty-one years of age, are institutionalized, or who are dually eligible for both state Medicaid and federal Medicare programs.
The department shall implement the Coordinated Care pilot program in at least one of the following areas: Greater St. Louis Area; Greater Kansas City area; or Greater Springfield area. The department shall implement the ASO pilot program in at least one of the same areas mentioned previously. However, the Coordinated Care pilot program and the ASO pilot programs shall not be implemented in the same areas. The department shall establish criteria for award selection to include preference for Missouri-based vendors and prior experience.
Participation in the pilot programs shall be mandatory, except that there shall be a formalized exemption process for recipients whose current treating physicians are not participating in the coordinated care network in an effort to prevent interruption in the continuity of care.
The Coordinated Care program shall operate generally under a traditional managed care model, including offering a consolidation of pharmacy management, claims adjudication, utilization review, and care coordination. The program shall be a risk-based program with a guaranteed savings level that is actuarially sound while limiting the profit that is generated to the coordinated care vendor.
The ASO pilot program shall have financial terms requiring the vendor fees to be reduced if savings and quality targets specified by the Department are not met. The ASO program shall provide care coordination, utilization management, and participant education. However, the state shall continue to retain provider reimbursement, pharmacy management, eligibility determination, and provider network management.
Both the coordinated care and ASO pilot programs shall incorporate the following elements:
(1) Three-year contract terms subject to annual savings and quality targets determined by the Department and which shall include consumer and provider satisfactions levels;
(2) Mechanisms in place to promote and determine the appropriate use of in-home care for participants prior to admissions in custodial skilled nursing facilities;
(3) Prompt payment to the providers within thirty days of receipt of a claim of reimbursement;
(4) Consumer call centers established based in Missouri;
(5) Consumer ombudsman programs;
(6) Partnerships with federally qualified health centers or rural health clinics, if such clinics are in the same geographic area.
This act also establishes an "Oversight Committee on Coordinated Care and Administrative Service Organizations" in the Department of Social Services. The Committee shall consist of eleven members: two members of the House of Representatives and two members of the Senate from the Joint Committee on Health; two consumer representatives; two healthcare providers; two healthcare advocates; and the Director of the Department of Social Services or the director's designee.
The Committee shall review the monthly consumer and provider satisfaction reports required of the pilot program vendors, the call center statistics, and the reports from the pilot ombudsman programs. The Committee shall determine how the data collected shall be analyzed to determine the health outcomes and cost savings from the pilot programs and how such findings may be communicated to consumers, health care providers and public officials. The Committee shall report significant findings indicating satisfaction or dissatisfaction with the programs to the Joint Committee on Health, as necessary.
There is a six-year sunset provision on the programs.