Serving Persons with Disabilities in Medicaid Managed Care

A Provider's Perspective on the HIV/AIDS Population

April 17, 2002

David H. Shippee, Executive Director, Chase Brexton Health Services, Inc.

Chase Brexton Health Services, Inc.

• Non-profit ambulatory care provider for 23 years
• 1986 - HIV primary care provider
• 1995 - FQHC look-a-like
• 1999 - Section 330 grantee
• 2 Ryan White CARE Act SPNS Awards
  • Primary Care/Mental Health Integration
  • HIV Treatment Adherance
• Currently manage care for 1400 HIV+ patients
• 250 patients are in an HIV risk-based Medicaid Managed Care arrangement

History with HIV/AIDS Risk Contract

July 1997

• Maryland HealthChoice Program starts
• 330,000 enrollees transitioned to mandatory Medicaid Managed Care

January 1, 1998

• CBHS starts a full-risk contract for AIDS defined enrollees
• Transitions 125 of its own patients

Initial Contract Terms

• CBHS received 86% of premium
• Responsibility excluded:
  • dental
  • vision
  • viral load testing
  • protease inhibitors
  • mental health services

January 2001

• Risk-adjusted rates for HIV positive/non-AIDS defined enrollees are implemented
• All medications are put into the HIV+ and AIDS-defined enrollee rates. New rates are issued for AIDS-defined enrollees
• CBHS begins receiving a market rate payment for FQHC visits and a wrap-around payment from DHMH

Keys to Living within the Premium Dollar

• In-house/on-site multidisciplinary staff to assist in managing comorbidities
• Ability to shift premium dollar to non-clinical needs of the enrollee that impede the enrollee’s ability to stay in care
• On-site pharmacy and access to 340B pricing
• On-site addictions intervention
• Experienced HIV primary care providers
• Referral network experienced with HIV
• Stabilization of patient prior to Medicaid eligibility (e.g., while Ryan White eligibles)
• Ability to work with state Medicaid office to keep cap rates current with contemporary tx modalities

Priority Partners Medical Loss Ratio (D-link)

PPMCO Gross Revenue Trends (D-link)

Priority Partners MLR-Pharmacy (D-link)

Community Medical Alliance Program Model (D-link)

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