ALC-Hospital and Medicaid Study Subcommittee

OK, members, if you'll take your seats, we're gonna go ahead and get started. Call the meeting to order, um, Members, I know we haven't had a lot of. A lot of, um, meetings in the hospital, Medicaid subcommittee meeting, but that's OK because everything is rocking and rolling and going along, um, as it should, I think so, um, But today, today in response to legislation that was passed, um, which actually allowed a carve out for our passes, our that deal with um our Medicaid population, um. They, uh, in response to this, they've created their own proposals, and so I'm going to go ahead and bring them up to the table. Um, the first group, um, would be Um Adam B. So if you all can just come on up to the table. What they're going to do is give an overview of the different plans that they have put together in response to the legislation dealing with prior authorizations and we'll go through that just a quick overview and the members, if you have questions, more specific, then we'll go to questions, but I've asked them each if you will just identify yourselves for the records, and then I believe there's a couple of you that are going to kind of give an overview of all the plans, so to speak. So, um, go ahead and introduce yourselves for the record and then off we go. Good morning members Corey Cox, um government relations director for the state of Arkansas for CareSource. Good morning members. My name is David Donahue. I'm the market president for CareSource. Good morning. My name is Mitch Morris. I'm CEO with Empower Healthcare Solutions. Good morning. My name is Brad and I. I'm government relations director for Summit Community Care. Jack Hopkins, director of government relations for Arkansas TotalCare. Hi, Kim Suggs, COO for Arkansas Total Care. All right. Thank you all. Thank you, Senator. Thank you, members of the committee, uh, again, Mitch Morris with Power. So we're here today to present our policies and programs in direct response to Act 575, um, that we refer to as the gold card, go karting or our gold card policy. And so what we have all tried to do, uh, some similarities and some differences between, uh, the four passes represented here. What we tried to do in developing our policy in response to the legislation was to strike a careful balance. between the act, between Act 575, uh, with the objective to reduce overall prior authorization volume. Um, but also keeping in mind, uh, some of the core provisions of the original past legislation from 2017 Act 775, which created uh the program that we all represent here today. And again, we do appreciate the special provision and the carve out that was provided in in uh Act 575, uh, for the passes, uh, and in recognition of the special high populations that we served in the past program. Um, so we're submitting our policies today for your consideration. Um, I'll speak, uh, so that was a few general comments. I'll speak real briefly since I had the microphone about and powers approach, um, and so what we did in crafting our policy, uh, which I believe you do have, uh, in front of you, um, was to, again, uh, spell out the objectives of the gold card Act 575, um, balancing it with the original past legislation provisions, and identify services, uh, that, um, we will, we have considered to be goldarted and excluded from prior authorization management, also pointing out services that we intend to continue managing through the prior authorization policy, uh, and the, the services, most of the services that we at this point intend to continue to manage through prior authorization, tie back specifically to our past population, um, and, and the unique services that many of those, uh, waiver. Related Medicaid beneficiaries access. Um, so, um, I can certainly, I'm certainly prepared to answer questions about empowers policy and our approach, but um I think I'll stop at that point, um, and, and consider that just a brief intro and an overview of, of why we're in front of you today. Thank you. Mr. Knight. Thank you, Madam Chair. Uh, So Summit Community Care took a very similar approach to empower, uh, with our gold card policy. So you'll see a lot of similarities as you look. Back and forth between the two programs, um, you know, again, I'd like to just reiterate our appreciation, uh, for the legislature bringing Act 575 during the 2023 session because it really Allowed us an opportunity to go back and look at the way we do prior authorizations, um, with, with what, what is a very unique program, so we, we appreciate that. Um, and so Summit. What we do, um, is we've actually established a quarterly committee, uh, we call it our Pluto committee. We meet quarterly, we take a look at. The current Arkansas Medicaid requirements around prior authorization and the limits, and we compare those to the prior authorizations that we've been receiving and what codes we've seen a high rate of approval across our provider network and so Going forward on a quarterly basis, we, we review and we reduce prior authorizations, uh, where it's appropriate to help ease with provider abrasion. uh, obviously, we want our providers. Providing services for our members. That's, that's what they're there to do. Um, I think. For those of you that were in the Public Health Committee, uh, last time, one of the questions that came up was, There was a lot of talk about how the past program implemented um some prior authorization changes when the past went into effect in 2019, but the question was raised, what have you done? Since this legislation was brought and so in keeping with the intent of the legislation. We immediately went back to work and then just report back that since Act 575 passed, there's been a 179 additional codes that we've identified. Where we've uh reduced or eliminated prior authorization. Again, uh, we, we mirror empower and we, we commit to you that through our quarterly meetings we'll keep, uh, looking through. Areas that it makes sense for us to. Again, uh, limit prior authorization and to ease administrative burden for our providers, and I'll take any questions when the time is appropriate. Thank you. Yeah, in Arkansas total care, um, you know, without being too redundant, um, our, our mission, um, from the beginning of this program was always to make things, uh, more efficient and easier to deal with, uh, with our provider partners as far as processes go on prior authorization, um, you'll see in our plan that, uh, our, our focus is to, uh, uh, reduce the burden of those day to day services, primary care, uh, E&M services, uh, for all of our members, while additionally being respectful of uh. unit-based home and community-based services that we see a high utilization of so um with that I'll take any questions. All right. And last but not least. Certainly, thank you, uh, from the CareSource Pass, uh, standpoint, we have also taken similar approaches to the other passes. Uh, we've also, uh, worked to try and put into our policy, uh, and outline the process for providers to participate as well as uh ways for us to proactively, uh, communicate to providers that that that they are open to and, and able to participate in the prior author of prior authorization exemption process, um. And we also have included uh provider look up tool, um, so that as uh any program changes or there are any, uh, coding changes that hopefully that tool will be uh something that will be easy for the providers to use to ensure that, um, uh, a service is exempt, um, based on, uh, the different policies, um, and then, uh, we also have a provider advisory council, which we meet with regularly. Uh, we meet with them to. Assess and get their feedback in terms of uh the PA process overall. Happy to answer any questions. OK, thank you, members, do you have questions? Senator Boyd. You're recognized for question. Thank you, Madam Chair, uh, and Really this is directed to all of you, I guess. Will any of you have policies which require less expensive generic drugs to have a PA while encouraging more expensive brand name drugs where there's no crystal clear evidence, uh, of scientific evidence to use the high dollar medication over the generic or, or biosimilar. Senator, we, we follow Medicaid's formulary to a T. It's a requirement of the program. Those decisions are made at Medicaid. Perfect. Thank you. Yes, sir. Are there other questions? I love it. OK. Oh well, while you're logging in, um, I appreciate the, the, um, provider lookup tools that I see. I think that's really going to be beneficial, and I think lay of the land. Uh, prior authorization was a good. third party. Uh, it was a third party, um, probably contracted by most insurers, insurance companies. However, as that has kind of morphed, it's, it became a strangling type of a, um, stranglehold on healthcare and on patients, not being able to get the care that they really needed and providers not being able to actually care for their patients. And so that it, it just really did strangle out the patient, um, physician, um, not physicians, but other healthcare providers, obviously in the space, but that relationship because they weren't able to do their jobs. And so, as you can see, tons of frustration from it, which has led to all the prior authorization legislation, but then the gold card legislation as well is kind of the, OK, let's just wrangle with this. So I really appreciate the fact that you're looking at that and just said instead of signing a third party contract over to some group to do this, but that you're saying, OK, well wait a minute, let's have an advisory committee. Let's like, let's do what makes. sense, and I think that's the whole spirit behind this legislation was, let's just be more intentional and more thoughtful. Use it as a tool, but not use it as, you know, the sledgehammer type of an approach. And so, I think you've all articulated that it seems to me in, in your plans. OK. Representative Eves, I, I stalled for you. You're recognized for a question. Wait, hold on. Oh gosh. Discussion. Sorry, just a second. There we go. It's easier if you use your finger. OK. This really is directed at Any of you who represent insurance companies, this specific example would be Am better, so I'm not trying to pick on anyone. But I've had several instances, um, and forgive me if this is not exactly the topic we're on today, but several instances of constituents who are taking drugs like Mojaro and Ozempic, these weight loss, diabetic medications, they go to the doctor, their A1C is sky high. They get on these medications, insurance is covering it for the most part. uh, and they, they're on it for 6 months, a year, maybe even 2 years, they go back to the doctor during regular checkups, the A1C is now in normal range, and at that point. insurance now will not cover these diabetic medications, so the choice the patient has to make is get it on the black market or stop taking it, get unhealthy. A1C goes through the roof again and then insurance will start covering it again. It, what is the reason for that other than money? And I'm, again, I'm not trying to put him on the spot. I just need, I don't know how to answer that question back home. Yeah, it also representing A better, you know, we're, we're aware of the GLP one, surge on the market, I think that there's still some finer details that we're working out, um, with those specific drugs, you know, relatively new as far as their, uh, mass utilization. So, um, that's definitely something, um, we can address, um, and talk to you about, uh, offline. I don't have the specific answer today about that policy, but it's something I can picking on specific and batter it's happened on all of the insurance companies that I've, I've. dealt with it just seems like a backwards way to go about if your goal is truly to help people become and stay healthy, it seems counterintuitive to once they do start becoming healthy, they have to get sick again before that's covered. I don't disagree, let us look at that. OK, I appreciate you guys. Thank you. Thank you. Well, and you're kind of also speaking to some of the fail first policies as well, uh, that, that sometimes can, can trick that up. So, I'm happy to work with you through that. Any other questions from members of the committee? All right, see none. um, I am, do I hear a motion to approve recommendations provided by the Public Health committees regarding the, yes, I think Brown. Oh Representative Brown. Thank you. Thank you, Madam Chair. Uh, I pushed my button late. I just wanted to inquire, do, do any of these, uh, any of you. Uh, cover dental. Or is this just all medical? The general is a, a different product than what we offer. It's an ancillary product to, to health insurance. It's a separate product, if you will. There's certain things that in conjunction with dental, uh, coverage, maxillo facials, certain things uh that fall underneath that, um. But no, it's, it's not, uh, it's not a primary coverage for us doesn't address dental at all. No, ma'am. OK. Thank you, Madam Chair. Any other questions? OK. All right. So, um, this group also went before our public health, um, committee, which made the recommendation to approve these plans before us. And so the purview of this subcommittee then would be a motion to approve the recommendations provided by the public health committees regarding the prior authorization proposals submitted by Summit Community Care, CareSource and Power Health Care Solutions and Arkansas Total Care. Do I have a motion, motion, and second, all those. in favor say aye and opposed, I always have it, and this, um, this passes. This motion will pass. OK, the next item is C. This is separate. This is a discussion of and better health plans, um, Mr. Hopkins, I'll recognize you. Thank you, Chair. Committee Again, Jack Hopkins, uh, this time with Arkansas Health and Wellness A Better is our qualified health plan or our marketplace product, um, uh, I'll let Kim introduce herself. Hi, Kim. Oh, sorry, uh, again, Kim Suggs, um, the CEO COO for Arkansas Health and Wellness as well. So pursuant to Act 575 additionally with the passes, uh, the, uh, Medicaid expansion or the, the, the plans that uh the state purchases Medicaid purchases, uh, for the Medicaid expansion population, um, consists of two primary plans, which is us and Better, and then Blue Cross Blue Shield. Today, our and better plans that are offered on the qualified health plans, uh, would be subject to the gold card legislation, however, they're just like the past program there is allowable carve out, um, where we would come, like we're doing today. they present you guys with uh a plan for uh a level of exemption for certain services, as you can see, I think they're attached today, um, the first thing we want to talk about though is, uh, what, what services don't require a prior authorization today, um, primary care, E&M services, behavioral health therapy services, emergency room services, um, you'll, you'll see that full list there, and then, of course, the question is what services are you guys, uh, uh, requesting exemption from? I'll let uh Kim go through those, uh, services of, of what we're requesting uh uh would be allowable um for continued prior authorization. Um, so moving forward, um, we would look to, um, require prior authorization only on, um, some certain outpatient services, uh, we would look to, uh, remove prior authorization requirements for all inpatient services, uh, currently today, those do require prior authorization, um, moving forward, we would remove those requirements, um, all together, um, in addition, um, there would also be, um, no authorization. requirements for some other, um, Fairly significant services, uh, where we see in large volumes such as sleep studies, quantitative drug testing, um, CPAPs, um, oxygen, diabetic supplies, um, amongst other things, very, um, similar to what you heard earlier, we have a, a process in place that we review services on, um, a routine basis to determine, uh, whether or not we should continue, uh, prior authorization requirements, um. At the beginning of this year, we actually removed prior authorization requirements on an additional 570-ish codes, um, to make it just easier for providers to, to do business. Um, we also have a PA tool in place. Very similar, um, to what you heard earlier where providers can go online and put in a code and determine if that service does require prior authorization or not, um, and the services that we will continue requiring a prior authorization on, um, are again some specific outpatient services, primarily, um, surgeries, um. And high tech, um, radiology, MRIs, CTs, um, those kind of services. Um, we will be removing prior authorization requirements for PET scans, though. Yeah, and I, I think it's important to make a distinction right now of, of what we're, um, um, requesting approval for. There's, there's the school of thought that prior authorization should go away altogether. We still think that it's a useful tool on high utilization, high-cost services that are outside of the hospital or inpatient setting. Um, additionally, the, the utilization management or the process of looking back at services that weren't prior auth and recouping, we don't necessarily believe that that would be our path forward. We think that there's still an expectation provided by providers that they want to know on the front end of whether they're going to get paid or not for a claim, uh, so, uh, our intention is to work in the spirit of this legislation, uh, continue prior authorization where we think that they're necessary and then removed again, all inpatient services, uh, the authorization where it's a little redundant or unnecessary. Thank you. I appreciate that last statement because, you know, as we can, as I have worked on this legislation for prior authorization since 2011. You know what was shocking to me was. The idea or the thought that you are authorized. To proceed with a surgery. And you have been granted prior authorization to proceed with the surgery, but then to come back and say, oh, but we're not going to pay you for it. Well then, what does prior authorization even mean? I mean, for a surgeon who does a surgery and it's authorized that their insurance company authorizes that, that should say, yeah, we're going to pay for this. And then they go in, they do the surgery, and then they lose all that money, the hospital, the doctor, in the whole arena there. Uh, I, I, I think that's an incredibly predatory practice, so I appreciate that you made that statement, and that was a big statement to make because that necessarily wasn't the case sometimes in meeting with some other insurance companies that, that I had met with years and years and years ago, that mindset was, you know, well, we can pay for it or we don't have to pay for it. Well then, what's the point of authorizing it then, you know, we're human error, we're not always perfect on those types of. Things and we do have, uh, look back to utilization, um, but again, our intention is to Uh, let providers know on the front end through the prior authorization process on these services that, you know, you're authorized to, to deliver the service, so that, that's our intent. Thank you, Representative Eves to recognized. Yeah, I was just looking through. Exhibit C, and I guess and better works faster than I thought. Um On the back page of that, it says you're no longer um Going to require prior authorization for the following services, and one of those services diabetic drugs. I'm assuming that's not the GOP one type drugs. That's actually supplies diabetic supplies, so it's your, um, all your needles, all your lancets. I believe that. I'm unsure, I'm unsure about that particular item. Um, I do know that we are going through the, the pharmacy process where we've submitted all of the codes that would require prior authorization, uh, to the, to board, to the board, uh, and we'll be following those recommendations, um, on what can require prior authorization and what can't, um, going forward, I'm unsure if those diabetic drugs are included in that, um. Let's take a look at that Representative Eve and I'll get back to you as soon as possible I'd like to diabetic drugs. I understand the supplies part of it, but which diabetic drugs are gonna be available without prioritization. OK, thanks. And this also follows the Medicaid formulary, correct? No, ma'am, it does not. We're, we're purchasing a qualified health plan off the exchange. We, we have our own formulary. That's right. OK. All right, Senator Boyd, do you recognize her question? Thank you, Madam Chair. Just curious, you know, one of the things I hear, not specifically from Ambetter, but some other insurance providers is that they use prior authorization as a pocket veto. In other words, they'll say, hey, in a transition of care, I've been in the hospital and now I need to go to the nursing home, uh, so that requires a prior authorization or approval, and so the insurance company just never quite gets around to approving that. in a timely manner, is that something that y'all utilize in your company to delay care and Um The removing the prior authorization requirement on all inpatient stays would include those step-down transitions. So there wouldn't be a requirement any longer on moving down to like a rehab facility or skilled nursing. We consider those still inpatient services, just step down. So those will not require prior authorization, um, moving forward, but currently we are still, um, under the Arkansas Transparency Act, which requires a two-day determination on any request, um, or. automatically approved. So we are, we're following that today and we'd continue to follow that on any service that required a PA going forward. I think this is important distinction to make that the environment today. Doesn't change through this as far as the prior authorizations goes. We're still held to the again, 48 hour turnaround times and all the, all the regulations and the insurance code as far as authorizations go. So the government regulation is helping the patients, is that what I'm hearing from you I mean you could say that as far as timelines goes and holding our feet to the fire to get those authorizations approved or otherwise. OK. Well, thank you for the update and change in the information. I appreciate it. Are there any other questions? None. Do I have a motion to approve the prior authorization proposal submitted by A Better. OK, without recommendation public health committees. Second, all those in favor say aye and opposed. I have it. And motion passes. Oppo. All right. Seeing, are there, is there any other business to come for this committee? seen none we are adjourned.