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Overview

The Bureau for Medical Services (BMS), Office of Medicaid Managed Care, initiated a risk-based managed care program for certain groups of Medicaid recipients in September 1996. The majority of West Virginia Medicaid beneficiaries receive their benefits via the managed care delivery system through the Mountain Health Trust program.  The Mountain Health Trust program currently contracts with four Managed Care Organizations (MCOs) for the provision of medical benefits, and include: Aetna Better Health of West Virginia (formerly Coventry Health Care of West Virginia), Health Plan of the upper Ohio Valley, Unicare, and West Virginia Family Health, which ended its contract with BMS effective 6/30/19.

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Coverage and Eligibility

Individuals who are not covered by an MCO receive benefits through traditional Medicaid and via a FFS delivery system. Currently, the FFS claims received by HMS on behalf of BMS are for the following services: 

  • Abortions
  • Early intervention services for children three years of age and younger
  • Intermediate Care Facility for the Mentally Retarded (ICF/MR)
  • Organ transplant services
  • Nursing facility services (nursing homes)
  • Medicaid Waiver services (aged & disabled, intellectual and developmental disabilities, and traumatic brain injury)
  • Non-emergency medical transportation
  • Personal care services
  • Pharmacy/prescription drugs
  • School-based services
  • Opioid Treatment Program services under the Substance Use Disorder (SUD) services waiver (as of 7/1/19)

As noted above, HMS receives FFS pharmacy benefits data form the State of West Virginia.  However, in July 2017, pharmacy benefits for members enrolled in MCOs were transitioned back into FFS to reduce pharmacy costs and improve efficiencies.  Because of this transition, HMS saw an increase in FFS pharmacy claims in 2018.

Conversely, also in 2017, the SSI population was carved into managed care.  However, the SSI group that moved into managed care does not include those members that receive Medicare, Medicaid waiver services, residents in long-term nursing facilities or children in foster care services.

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Data Considerations

HMS does not receive Managed Care Organization (MCO) encounter data under its contract with the West Virginia Bureau of Medical Services. The MCO entities are responsible for coordination of benefits and recovery.

In July 2017, pharmacy benefits for members enrolled in MCOs were transitioned back into FFS to reduce pharmacy costs and improve efficiencies.  Because of this transition, HMS saw an increase in FFS pharmacy claims in 2018.

Overall, HMS has seen a decline in FFS data from West Virginia due to the migration to a managed care model and the types of services that have been carved into managed care model over time as the State has refined its model.

The FFS population in the data set represents the full universe of claims data HMS receives under its contract with the West Virginia Bureau of Medical Services.

 

Sources

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