Page 1

Regional Network

Table of Contents Articles of Incorporation

Page 3

Organizational Structure

Page 9

Proposed Work Plan

Page 14

ACA's Medicaid Expansion - Michigan Impact

Page 16

MI Medicaid Managed Care & Advantage Enrollment

Page 24

Draft Budget

Page 27

Fee Options

Page 28

3 of 28

4 of 28

5 of 28

6 of 28

7 of 28

8 of 28

Network Organizational Structure – Key Decision Items for Michigan Implementation with Timetable Date: October 15, 2012 1. Name of Network 2. Mission

Model TBA Charge and Purpose The Aging Services of Michigan Regional Network Collaborative supports not-for-profit member providers by providing shared services and coordination activities in areas of the state. The network will assist members in improving health by facilitating and structuring the sharing of best practices, developing consistent standardized care pathways, and providing access to advanced care practitioners and improved business strategies. The network will reduce costs through providing member shared services such as shared electronic record systems, Managed Care Contracting, billing and other back office services, and information technology.

3. Steering Committee Charge and Purpose

The Regional Network Collaborative includes nine (9) Aging Services of Michigan members and partners who will work to guide the development of the business model including: Phase I  Developing Corporate Documents and by-laws  Establishing a financing plan and interim budget  Establishing a Board of Directors  Identifying/refining the business structure  Developing potential staffing models  Providing guidance and input to BPI and CMMI initiatives.

Action Items/ Issues for Clarification Senior Care Network TBD

4. Purpose

5. Governance structure

a. Establishing network as sole health plan contracting entity for enrolled member facilities and programs. b. Maximizing rate reimbursement for services under contracts with Medicare Advantage Plans and Medicaid Health plans in applicable regions and/or health systems, where appropriate; c. Negotiating pay for performance incentives with selective plans. d. Developing collaborative relationships with key provider groups and systems, including hospitals, physicians, ancillary providers etc; e. Educating member staff on managed care contracts (i.e. Rates/prior authorization, billing, data reporting) f. Developing and/or sharing best practices for care management, care coordination, cost effectiveness, etc g. Collecting and analyzing cost and performance data to improve members’ performance under the health plan contracts; develop uniform set of quality and cost effectiveness metrics and standards;

a. Formed as separate not for profit501 c 4 b. Executive, Credentialing and Managed care/quality committee structure established c. Officers: Chair, Past Chair, Chair Elect, VP/Chair of Managed care committee, Treasurer and Secretary

Summarize in member contract

1. Question: Does Network contract for Medicare Advantage as well as Medicaid Services? 2. Put together listing of Medicare Advantage plans and compare with Medicaid plans 3. Main role is to contract and provide education.

Structure already created. Need Bylaws:

Does it have a managed care committee?

6. Application for Membership


Members with voting/board membership: Members with nursing homes that offer skilled Medicare (SNF-A) nursing home care, other Medicare services (home health care, and/or Medicaid type services i.e. elderly waiver/adult day care). Members include governmental and not for profit nursing homes. PACE providers

1. Does ASM have credentialing to join its network or can any member join? Are there minimum quality requirements? 2.

Are not for profits who are not members of ASM eligible to join? 3. Possible application requirements Nursing Homes a. An average Score of 3 or better Nursing Home Compare report over a period of two years is preferred; if less than that, submit documentation of quality improvement program to improve score; b. Adequate insurance coverage to meet health plans’ requirements c. Current state Medicaid license and federal Medicare certification. d. Copy of last state survey/corrective action plan

Residential Care Facilities/ALF Home Health Care

Adult Day/Other

State License State License or state/federal certification to provide services under Medicare/Medicaid State License or state/federal certification to provide services under Medicare/Medicaid

7. Member Fee /Two Tier Structure

a. The operating budget is supported by member dues within Network; 1. What is fee structure to support operating budget? b. All members pay a base fee to cover the administrative costs. c. Remaining budget is paid by voting members benefiting under the managed care contracts from both reimbursement rates and performance incentives. Dues could be based on per bed/licensed occupancy.

8. Member responsibility

9. Staffing Model

a. Adhere to contracts negotiated by network, including compliance with billing, payment and data reporting responsibilities. b. Submit necessary credentialing information to be set up as health plan provider; also meet or exceed network own credentialing requirements. c. Submit claims pursuant to health plan requirements. d. Submit cost and performance data to Network as approved by committee. e. Participate on Network’s board/committee structure as needed. f. Attend educational and training sessions. g. Implement best practices. a. Executive Director/CEO (1 FTE) b. Clinical Contract (1 FTE)Manager/Quality and Training c. Data/Office Support (.8) d. Contract for data/web

2. Are there other Networks already established that members use for contracting for their Medicare Advantage programs? 3. How detailed is your member profile?

Part of Member Contract

Hire CEO and data/administrative Support: Clinical Director until be one half and FTE until membership grows.

e. Contract for financial/HR/ (Indirect cost charge from ASM) f. Communications/PR – newsletters (contracted)

10. Budget

11. Timetable:

a. Office Set Up (One time costs) - Share space with ASM b. Operating budget -staff (salaries/benefits/or contract) -legal –office rent/utilities/telephone -meeting expenses -travel/training -website development/charge -office supplies -Indirect cost for HR/Accounting/auditing

Share space with ASM; If separate entity, contract back with ASM for management of Network, employees and benefits package; use office resources efficiently. Proposed budget: $350,000 estimate only 1.8 FTE’s: 1 CEO .8 Administrative support Contract dollars for clinical consultation.

October 31th: Steering Committee meeting November l st. Regional Collaborative Seminar: Oct- Dec :  After Board approval send out educational packets/Letter of Intent to individual members:  Conduct Webinars for members to explain network/respond to questions: Letter of Intent due back Dec 31st  Dec: 1: Start Recruitment for CEO:  Finalize Network: January 1, 2013:  Operations start-up target date April 1, 2013

Nellie Johnson and Associates - Consulting Services Proposal for Aging Services of Michigan (ASM) Activity/Request 1. Workshop/Seminar on Managed care 2.

Phase I (a): Business Plan Development Section:


Phase I (b): Organizational Structure- section

Deliverables : Workshop to brainstorm issues on managed care contracting; organizational network model/structure; credentialing; any work plan/timetable. 1. Prepare written report that includes: a. Summarize /Highlight status of current ASM efforts; identify issues and questions; comment on any reports completed over past year; b. Summarize Medicare Advantage Plan coverage within state; c. Summarize Medicaid/Dual status and status of state discussions; d. Identification of CMS designated ACOs; e. Review member profile data available from ASM; prepare survey to collect (e.g... TCU beds) if necessary; f. Identification/analysis of any competing networks that members and others are using for health plan contracting; g. Review status of performance data collection and analyze gaps. 1. a.

Prepare separate written report that includes: Review of current proposed organizational structure under 501.(c) (4) and status of implementation (i.e. Bylaws, governance structure)


Recommend organizational model, mission, purpose/responsibilities of entity; Propose organizational staffing model with preliminary budget (contracted versus paid staff); Discuss operating costs; e.g. office space, legal and financial services; Discussion of proposed fee structure for members Recommend process to solicit interested members through (MOA)/educational packet on benefits, costs etc; determine when to send out;


d. e.

Timing/Due November l, 2012. Cy 2013: Presentations at Institutes Complete and present to ASM CEO /present at November seminar

Review with ASM CEO and with Steering Committee: November lst:

14 of 28


Phase II (a): Business Plan Implementation Preparation


Identify capitalization/investment by members


Corporate structure resolved: finalize legal structure as required; implement Board and committee structure; Finalize name and office space arrangements; Finalize Operating budget for approval by Board; Based on staffing model, prepare draft job descriptions for network staff; Identify/propose credentialing requirements for membership Identify/propose best practices/quality requirements/care management strategies; (e.g. implementation of Interact II) Identify/propose reporting requirements /outcome measures/cost data; Send out MOA (Memorandum of Agreement) to confirm interest and commitment to participating in Network:

Steering Committee meeting first week of Dec, 2012:


Dec-March, 2013. Board Members /Committee members appointed; set up calendar of meeting for year.

2. 3. 4. 5. 6.

7. 8.


Phase II (b)- Assist with Business Plan/Operational Plan Implementation


3. 4. 5.


Phase IV. Ongoing Business Implementation



Set up Network Board meeting/committee meeting calendar for Cy2013. Review returned MOA’s to confirm initial member participation in Network: return by Feb 1st; date or date determined by Steering Committee; Support solicitation of members to join network through webinars, etc. Assist with hiring staff/training of staff as approved per model; Finalize and begin implementing reporting/tracking of performance/cost data; best practices/quality improvement. Consult with staff as needed on contracting strategy/meetings with health plans/review of contract proposals; Participate/present educational seminars as scheduled and requested;

Obtain necessary approvals and/or recommendations; Final decisions by 1/1/2013


2. 3.

Operations start-up target date: April 1, 2013. Ongoing- Cy2013 Annual Institute in August for updates

15 of 28


Issue Brief October 2012

The ACA’s Medicaid Expansion: Michigan Impact State Budgetary Estimates and Other Impacts


hile the U.S. Supreme Court’s decision on June 28, 2012, largely upheld the constitutionality of the Affordable Care Act (ACA), one provision was not upheld: penalties for states that opt out of the law’s Medicaid expansion. This left the decision to expand Medicaid—or not—to individual states, and as a result, it is now uncertain whether or not Medicaid will be available to all individuals below 138 percent of poverty in 2014 as the law intended. Policy makers in each state must analyze the implications of the Medicaid expansion and determine whether or not the expansion makes sense for their state, taking into account state budgetary considerations, federal financial incentives, human service priorities, and the anticipated effects of the expansion on the general economy and population health.

This issue brief is intended to provide Michigan policy makers and the public at large with a useful tool to consider this question by projecting the likely 10-year economic impacts in our state. Wherever possible, the issue brief uses publicly available and independently validated information and sources; the analysis was based on conservative assumptions. A companion paper to this issue brief models three different scenarios: high, medium, and low rates of Medicaid enrollment as a result of the expansion. The paper is available online at This issue brief reports on the middle scenario.

The Center for Healthcare Research & Transformation (CHRT) illuminates best practices and opportunities for improving health policy and practice. Based at the University of Michigan, CHRT is a non-profit partnership between U-M and Blue Cross Blue Shield of Michigan to promote evidence-based care delivery, improve population health, and expand access to care.

Visit CHRT on the Web at:

Key Impacts of Medicaid Expansion

Coverage . . . . . . . . . . . . . . . . . 2

Financial Impacts . . . . . . . . . . . . 4

Other Impacts . . . . . . . . . . . . . . 6

Conclusion . . . . . . . . . . . . . . . . 8

Suggested citation: Udow-Phillips, Marianne; Fangmeier, Joshua; Buchmueller, Thomas; Levy, Helen. The ACA’s Medicaid Expansion: Michigan Impact. October, 2012. Center for Healthcare Research & Transformation. Ann Arbor, MI.

16 of 28

Key Impacts of Medicaid Expansion

Coverage In August 2012, 1.9 million Michigan residents had Medicaid coverage.1 According to the Urban Institute and the State Health Access Data Assistance Center (SHADAC), if Michigan opts to expand Medicaid, another 1.2 million will become eligible in 2014, about half of whom are currently uninsured.2 Not everyone who is eligible for a public program actually enrolls. Of the potential Medicaid pool (those newly eligible in 2014 under the expansion), our middle scenario assumes that 36.3 percent (204,732) of those who are uninsured and 14.2 percent (83,496) of those who are privately insured would actually enroll (“takeup rates,” based on Urban Institute analyses). We also assume that over time, as information about the Medicaid expansion becomes more widely disseminated, these percentages would increase—to 72.6 percent (409,464) and 35.5 percent (208,740), respectively, by 2020.3 Figure 1 Whether or not it implements the Medicaid expansion, Michigan should see an increase in enrollment among those who are already eligible for Medicaid resulting from publicity about the Affordable Care Act, the individual mandate, and eligibility simplification. If Michigan implements the Medicaid expansion, this “woodwork effect” should be even stronger, increasing enrollment among those who are currently eligible but not enrolled by one percentage point (1,160) in 2014 and growing to 1.5 percentage points (1,658) by 2020. Overall, we estimate that if Michigan does opt for the Medicaid expansion, the state will have an additional 289,000 Medicaid recipients in 2014; and 620,000 over current enrollment by 2020. Figures 2 and 3

Figure:1 Projected Adult Medicaid Take-up Rates, 2014 and 2020

2014 Newly eligible, uninsured


















Newly eligible, privately insured Currently eligible, uninsured (due to expansion)

Figure:2 Michigan Non-Elderly Adult Coverage, 2010 v. 2020 Projection

2010 192,000 3%


1,086,000 18%

1,403,780 23%

192,000 3% 290,960 5%

769,000 12%

4,246,260 69%

4,086,000 67%

Private Coverage Medicaid Enrolled Other Public Coverage Uninsured


 ichigan Department of Human Services. Green Book Report of M Key Program Statistics. August 2012. documents/dhs/2012_08_GreenBook_397962_7.pdf

  2 Kenney, G., et al. Opting in to the Medicaid Expansion under the

ACA: Who are the Uninsured Adults Who Could Gain Health Insurance Coverage? Urban Institute. August 2012. Available at: SHADAC analysis of private coverage in Michigan via its data center at

  3 Take-up rates from the Urban Institute’s June 2012 report on the

ACA Medicaid Expansion in Washington State, available at

17 of 28 2 • CHRT Center for Healthcare Research & Transformation

Key Impacts of Medicaid Expansion

It is important to note that if the state decides not to expand Medicaid eligibility, uninsured adults with incomes between 100 and 138 percent of the federal poverty level would be eligible for federal subsidies to purchase private health coverage on the health insurance exchange; however, only 24 percent of the uninsured who would be newly eligible under the expansion have incomes in this range. The other 76 percent have incomes below 100 percent of the federal poverty level; the ACA does not provide subsidies for purchase of private coverage for those below 100 percent of poverty. Figure 4

Figure:3 Michigan Non-Elderly Adult Coverage, 2010 Actual, 2014 and 2020 Projected

2010 # Private Coverage, Total Private Coverage, Existing Eligible for Private Coverage Tax Credits

2014 %


2020 %





















Medicaid Enrollment, Total







Medicaid Enrolled, 4 Existing





























Uninsured but Medicaid Eligible







Other Uninsured







Medicaid Enrolled, Due to Expansion


Medicaid Enrolled, Not Due to Expansion



Other Public, Total Uninsured, Total


6,133,000 100.00% 6,133,000 100.00%

6,133,000 100.00%

Figure:4 2014 Subsidy Eligibility Without the Expansion

134,000 24% 430,000 76%

  4 Approximately 57% of those covered by Medicaid are

children or elderly dual eligibles. Those coverage numbers are not reflected in this table.

  5 Other public includes those with other public coverage that

Subsidy Eligible (Between 100% and 138% FPL) Not Subsidy Eligible (Less than 100% FPL)

will not be directly affected by the Affordable Care Act (e.g. Tricare, VA, pre-65 Medicare). For purposes of this analysis, enrollment in those programs was kept constant.

18 of 28 Issue Brief: The ACA’s Medicaid Expansion: Michigan Impact,  October 2012 • 3

Key Impacts of Medicaid Expansion

Financial Impacts Increased Federal Match

The federal government provides 100 percent of the funding for the newly eligible Medicaid population in the first three years of the expansion. Starting in 2017, the federal share of funding begins to drop, and states are expected to provide matching funds for the expansion population. In 2020 and all subsequent years, the federal match is 90 percent and the state share is 10 percent. Unlike the current Medicaid program, the Affordable Care Act provides a stable 90 percent federal match rate on an ongoing basis, regardless of a state’s financial circumstances. In the existing program, the federal match rate varies from year to year based on the state’s per capita income. Fiscal year 2013 federal matching rates range from a low of 50 percent (the lowest match rate allowed under federal law) to a high of 73.43 percent (for Mississippi). Michigan’s 2013 federal match rate for those in the existing Medicaid program is 66.39 percent, a rate far lower than the rate that would apply to the newly covered population under the ACA.

Figure:5 Cost Savings to the State from the Medicaid Expansion, 2014-20236, in Millions First 5 Years (2014-2018)

Second 5 Years (2019-2023)

Total 10 Years (2014-2023)

Increase in Provider Tax Revenue




Elimination of Adult Benefit Waiver Program




Reduction in Non-Medicaid Mental Health




Reduction in Prisoner Inpatient Medical Services




Savings in State Employee Health Care Costs




Total State Budget Savings due to Expansion




Cost Savings There will also be savings resulting from the ACA’s broader scope of Medicaid eligibility. If the state chooses to go forward with the Medicaid expansion, many people will become eligible for Medicaid coverage (and the attendant federal financing) who today receive some or all of their health care through state-funded programs. This includes many who receive mental health care through the community mental health system, prisoners who receive inpatient medical care in noncorrectional facilities, and adults who are covered today under the Adult Benefit Waiver program. In addition, the state is expected to receive revenues for the newly eligible Medicaid population from various provider taxes in existence today. Finally, the state, like other employers that provide health coverage to employees, is projected to realize savings in health care premiums. With a reduction in the number of uninsured individuals and attendant uncompensated care hospital costs, there should be a reduction in the transfer of such costs to employers who provide health coverage (often referred to as the “cost shift”). Figure 5

  6 Savings amounts may not add up to total savings due to rounding.

19 of 28 4 • CHRT Center for Healthcare Research & Transformation

Key Impacts of Medicaid Expansion

Figure:6 Net Cost Impacts to the State of the Medicaid Expansion, 2014-20237 Cumulative 2014-2023

































Net Costs (Savings)












Net Costs (Savings) per Expansion Enrollee











Gross Costs $ millions Budget Offsets

Net Cost

The net cost, not costs or savings in isolation, is the most important number for policy makers to understand in deciding whether or not to expand Medicaid under the provisions of the Affordable Care Act. In our projections: • The state would save money every year from 2014 through 2019 for a total of $1.17 billion in net savings through 2019. • In 2020, when the federal match goes to 90 percent, the state begins to experience a net cost rather than net savings. The net cost to the state in 2020 is projected to be approximately $41 million ($65 per covered individual per year), growing to $52 million by 2023 ($83 per covered individual per year). • The total impact of the Medicaid expansion to the state of Michigan over 10 years is a net savings of approximately $1 billion. Figure 6 and 7 These estimates are based on a set of assumptions that seem most likely to occur, based on research and prior experience. As a sensitivity test, we also calculated the expected net cost under alternative scenarios, which vary primarily according to assumptions regarding enrollment behavior. In our low take-up scenario, the net savings to the state are even greater ($1.4 billion) because the state’s direct cost of covering the newly insured is lower. By the same logic, a higher take-up rate yields yields smaller net savings over the 10-year period ($840 million). The full analysis with all three scenarios is available at

Figure:7 Summary of Fiscal Impacts of Medicaid Expansion, 2014-2023, in Millions $35,000


$30,000 $25,000 $20,000 $15,000 $10,000 $5,000





$-5,000 State Match for Expansion

Federal Match for Expansion

State Offsets from Expansion

Net State Costs for Expansion

  7 Gross costs and budget offsets may not add up to net costs due to


20 of 28 Issue Brief: The ACA’s Medicaid Expansion: Michigan Impact,  October 2012 • 5

Key Impacts of Medicaid Expansion

Other Impacts When it comes to important policy decisions, policy makers and the public are interested in more than budget impacts. When deciding whether or not to expand the Medicaid program, policy makers will also want to consider health impacts, impacts to the broader economy, and impacts to particular sectors of the economy.

Health Impacts

First and foremost, the public and policy makers will want to consider the health benefits of expanding Medicaid. A substantial body of research confirms what would seem to be common sense: not having health insurance is bad for your health. This work is summarized in a 2009 study by the Institute of Medicine.8

A more recent study analyzed outcomes in Oregon, which in 2008 made Medicaid benefits available to a group of approximately 10,000 previously uninsured, low-income adults, chosen by lottery from among almost 90,000 who applied for coverage.9 One year later, the study group was compared with a control group of applicants who did not gain coverage through the lottery. The results were clear: those who gained Medicaid coverage enjoyed significantly better physical and mental health than the control group. In addition to health benefits, Medicaid coverage also conferred financial benefits on the newly enrolled, who had lower medical debt—including fewer bills sent to collection—than the control group. The population of very low-income adults covered in Oregon’s expansion is similar to the population that would be affected by the expansion decision facing Michigan today. The evidence is clear and convincing, therefore, that the Medicaid expansion would significantly improve the health of low-income Michiganders. Policy makers may also want to weigh whether the state’s investment in the Medicaid expansion could be used in other ways to improve health and reduce mortality; there is less clear evidence on the effectiveness of alternative approaches to improving the health of low-income adults.

  8 Institute of Medicine. America’s Uninsured Crisis: Consequences

for Health and Health Care. February 2009. Available at http://

  9 Finkelstein, A., et al. The Oregon Health Insurance Experiment:

Evidence from the First Year. The Quarterly Journal of Economics. Vol. 127, Issue 3. August 2012. Available at: edu/files/8139

21 of 28 6 • CHRT Center for Healthcare Research & Transformation

Key Impacts of Medicaid Expansion

Economic Impacts

The Medicaid expansion would have direct economic effects on hospitals, and on employers who offer health coverage. In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act. This law requires most hospitals to treat or appropriately transfer any patient presenting at its emergency department until the patient is stable, regardless of insurance status. Most health plans provide some payment to hospitals to offset the costs of treating the uninsured. Some of this cost is transferred— through higher premiums—to employers who provide (and individuals who purchase) health insurance coverage. While there is much debate about the extent of these costs, an analysis of one large payer’s hospital payment policies indicates the Medicaid expansion—by reducing the amount of uncompensated care hospitals must provide—is likely to result in savings to employers and individuals who purchase health coverage. On a statewide basis, 10-year aggregate savings in the range of $640 to $985 million could accrue to employers and individuals who purchase private health insurance as a result of the expansion of the state’s Medicaid program. Finally, the state’s decision will have considerable impact on hospitals. In 2010, Michigan hospitals provided nearly $2.4 billion in uncompensated care, a 33 percent increase since 2007.10 Under current hospital reimbursement policy, hospitals that treat high rates of uninsured and publicly insured patients receive extra compensation called disproportionate share hospital (DSH) adjustment payments. The Affordable Care Act includes provisions to reduce DSH payments from the federal Medicare program. to hospitals nationally by $17.1 billion between 2014 and 2020, based on the assumption that the number of uninsured patients would decline during this period. The state-specific formula for that reduction has not yet been published; however, if Michigan opts out of the Medicaid expansion, Michigan hospitals would likely experience both an increase in uncompensated care costs, and a reduction in the DSH payments that have helped many hospitals mitigate that loss.


Blue Cross Blue Shield of Michigan

22 of 28 Issue Brief: The ACA’s Medicaid Expansion: Michigan Impact,  October 2012 • 7

Conclusion Our analysis of the impacts on the state of Michigan shows a 10-year savings to the state under all scenarios. In our middle scenario, the state would save almost $1 billion net of the cost of the Medicaid expansion over 10 years. In that scenario, the Medicaid expansion would bring an additional 620,000 people—most of whom are uninsured today—into the state’s Medicaid program, at an average annual savings of $176 per enrollee, with no net costs to the state until the year 2020. In 2020, the net cost to the state would be $65 per covered enrollee. Other effects are harder to quantify with reliable data, but the Medicaid expansion is likely to have a favorable impact on the economy in general and hospital finances in particular. Finally, compelling research tells us that having health insurance significantly improves health, quality of life, and mortality rates. Human costs may be harder to measure than budgetary impacts, but they are likely to be the most important reasons for the state to consider moving forward on the Medicaid expansion as enacted in the Affordable Care Act.

Center for Healthcare Research & Transformation 2929 Plymouth Road, Suite 245 • Ann Arbor, MI 48105-3206 Phone: 734-998-7555 • •

8 • CHRT Center for Healthcare Research & Transformation

23 of 28

Snapshot of Michigan Medicaid Managed Care and Medicare Advantage Enrollment Plan Name Blue Cross Complete of Michigan (formerly BlueCaid of Michigan)

Ownership Independent: an affiliate of Blue Cross Blue Shield of Michigan and the Blue Cross and Blue Shield Association Subsidiary of National Plan: Coventry

Profit Status Non-profit

Enrollment Medicaid: 22,295 (including 493 duals)

Medicaid Service Area Counties of: Washtenaw Livingston Wayne


Independent; subsidiary of HealthPlus of Michigan


Medicaid: 43,222 (including 426 duals) Medicaid: 65,743 (including 730 duals)

McLaren Health Plan (now includes CareSource and counties served by that plan as well)

Hospital-Owned: McLaren Health Care


Medicaid: 114,935 (including 1,461 duals) SNP: 559

Counties of: Cass Kalamazoo Counties of: Bay Genesee Lapeer Counties of: Alcona Allegan Alpena Antrim Arenac Bay Berrien Branch Calhoun Cass Charlevoix Cheboygan Clare Clinton Eaton Emmet Genesee Gladwin Grand Traverse Gratiot Hillsdale Huron Ingham Ionia Iosco

Meridian Health Plan of Michigan

Physician-owned and physician-managed


Medicaid: 289,122 (including 3,517 duals) SNP: 245

CoventryCares of MI (formerly OmniCare Health Plan) HealthPlus Partners, Inc.

Counties of: Alcona Allegan Alpena Antrim Arenac Barry Bay Benzie Berrien Branch Calhoun Cass Charlevoix Clare Clinton Crawford

Oakland St. Joseph Wayne Saginaw Shiawassee Tuscola Isabella Kalamazoo Kent Lapeer Leelanau Macomb Mason Mecosta Midland Monroe Montcalm Montmorency Muskegon Newaygo Oakland Ogemaw Oscoda Otsego Ottawa Presque Isle Roscommon Saginaw St. Clair St. Joseph Sanilac Shiawassee Tuscola Van Buren Lake Lapeer Lenawee Livingston Macomb Manistee Mason Mecosta Midland Missaukee Monroe Montcalm Montmorency Muskegon Newaygo Oakland Oceana

24 of 28

Snapshot of Michigan Medicaid Managed Care and Medicare Advantage Enrollment Plan Name


Profit Status


Midwest Health Plan

Hospital-Owned: Henry Ford Health System (recently acquired)


Molina Healthcare of Michigan

Subsidiary of National Plan: Molina Healthcare, Inc.


Medicaid: 77,687 (including 1,347 duals) SNP: 538 Medicaid: 206,533 (including 8,567 duals) SNP: 7,831

PHP of Mid-Michigan FamilyCare

Hospital-Owned: Sparrow Health System


Priority Health Government Programs, Inc.

Hospital-Owned: Spectrum Health Care


Medicaid: 17,773 (including 184 duals) Medicaid: 65,410 (including 1,252 duals)

Medicaid Service Area Eaton Ogemaw Emmet Osceola Genesee Oscoda Gladwin Otsego Grand Ottawa Traverse Presque Isle Gratiot Roscommon Hillsdale Saginaw Huron St. Clair Ingham St. Joseph Ionia Sanilac Iosco Shiawassee Isabella Tuscola Jackson Van Buren Kalamazoo Washtenaw Kalkaska Wayne Kent Wexford Counties of: St. Clair Livingston Washtenaw Macomb Wayne Oakland Counties of: Macomb Alcona Manistee Allegan Mason Alpena Mecosta Antrim Midland Arenac Missaukee Bay Monroe Benzie Montcalm Berrien Montmorency Clare Muskegon Crawford Newaygo Genesee Oakland Gladwin Oceana Counties of: Ogemaw Grand Osceola Traverse Oscoda Gratiot Otsego Huron Ottawa Ingham Presque isle Ionia Roscommon Iosco Saginaw Isabella Sanilac Kalkaska Washtenaw Kent Wayne Lake Wexford Lapeer Counties of: Ingham Clinton Ionia Eaton Shiawassee Counties of: Mason Allegan Mecosta Grand Montcalm Traverse Muskegon Hillsdale Newaygo Jackson Osceola Kent Ottawa

25 of 28

Snapshot of Michigan Medicaid Managed Care and Medicare Advantage Enrollment Plan Name


Profit Status


Pro Care Health Plan



Total Health Care



UnitedHealthcare Community Plan (formerly Great Lakes Health Plan)

Subsidiary of National Plan: UnitedHealthcare


Medicaid: 2,159 (including 28 duals) Medicaid: 55,046 (including 637 duals) Medicaid: 235,979 (including 6,084 duals) SNP: 3,902

Upper Peninsula Health Plan

Hospital-Owned: Marquette General Hospital


Medicaid: 29,167 (including 534 duals) SNP: 219

Medicaid Service Area Leelanau Van Buren Manistee Wayne County Counties of: Genesee Macomb Counties of: Allegan Berrien Branch Calhoun Cass Hillsdale Huron Jackson Kalamazoo Kent Lenawee Livingston Counties of: Alger Baraga Chippewa Delta Dickinson Gogebic Houghton

Oakland Wayne Macomb Monroe Muskegon Oakland Oceana Ottawa Saginaw St. Clair St. Joseph Sanilac Tuscola Van Buren Wayne Iron Keweenaw Luce Mackinac Marquette Menominee Ontonagon Schoolcraft

Medicaid: August 2012 Medicare SNP: June 2012

26 of 28

27 of 28

Draft Oct 10th: Michigan



Assumptions: Options: Difference in budget and % participation total operation budget for network % Member participation in network


Total Membership

FEE OPTIONS TO COVER ADMINSTRATIVE COSTS Example Only OPTION 1: Full Option 1A: Full $300,000 $300,000 25% 50%

Type of Member CCRC Campuses


Skilled Nursing Facilities not included in CCRC's Skilled Nursing/ALF Misc Multi-Level Skilled/market rent/alf home Health Care Hospice Adult Day Centers Affordable Housing Total # of Members: Charge flat fee Part 1



II: Calculation/Part Two of Management Fee: User fee

Adult day/Home health? Didn't add in at this time Total



Fee Options for budget members participating Base fee of $1,000

0 0 0 0 0 0 0

0 0 0 0 0 0 0



2,200 750

4,400 1,500






Fill in Column D with Number of members

0 Option 1A: Full

Example Units insert total 8,800 3,000


Fee based for Tier One/based on beds/ Per bed/per year

Calculate Network Costs: Insert your bed numbers Flat fee: User per bedfee: Number of Beds total user fee TOTal member Fee


OPTION 1: Full

Nursing home beds Licensed ALF units



50% How many beds are there in Member profile Does Medicaid pay for ALF out of waiver program

Option 1: Full operations $300,000 $300,000 25% 50% $22,000.00 $44,000.00

$278,000.00 94.24

$256,000.00 $43.39

$1,000.00 $9,423.73 based on 25% membership 100 insert number of total beds $10,423.73

28 of 28

Regional Network Book  

regional network book

Read more
Read more
Similar to
Popular now
Just for you