2. RI AK HI Current MLTSS program (regional **) Duals demonstration program only MLTSS under consideration for 2016 or later OR NV UT AZ SD NE KS AR LA WI ** IN KY TN GA SC VA ME MS AL WV CA ** ID MT WY NM TX ND OK MN IA MI IL ** MO OH FL PA NY CO NC WA ** VT NH MA MD DE NJ DC RI CT Source: NASUAD survey; CMS data

3. New Jersey Background In the mid 1990s, NJ transitioned adults and children (not aged, blind and disabled) to Medicaid managed care FFS operated alongside various waivers for ABD populations Rebalancing efforts underway for several years – Independence Dignity & Choice Act established a Medicaid Funding Advisory Committee In 2011 adult day health services, home health services, rehabilitation, pediatric medical day care were “carved in” to Medicaid Managed Care This began a transition that involved extensive communication, education and relationship building between providers, regulators and payers that had not interacted in a managed care environment before Movement of the remaining settings (NF, AL, non-traditional long term care providers, TBI, etc.) into managed care on the horizon via the comprehensive Medicaid waiver (1115c) decided.

4. Formation of Work Groups Assuring Access Assessment to Appeals Provider Transition Quality and Monitoring Two-plus years (2011 – 2013)of frequent, roll up your sleeves meetings

5. Taking it on the road ---- Tennessee Amerigroup Provider Associations Provider Representatives State Representatives

6. Key Advocacy Points Any Willing Provider Continuity of Care Rate Protection Timely Payment Conflict-free Care Management Standardization of forms, credentialing, codes, definitions

7. MLTSS: New Jersey’s Experience Lowell Arye Deputy Commissioner, NJ Department of Human Services A Shift toward Medicaid Managed Care: Lessons Learned November 3, 2015

8. Backdrop for Move to MLTSS 1995 – Medicaid managed care was introduced in NJ to improve quality, health outcomes and contain costs for Medicaid and NJ FamilyCare clients. July-October 2011 – The aged, blind and disabled populations, and duals (individuals with both Medicare and Medicaid benefits) were moved into managed care for Medicaid benefits. HCBS and facility-based long term care stayed in the Fee For Service (FFS) system. July 2011, Medical Day Care, Personal Care Assistance and therapies moved into managed care. 8

9. NJ Comprehensive Medicaid Waiver NJ Comprehensive Medicaid Waiver (NJCW) demonstration 1115 (a) was approved effective 10/1/12-6/30/17 to: – Implement statewide health reform and expand current managed care programs to include managed long term services and supports and expand home and community based services (HCBS) to some populations. – Combine authority for several existing Medicaid and CHIP waiver and demonstration programs. – Create a funding pool to promote a health delivery system transformation. 9

10. NJCW and MLTSS Enables NJ to expand Medicaid eligibility and coverage options for people who needed HCBS but who were ineligible for Medicaid due to income. Gives NJ broad authority to modify rules for efficiency while providing quality care. Combined four existing HCBS waivers: 1.Global Option (GO) for Long Term Care; 2.AIDS Community Care Alternatives Program (ACCAP); 3.Traumatic Brain Injury (TBI); and 4. Community Resources for People with Disabilities (CRPD). 10

11. New Jersey Go-LIVE Scenario MLTSS went live on July 1, 2014 with automatic enrollment of about 13,000 individuals in four distinct Medicaid Waiver programs. About 27,000 nursing home residents who were already considered custodial care and on fee-for- service Medicaid were excluded, but newly eligible individuals after July 1 would be on MLTSS.

12. Exclusions to MLTSS on July 1, 2014 Division of Developmental Disabilities’ CCW (Community Care Waiver) or Supports Program beneficiaries People with Pervasive Developmental Disabilities (DD) Intellectual/DD Beneficiaries in out-of-state HCBS settings Persons receiving inpatient services for intellectual or developmental disability and mental health illness in a psychiatric hospital PACE Program beneficiaries Persons enrolled in Dual Eligible Special Needs Plans (D-SNP) Continued….

13. Exclusions to MLTSS on July 1, 2014 Fee-for-service (FFS) Medicaid beneficiaries who are in custodial nursing home care on or before July 1, 2014 Medicaid beneficiaries living in Special Care Nursing Facilities (SCNFs) as of July 1, 2014 will remain in the current fee-for-service environment for two years (until July 1, 2016)

14. Background The PACE organization coordinates and provides ALL services including nursing facility care, if needed. Applicant must be 55 or older, able to live safely in the community at the time of enrollment and have care needs at the nursing home level. Currently there are now five PACE organizations in seven counties serving a total of 891 individuals. Applicant must live in the PACE provider service area to be eligible to enroll. Program of All-Inclusive Care for the Elderly (PACE) Program of All-Inclusive Care for the Elderly (PACE) 14

15. MLTSS Approval Process The DHS has responsibility for clinical eligibility determination; care management rests with the MCOs. MCO contract establishes clear delineations between determining clinical eligibility; developing and authorizing plans of care; establishing service caps; and overseeing quality assurance management. State must approve assessment findings and ensure that the findings match the health care needs of the MLTSS members, as detailed in the plans of care. NJ-Choice assessment tool sets the standard. 15

16. Aetna – Bergen, Camden, Essex, Hudson, Middlesex, Passaic, Somerset and Union. Amerigroup New Jersey -- all counties except Salem Horizon NJ Health -- all counties UnitedHealthcare Community Plan -- all counties WellCare Health Plans of New Jersey – Bergen, Essex, Hudson, Middlesex, Passaic, Somerset, Sussex and Union 16 MLTSS Managed Care Organizations (MCOs)

17. August 2015 MLTSS Headlines 35.4% of the NJ FamilyCare LTC Population is in Home and Community Based Services Highest Since MLTSS Implementation Nursing Facility Population Has Decreased by Almost 1,500 Since June 2014

18. FFS pending MLTSS (SPC 60-64)594 Total Long Term Care Recipients* 42,247 FFS Nursing Facility (SPC 65) 18,250 FFS SCNF Upper (SPC 66) 233 FFS SCNF Lower (SPC 67) 165 MLTSS HCBS10,866 MLTSS Assisted Living3,019 23,811 18,436 Fee For Service (FFS/Managed Care Exemption) Managed Long Term Support & Services (MLTSS) Source: NJ DMAHS Shared Data Warehouse Regular MMX Eligibility Summary Universe, accessed 9/9/15 Notes: Information shown includes any person who was considered LTC at any point in a given month and includes individuals with Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, 78499 & 88499, Special Program Codes 03, 05, 06, 17, 32, 60-67, Category of Service Code 07, or MC Plan Codes 220-223 (PACE). * ‘FFS NF – Other is derived based on the prior month’s population with a completion factor (CF) included to estimate the impact of nursing facility claims not yet received. Historically, 90.76% of long term care nursing facility claims and encounters are received one month after the end of a given service month. ** Includes Medically Needy (PSC 170,180,270,280,340-370,570&580) recipients residing in nursing facilities and individuals in all other program status codes that are not within special program codes 60-67 or capitation codes 79399, 89399, 78199, 88199, 78399, 88399, 78499 & 88499. FFS NF – Other (Feb 2015)**3,733 PACE836 MLTSS HCBS/AL (unable to differentiate)8 MLTSS NF4,486 MLTSS Upper SCNF35 MLTSS Lower SCNF22

19. Long Term Care Population by Setting Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed on 9/9/2015. Notes: All recipients with PACE plan codes (220-229) are categorized as PACE regardless of SPC, Capitation Code, or COS. Home & Community Based Services (HCBS) Population is defined as recipients with a special program code (SPC) of 60 (HCBS) or 62 (HCBS – Assisted Living) OR Capitation Code 79399,89399 (MLTSS HCBS) with no fee-for-service nursing facility claims in the measured month. Nursing Facility (NF) Population is defined as recipients with a SPC 61,63,64,65,66,67 OR CAP Code 78199,88199,78399,88399,78499,88499 OR a SPC 60,62 with a COS code 07 OR a Cap Code 79399,89399 with a COS code 07 OR a COS 07 without a SPC 60-67 (Medically Needy). COS 07 count w/out a SPC 6x or one of the specified cap codes uses count for the prior month and applies a completion factor (CF) due to claims lag (majority are medically needy recipients).

20. Percent of LTC Population in NF vs HCBS vs PACE Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed on 9/9/2015. Notes: All recipients with PACE plan codes (220-229) are categorized as PACE regardless of SPC, Capitation Code, or COS. Home & Community Based Services (HCBS) Population is defined as recipients with a special program code (SPC) of 60 (HCBS) or 62 (HCBS – Assisted Living) OR Capitation Code 79399,89399 (MLTSS HCBS) with no fee-for-service nursing facility claims in the measured month. Nursing Facility (NF) Population is defined as recipients with a SPC 61,63,64,65,66,67 OR CAP Code 78199,88199,78399,88399,78499,88499 OR a SPC 60,62 with a COS code 07 OR a Cap Code 79399,89399 with a COS code 07 OR a COS 07 without a SPC 60-67 (Medically Needy). COS 07 count w/out a SPC 6x or one of the specified cap codes uses count for the prior month and applies a completion factor (CF) due to claims lag (majority are medically needy recipients).

21. Diagnosis – Alzheimer’s/dementia; Diabetes; and/or Coronary disease (self-reported diagnosis in each category - approximately 33% ) Difficulty making decisions (54%) IADLs: difficulty preparing meals, doing housework, managing finances and managing medications (72% or greater) ADLs: requires extensive assistance with bathing (65%) and lower dressing (55%) ADLs: requires supervision and/or limited assistance with dressing upper body, transfers, transfer toilet, toilet use, walking and locomotion (60% or greater) 21 MLTSS Composite Member Profile

22. Lives with spouse/partner or relative (41%) Average hours of informal care in a 3 day period (non- paid family/friends) - 17.9 hours Lives alone (35%) Falls within last 3 months (30%) Difficulty using a phone (27%) 22 MLTSS Member’s Other Risk Factors

23. MLTSS Quality Strategy Several State agencies are involved, but the Division of Medical Assistance and Health Services has authority over programs and exercises oversight and monitoring. Besides the existing NJ Family Care managed care contract requirements, MLTSS reporting requirements are in the MCO contract. The External Quality Review Organization is conducting a unified set of mandatory external quality review activities outlined in 42 CFR438.358, including the annual assessment of operations, performance measures and quality improvement projects, that will review the quality of the NJ FamilyCare plan and MLTSS requirements. NJ’s approach is to use nationally recognized benchmarks and to establish performance benchmarks. 23

24. MLTSS Pay for Performance Measures 24 Level of Care Assessment Prior to Enrollment Reporting of Critical Incidents within required timeframe Plan of Care Established within 30 Days of Enrollment Plans of Care Aligned with Member’s needs based on the NJ Choice Assessment Compliance with Contractual Provider Network Standards Follow up with MH Professional within 7 Days of Hospitalization for Mental Illness Complaint/Appeal/Grievance Reviews Completed in 30 Days # of MLTSS Members Moving from Nursing Facilities to Community MLTSS/HCBS Member Hospital Readmissions within 30 Days Emergency Room Utilization by MLTSS HCBS Members

25. Next Steps Work with External Quality Review Organization on the Quality Performance Measurements Collaboration with the MCOs and NFs to ensure timely claim payments Discussion of Any Willing Provider provision Renewal of NJ Comprehensive Medicaid Waiver for June 30, 2017

26. For More Information Lowell Arye, Deputy Commissioner NJ Department of Human Services 609-633-6645 Lowell.Arye@dhs.state.nj.us http://tinyurl.com/New-Jersey-MLTSS

28. Operational Changes at the Jewish Home Assisted Living Implement communication changes throughout the organization. Each insurance has slightly different reporting requirements and forms so clear communication across all lines of staff is needed to ensure that everything is being communicated to the proper payer. Authorization Tracking systems needed to be created as each enrollee is authorized at a different time and while the authorizations are typically for an extended period, they all renew at different times.

29. Operational Changes Tickler system to track enrollee enrollment. There is often a significant lag time before the actual enrollment information is received by the facility are therefore able to be billed. Not all insurance companies are utilizing the same claim submission platform (clearing house) so multiple websites need to be accessed for claim submission and multiple billing files need to be created for billing. There is no consistency in the MCO care manager and often times they are not interacting with staff regarding clients. We have joined a managed care association which provides us with contracting assistance in development and negotiations.

30. Challenges There have been several occasions in which the MCO is auto- enrolling even though the client/family has chosen a different insurance provider. The resolution often takes several months. Cash flow has been impacted. Under the old system we were paid in 14 days and now are waiting up to 60 days for payment.

31. Challenges Claims adjustments are not occurring when resident liability is not accurate. Resident liabilities are often wrong on the part of the insurance provider. We have had challenges with getting timely notifications of denials and often the denials are the result of “system glitches.”

32. Quality Metrics & Quality Based Contracting Concerned about the ability to compare apple to apple with regards to quality and what impact this will have on contracting moving forward. There is a concern about the how to truly identify residents in long term care settings who need their service needs met without the facility absorbing the costs.

33. Learning Lessons You must implement systems to track residents, MLTSS partners, authorizations and billing status. Join a network or association that will help you navigate through the system and provide assistance with contract negotiations and claim dispute resolution.

34. Learning Lessons Recognize that facilities and MCO’s both operate with slim, or negative, margins under the MLTSS program. We must begin to work together to build new care transition platforms that create benefits for our residents, our facilities and our MLTSS partners.

35. 301 Sicomac Ave., Wyckoff, NJ 07481 (201) 848-5200 ChristianHealthCare.org A shift toward Medicaid Managed Care: Lessons Learned PRESENTED BY: D OUGLAS S TRUYK, CPA, LNHA President/CEO Christian Health Care Center dstruyk@chccnj.org

36. Senior Life Short- term Rehab Mental Health The Vista Fostering health, healing and wellness for people of all ages. Heritage Manor Nursing Home Southgate Nursing Home Longview Assisted Living Residence Hillcrest Residence Evergreen Court Residence Christian Health Care Adult Day Services David F. Bolger Post-acute Care Unit Continuing Care Retirement Community Ramapo Ridge Psychiatric Hospital Ramapo Ridge Partial Hospital Program Christian Health Care Counseling Center

37. Programs impacted by MLTSS 254-bed nursing facility (SNF) 44-bed special-care nursing facility (SCNF) for behavior management 95-bed assisted living for the frail elderly and memory impaired Serving up to 100 clients daily, Monday through Friday Heritage Manor Nursing Home Southgate Special-care Nursing Home Longview Assisted Living Residence Christian Health Care Adult Day Services

38. New Jersey’s Comprehensive Medicaid Waiver demonstration 1115(a) was approved effective beginning in October 2012. Now what?

40. Planning operational changes to prepare for MLTSS Understand NJ’s plan Lessons learned from Medicaid Managed Care with adult day services System and process changes at our organization Education and training

41. Understand NJ’s Plan Information sessions with State officials and leaders of stakeholder groups Participation in steering committee work Learn from other states’ experiences

42. Lessons learned from Medicaid Managed Care with adult day services ContractingCredentialingAuthorization processPayment

43. Contracting Individual MCO contracts Legal advice and review Stand together with others Any willing provider

44. As with much of life, it’s about managing relationships.

45. Credentialing Facility – multi-faceted? Complete & accurate information MCO needs a clear understanding of your organization. Build relationships NOW!

46. Authorization process MCO always looking for lowest level of care We are advocating for our residents Build relationships Align everyone’s incentives

47. Payment Prepare for a change in cash flow Track monitor follow-up Cost sharing (as an example) Testing shmesting

48. System and process changes TechnologyIntegrated teamsData gathering to improve quality

49. Education & Training 1 2 3 Clinical & non- clinical staff Educating MCOs Educating State government 12 3

50. State of NJProvidersMCO’s Beneficiaries

51. MLTSS Steering Committee Fifteen diverse, talented, opinionated leaders brought together to guide policy decisions, consider recommendations from the work group, offer feedback and help ensure that New Jersey’s implementation of managed long term services and supports is the best it can be. Core group was Medicaid Long Term Care Advisory Council created through prior legislation (Independence, Dignity & Choice Act) Report of Recommendations finalized June 2012. Continues to meet quarterly; expanded to include PACE Organization, more consumer representatives (AARP, Legal Services of NJ, family caregiver). Facilitated by Center for Health Care Strategies.

52. MLTSS Steering Committee Principles New Jersey’s overall goal is to provide quality long-term services and supports to individuals of all ages in the most integrated setting appropriate to their needs. New Jersey will build a system that is cost effective and sustainable for the future. Home and Community-Based Services is the preferred service delivery method for people receiving Managed Long Term Services and Supports (MLTSS). Consumer choice and participation in selecting service providers and living settings, to the maximum extent feasible, should be a priority of New Jersey’s MLTSS. Participation of all stakeholders in the planning and implementation of MLTSS.

53. MLTSS Steering Committee Recommendations Presented in a June 2012 report Served as a guide for implementation phase Assists with monitoring progress Unanticipated “bumps” in the road

54. Achievements To-Date Any willing provider for 2 years State rate protection for 2 years Continuity of care and non-par coverage Gradual MCO enrollment for NF population Standard service definitions, codes and billing format 15/30 day payment period for NF/AL claims PACE parity as an option Standardized assessment tool

55. Achievements To-Date Options counseling training Transition of care management Any willing provider for LTC pharmacy with no time limit Good cause provision for changing MCO Beginning of quality measures – structure, process and utilization

56. Work in Progress MLTSS network adequacy standards Streamlining credentialing Future of any willing provider State’s role in rate setting – FFS and MCO Transparency of capitation rate setting Timely payment of clean claims Timely completion of assessments – MCO & OCCO Medicaid financial eligibility determination timing Stability and effectiveness of care management Room and board for residents who elect the hospice benefit Quality measures related to outcomes, satisfaction and value Delegation of medication administration to home health aides

57. Lessons Learned Advocacy and persistence are important Education is as important as advocacy Delivery system stability is essential Special care populations (vent, HIV, behavior management, pediatric, Huntington’s) require attention Non-traditional providers need more attention Turnover in state staff, ADRC/AAA staff, MCO staff and provider staff is a challenge Constrained State resources force some choices among high priorities Monitoring options counseling is a priority Clear delineation of responsibility is elusive Ongoing structure for communication outside the Steering Committee is really required for “on the ground” feedback

58. A Little More on AWP Any Willing Provider Provision - Contracts between MCOs and DHS should contain an Any Willing Provider (AWP) provision so that any Nursing Facility (NF) or Assisted Living (AL) provider that complies with the requirements of participation in the MCO can be included in the network of that plan. The AWP provision should be reciprocal whereby Any Willing Plan that meets a NF/AL provider’s requirements can enter into a contract with them to serve Medicaid clients. The AWP provision should run for two years, and the State shall conduct an evaluation at 18 months to determine if the AWP provision can be converted at the end of two years so that the MCOs and providers would implement negotiated contracts with negotiated rates as needed to satisfy network adequacy requirements.

59. A Little More on AWP Nursing facilities, excluding special care nursing facilities, should be paid for custodial residents at a minimum using the existing state case-mix index methodology during the two-year AWP period. However, this provision would not prevent any NF provider and MCO from entering into rate negotiations during this two year period. Assisted Living facilities should be reimbursed at a minimum using the existing state methodology during the two-year AWP period. However, this provision would not prevent any AL provider and MCO from entering into rate negotiations during this two year period. In the event a provider exits an MCO provider network, covered beneficiaries have the option to change MCOs, or the MCO will continue to cover the service by that provider as a non-participating provider.

60. Quality and Monitoring Recommendations Transparency – The State’s Quality Strategy for MLTSS should be transparent and broadly understood all levels; the Strategy should mandate data-driven decision making that ensures quality improvement systems in place at the delivery system level. Accountability - The state should hold the government entities, providers and health plans responsible and accountable for quality assurance and quality improvement activities within their own settings and across systems. Ensure the availability of provider and Health Plan Quality Information so consumers may make an informed choice of provider and health plan based on quality performance. The state is also accountable for making available the results of its quality monitoring to consumers and plans

61. Quality and Monitoring Recommendations Consistent Approach - The State should design and implement consistent and coordinated quality framework and interagency approach across waiver populations while maintaining accountability and responsibility for quality monitoring, management, remediation and improvement within specific departments. The State should establish key performance e indicators with oversight and monitoring of quality assurance and improvement processes and activities conducted by its service providers, including discovery, remediation and improvement. Monitoring Quality - The State should mandate the transparency of the monitoring process; use evidence based metrics that can be benchmarked wherever possible and which promote best practice and quality improvement; data collection should result in user-friendly access to data, analysis of key trends, reporting and dissemination of clear and concise information across all agencies with responsibility for Medicaid populations and to external stakeholders. Use of Benchmarked Metrics - limit the use of “home grown” measures and instead, work with industry leaders to get metrics vetted, analyzed and rated.

62. Quality and Monitoring Recommendations Domains Health and safety Personal preferences/choice Access System balance Transitions and organization of care Quality of care Care management Provider networks Services Quality of life Caregivers

63. MLTSS FAQs Regularly updated in response to provider questions and recommendations

64. Provider Inquiry Process

65. Ongoing Communication Stakeholder Forums Seminars Issue-Specific Meetings MCO Contact Grid Open Door – DHS Deputy Commissioner, Medicaid Director, Office of Managed Health Care, Division of Aging Services Rutgers Center for State Health Policy Initial Evaluation Report

66. Questions