Presentation is loading. Please wait.

Presentation is loading. Please wait.

Moving to a Medicaid Managed Long Term Services and Supports (MLTSS) Model Regina Vercilla and Jeanine Kilgore.

Published byAnnice Jenkins Modified over 8 years ago

Similar presentations

Presentation on theme: "Moving to a Medicaid Managed Long Term Services and Supports (MLTSS) Model Regina Vercilla and Jeanine Kilgore."— Presentation transcript:

1

2 Moving to a Medicaid Managed Long Term Services and Supports (MLTSS) Model Regina Vercilla and Jeanine Kilgore

3 MLTSS – Current Situation
MLTSS grew significantly between 2004 and The number of States with MLTSS programs doubled from 8 to 16, and the number of persons receiving LTSS through managed care programs increased from 105,000 to 389,000 (Saucier et al. 2012) Arizona and Wisconsin – early pioneers Close to home: Delaware – 2012 New Jersey – 2014 Several other states with plans to implement MLTSS

4 MLTSS – Pennsylvania Situation
June DHS released a “Managed Long-Term Services and Supports (MLTSS) Discussion Document This began the stakeholder input process September DHS subsequently released a “Community HealthChoices Concept paper” Stakeholder input through public hearings, stakeholder written comments, and sub-MAAC DHS hosting monthly webinars to provide updates and answer questions DHS and several provider organizations holding Meet and Greet sessions with MCO’s MLTSS RFP released in March, 2016 DHS received 14 bids for a MLTSS contract

5

6 Objectives Participants will gain an understanding of a Managed Long Term Services and Supports model. Participants will gain an understanding of the specifics of Pennsylvania’s MLTSS model that will be implemented beginning January 1, 2017. Participants will learn the key areas of readiness to position their organizations for MLTSS.

7 Managed Care 101 - Capitation
Capitation Basics Fee-for-Service (FFS) Providers are paid for each service Payment dependent on the quantity, rather than quality, of care Capitation Providers are paid a set amount for each enrolled person assigned to them Per Member/Per Month (PMPM) – typically the period of time that is set Advantages of Capitation Predictability Shifts risk

8 Managed Care 101 – Managed Care Organizations
Managed Care Organization (MCO) An umbrella term for health plans that pay for health care services in return for a predetermined monthly fee (PMPM) and coordinate care through a defined network of providers. Lower cost alternative to traditional, fee-for-service health insurance because care is managed through various cost-saving strategies. Contracted network of providers Primary Care Physician (PCP) as gatekeeper/medical home Prior authorization for high cost services Utilization review process and criteria Drug formulary and utilization review process Case/Disease Management Preventive Health

9 Managed Care 101 – Case/Disease Management
CMS and State Medicaid agencies require Case/Disease Management For Medicaid, varies by state NCQA requires MCO’s to have: Disease Management programs Complex Case Management program MCO’s develop or contract for case/disease management programs to help their members control chronic conditions Outreach and Intervention is both telephonic and face-to-face CMS and State Medicaid agencies reward innovation and outcomes State Medicaid agencies often highly prescriptive about process/procedures, staff, training, caseloads, supervision, etc.

10 Managed Care 101 – Quality & Regulatory
NCQA – National Committee for Quality Assurance MCOs must be accredited Accreditation scores are based on a plan’s P&Ps, set of clinical measures (HEDIS), and consumer experience (CAHPS) HEDIS – Healthcare Effectiveness and Data Information Sets Measures how well plans are impacting health outcomes Includes 81 specific measures across 5 domains (mostly focused on preventive health) CAHPS – Consumer Assessment of Healthcare Providers and Systems Measures how well plans are meeting member’s expectations and needs HOS – Health Outcome Survey (Medicare-specific) Measures how well a plan has been able to maintain or improve the physical and mental health of it’s members over 2 year period. Medicare STAR Rating Measures how well a plan performs based on cross-section of quality metrics including clinical, pharmacy, member satisfaction with their plan and providers, health outcomes and plan operations CMS and State requirements MCO Contracts are highly regulated by CMS, State Medicaid agencies. Other regulators include the DOI and DOH

11 Managed Care 101 – Special Needs Plans (SNP)
Provides a managed care option for Medicare beneficiaries who Are dually eligible for Medicare and Medicaid (D-SNP) Live in nursing homes, other institutions, or community (I-SNP) Have severe chronic or disabling conditions (C-SNP) Majority of SNP enrollees are in plans for dual-eligible (D-SNP) DHS is requiring all CHC MCOs to have a D-SNP

12 Questions?

13 MLTSS Overview – What is MLTSS?
The delivery of long-term services and supports (LTSS) through capitated Medicaid managed care programs. An arrangement between the state Medicaid agency and contractors. MCOs receive capitated payments for LTSS MCOs are accountable for the health and welfare of participants through the delivery of services and supports that meet quality and other standards set in the contracts.

14 MLTSS Overview – Why MLTSS?
Changes payment model for state from Fee-for-Service (FFS) to Capitation Fixed fee Per Member/Per Month (PM/PM) Predictable MCOs assume risk Control Costs Expand HCBS to all Medicaid recipients who meet criteria Improve health outcomes via better coordination of care

15 MLTSS Overview - Program Design
MLTSS program design varies by state States have flexibility to determine eligibility and design benefit structure States must get approval from CMS (1915a, 1915b, 1115 waiver) Focus is typically on the Elderly, Physically Disabled Adults, Duals Typically ID/DD population and children are excluded, at least initially Moves individuals from 1915c waivers to Managed Care but with similar benefits Money Follows the Person is typically rolled in Heavy emphasis on Face-to-Face Case Management and Service Coordination Most states include Self-Directed care Incentivizes plans to support individuals at home or in the community (blended rate)

16 Pennsylvania MLTSS Model
DHS has named the Pennsylvania MLTSS Program “Community HealthChoices (CHC) Phased-in approach January 1, 2017 – South West Zone January 1, 2018 – South East Zone January 1, 2019 – Lehigh Capital, North East, North West zones DHS will select between 2-5 MCO’s per zone DHS will announce selected MCO’s early July DHS focused on… Increased access to HCBS for individuals not previously eligible Shifting bias from institutional care to HCBS Community and Workforce participation

17 Pennsylvania Medicaid Managed Care Zones

18 Community HealthChoices - Population
Population Included Adults age 21 or older who require Medicaid LTSS (whether in the community or in private or county nursing facilities) because they need the level of care provided by a nursing facility or ICF/ORC; and Dual eligible age 21 or older whether or not they need or receive LTSS Enrollment will be mandatory CHC will serve an estimated 450,000 individuals, including 130,000 older persons and adults with physical disabilities who are currently receiving LTSS in the community and nursing facilities

19 Community HealthChoices - Population
Population Excluded Individuals eligible for Medicaid-funded or Base-funded programs available through the Office of Developmental Programs Act 150 program participants Individuals receiving their services through lottery funded Options programs Residents of state-operated nursing facilities, including the State Veterans’ Homes

20 Community HealthChoices – Dual Eligible Participants
Eligible for full Medicare and Medicaid benefits Duals have option to select: Medicare FFS Medicare SNP Does not have to be same MCO as their CHC-MCO MCO’s are required to facilitate coordination between Medicare, Medicaid, LTSS, and BH benefits

21 Community HealthChoices – Financial and Clinical Eligibility
Financial Eligibility for CHC CAOs will continue to process financial eligibility Level of Care Process Standardized level of care tool will be developed to replace what is currently in use across OLTL LTSS programs The Commonwealth will contract with an entity to perform LTSS level of care determinations The entity selected will not be permitted to be a provider of service

22 Community HealthChoices – Benefit Package
Physical Health All physical health benefits specified in the Medicaid State Plan LTSS Nursing facility services and HCBS currently covered in the Aging, OBRA, Independence, COMMCare, AIDS, and Attendant Care waiver programs Assisted Living Facilities CHC will not pay for room and board in assisted living facilities. However, it will be an allowable setting in which to receive certain home- and community-based services covered by CHC. Home Modifications Commonwealth will select entity(s) to act as brokers CHC-MCOs may contract with these entities Participant-Directed Personal Assistance Services CHC-MCOs will offer choice of three models: Agency model Participant-directed employer authority model Services My Way Financial Management Services (FMS) Commonwealth will continue agreement with single state-wide entity

23 Community HealthChoices – Benefit Package
Nursing Home Transition (NHT) CHC-MCOs may contract with NHT providers to identify NHT-appropriate participants and coordinate their NHT services or; CHC-MCOs may perform this function Service Coordination CHC-MCOs will be permitted to provide directly or through community partners, as long as expertise can be demonstrated. CHC-MCOs will be required to implement care transition protocols whenever participants are admitted to or discharged from hospitals, nursing facilities or residential settings. DHS prescribes that a Service Coordinator be assigned to every CHC participant that is Nursing Facility Clinically Eligible (NFCE).

24 Community HealthChoices – Behavioral Health
Behavioral Health Services will continue to be managed by BH-MCO’s CHC-MCO’s are required to have Letters of Agreement (LOA’s) with BH-MCO’s to coordinate care CHC-MCO’s are required to have a full-time dedicated BH liaison

25 Questions?

26 Organization Transformation
An Opportunity to Grow and Diversify

27 Organization Transformation
Market Develop Strategy Perform SWOT Analysis Explore New Opportunities Be Informed

28 Be Informed Take every opportunity to know what is happening and when
Read the CHC waiver Read the CHC Contract and RFP Attend MLTSS sub-MAAC meetings Participate in the DHS Third Thursday webinar updates Research other state experiences Ask questions Meet with MCO’s How do you get into the network? How do they accept billing? How will they approach service coordination and NHT?

29 Explore New Opportunities
Demand for HCBS will increase. What gaps can you fill? Housing Home-delivered Meals Transportation Employment Community Integration Nursing Home Transition Home Modifications PAS Respite Dementia Care

30 Perform SWOT Analysis

31 Develop Strategy Service Offerings Service Area Communication Strategy
Design Materials Develop Readiness Plan

32 Market Describe your services Sell your value added services
What makes you stand out? Why are you essential to the MCO’s network? Sell your value added services Think about pain points for MCO’s Acute care admissions/readmissions HEDIS Participant satisfaction Special populations Network adequacy Show outcomes Operational excellence Quality outcomes

33 Thank you for attending!
Leave with this… High quality providers are essential for an MCO to exist and to successfully fulfill their obligation to their enrolled participants. Thank you for attending!

34 Resources Saucier, P.; Kasten, J.; Burwell, B.; Gold, L. The Growth of Managed Long Term-Services and Supports Programs: A 2012 Update.2012. Musumeci, M. Key Themes in Capitated Medicaid Managed Long-Term Services and Supports Waivers. Kaiser Family Foundation (KFF) Community-Based Organizations and MLTSS: An Issue Brief to Assess CBO Readiness. National Association of States United for Aging and Disabilities (NASUAD)

Download ppt "Moving to a Medicaid Managed Long Term Services and Supports (MLTSS) Model Regina Vercilla and Jeanine Kilgore."

Similar presentations

Making Payment Reforms Work for Patients and Families Lee Partridge Senior Health Policy Advisor National Partnership for Women and Families January 28,

Making Payment Reforms Work for Patients and Families Lee Partridge Senior Health Policy Advisor National Partnership for Women and Families January 28,
Scott Leitz Assistant Commissioner for Health Care Minnesota Department of Human Services Minnesotas Approach: Integrated Medicare & Medicaid Programs.

Scott Leitz Assistant Commissioner for Health Care Minnesota Department of Human Services Minnesotas Approach: Integrated Medicare & Medicaid Programs.
Medicaid Managed Care Initiatives December 2011. 2 STAR Capitated, Health Maintenance Organization (HMO) model for non-disabled pregnant women and children.

Medicaid Managed Care Initiatives December STAR Capitated, Health Maintenance Organization (HMO) model for non-disabled pregnant women and children.
Medicaid Division of Medicaid and Long-Term Care Department of Health and Human Services Managed Long-Term Services and Supports.

Medicaid Division of Medicaid and Long-Term Care Department of Health and Human Services Managed Long-Term Services and Supports.
Medicaid Division of Medicaid and Long-Term Care Department of Health and Human Services Managed Long-Term Services and Supports 1.

Medicaid Division of Medicaid and Long-Term Care Department of Health and Human Services Managed Long-Term Services and Supports 1.
Presented by: Melissa O. Picciola, Equip for Equality June 27, 2012.

Presented by: Melissa O. Picciola, Equip for Equality June 27, 2012.
Medicaid Managed Care for Elderly and Persons with Disabilities Pam Coleman Texas Health and Human Services Commission October 11, 2006.

Medicaid Managed Care for Elderly and Persons with Disabilities Pam Coleman Texas Health and Human Services Commission October 11, 2006.
Illinois Human Service Commission Rebalancing Workgroup August 2, 2012.

Illinois Human Service Commission Rebalancing Workgroup August 2, 2012.
MEDICAID – CONTEXT FOR CHANGE Mike Cheek Vice President, Medicaid and Long Term Care Policy.

MEDICAID – CONTEXT FOR CHANGE Mike Cheek Vice President, Medicaid and Long Term Care Policy.
Donald Mack, M.D. Ohio State University Medical Center Gregg Warshaw, M.D. University of Cincinnati College of Medicine.

Donald Mack, M.D. Ohio State University Medical Center Gregg Warshaw, M.D. University of Cincinnati College of Medicine.
FLORIDA SENIOR CARE Improving Medicaid Services for Florida’s Seniors Beth Kidder Chief, Bureau of Medicaid Services Agency for Health Care Administration.

FLORIDA SENIOR CARE Improving Medicaid Services for Florida’s Seniors Beth Kidder Chief, Bureau of Medicaid Services Agency for Health Care Administration.
Can Health Care Savings Drive a New Funding Model For Affordable Housing?

Can Health Care Savings Drive a New Funding Model For Affordable Housing?
1 Wisconsin Partnership Program Steven J. Landkamer Program Manager Wisconsin Dept. of Health & Family Services July 14, 2004.

1 Wisconsin Partnership Program Steven J. Landkamer Program Manager Wisconsin Dept. of Health & Family Services July 14, 2004.
It’s All About MME Tasia Sinn September 18, 2014 Understanding Colorado’s New Medicare- Medicaid Enrollee (MME) Program.

It’s All About MME Tasia Sinn September 18, 2014 Understanding Colorado’s New Medicare- Medicaid Enrollee (MME) Program.
Health Care Financing and Managed Care. Objectives  To understand the basics of health care financing in the United States  To understand the basic.

Health Care Financing and Managed Care. Objectives  To understand the basics of health care financing in the United States  To understand the basic.
Delaware Health and Social Services Delaware’s Delivery of Long Term Services and Supports The Need for Change Delaware Health Care Commission January.

Delaware Health and Social Services Delaware’s Delivery of Long Term Services and Supports The Need for Change Delaware Health Care Commission January.
Medicare Improvement for Patients and Providers Act of 2008 Preliminary Summary of Beneficiary and Plan Provisions July 14 th, 2008 1.

Medicare Improvement for Patients and Providers Act of 2008 Preliminary Summary of Beneficiary and Plan Provisions July 14 th,
Medicaid Managed Care: KanCare Request for Proposals House Social Services Budget Committee Topeka, Kansas January 11, 2012 Scott Brunner Senior Analyst.

Medicaid Managed Care: KanCare Request for Proposals House Social Services Budget Committee Topeka, Kansas January 11, 2012 Scott Brunner Senior Analyst.
Managed Long Term Care Plans Mandatory Enrollment Linda Gowdy Home Care Association May 31, 2012 1.

Managed Long Term Care Plans Mandatory Enrollment Linda Gowdy Home Care Association May 31,
Virginia’s Blueprint for the Integration of Acute and Long-Term Care Services The Second National Medicaid Congress Cindi B. Jones, Chief Deputy Director.

Virginia’s Blueprint for the Integration of Acute and Long-Term Care Services The Second National Medicaid Congress Cindi B. Jones, Chief Deputy Director.

Similar presentations

Ads by Google