1. H EALTH H OMES AND C ARE M ANAGEMENT Proposed Initiative by the Division of Health Care Financing and Policy (DHCFP)

2. O BJECTIVES Define health homes, medical homes and care management organizations Explain how these health care models will work in Nevada Address concerns and issues related to the project Discuss the current plan Review expected timelines for these new health care models Answer any questions 2

3. M EDICAL H OME – VS. – H EALTH H OME What is a Medical Home? An enhanced primary care model where a team of health professionals attend to the multifaceted needs of patients by providing comprehensive and coordinated patient-centered care What is a Health Home? Outlined under Section 2703 of the Patient Protection and Affordable Care Act (ACA) Same concept as a Medical Home, but it incorporates additional services, such as: Behavioral and mental health Long term care transitions Health Information Technology 3

4. R EQUIREMENTS TO BE A H EALTH H OME Health Home defined by the ACA (Sec. 2703): A designated provider that operates in coordination with a team of health care professionals, or a health team selected by an eligible individual with chronic conditions to provide health home services. Required Services by Health Home: comprehensive care management; care coordination and health promotion; comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; patient and family support (including authorized representatives); referral to community and social support services, if relevant; and use of health information technology to link services, as feasible and appropriate. 4

5. R EQUIREMENTS TO BE A M EDICAL H OME Medical Homes Can be similar to the ACA health home definition, but it is not required to offer the same services Are not required to be certified or accredited under the same criteria as health homes Can offer more flexibility to address the needs of the targeted population 5

6. W HAT IS C ARE M ANAGEMENT Traditional Care Management or Primary Care Case Management (PCCM) typically consists of the primary care provider coordinating care with other medical specialists. Enhanced Care Management models expand on the PCCM concept by focusing on all needs of the patients care, including linking with community resources and other medical services. This one-on-one and hands-on approach ensures that the health needs of individual recipients are met. 6

7. V ISION TO C OORDINATE THE CARE OF THE M EDICAID P OPULATION Project based on DHCFP Legislatively approved budget to help address rising costs of certain Medicaid populations Project initially will provide management for Nevadas high need (chronic conditions and/or based on utilization patterns) fee for service (FFS) population (with some exclusions). This will be done through the use of: Care Management Organization (CMO) – A Request for Proposal (RFP) was released on February 1 st 2012 with planned program initiation in August 2012. Pilot Health Homes with planned RFP release in Spring of 2012 and implementation in Fall of 2012 If found favorable, the project will be extended to coordinate the care of all Medicaid recipients, either through a managed care organization (MCO) or a managed FFS program. 7

8. M ANAGED F EE - FOR -S ERVICE The health home and the care management programs integrate the medical care, behavioral health and long term care needs of the patient into one coordinated plan of care through a medical team all focused on the needs of the patient. They monitor and manage the provision of patient care through case management and health information technology. They utilize national benchmarks to track outcomes (hospital re-admission rates, ER use, well child visits) Payment may be: A per-member per-month (PMPM) dollar amount, Payment for improved outcomes (usually indicating savings), An increase in the regular service rate, Or a combination of these. 8

9. C ARE I NTEGRATION Care integration includes: Obtaining a health/medical home – a primary care provider responsible for overall coordination Medical disease management for persons with mental illness; mental health management for persons with chronic medical conditions Preventive healthcare screening and monitoring by mental health providers; mental health screening and monitoring by primary care providers Integrated and consolidated mental health and medical services Medication adherence, both mental health (MH) and non-MH medications Assisting in scheduling and keeping appointments Monitoring follow through, developing health and wellness services Verifying healthcare services are occurring by utilizing data management Providing real time healthcare information to appropriate healthcare service providers 9

10. C OMPREHENSIVE C ARE M ANAGEMENT O RGANIZATION (CMO) The CMO would: 1)Complete the integrated Care Management; and/or 2) Develop a cost-effective infrastructure to help small medical practices meet the requirements of a health home, thereby promoting the expansion of health homes in Nevada. (Nevada currently only has a few medical practices that have the infrastructure needed to be a health home.) CMO cost-effective activities includes: health care information exchange, data analysis and performance measurement, care coordination and patient outreach, patient education and wellness services 10

11. I SSUES THAT D EVELOPED Per Discussion with Centers for Medicare and Medicaid (CMS), it was determined Nevada would require a Section 1115 Research and Demonstration Wavier: The scope of the desired health homes and care management programs under the ACA (Sec. 2703) were not an option under the Nevada Medicaid State Plan. Therefore, Medicaid needed to waive some of the requirements in 1902 of the Social Security Act through the use of a Social Security Section 1115 demonstration waiver. Some patients are receiving case management services through existing programs (i.e. Targeted Case Management (TCM) and medical case management provided to community long term care clients through a Home and Community Based Waiver). Nevada does not want to duplicate medical services for these individuals, so they need to be excluded from the program. 11

12. I SSUES THAT D EVELOPED ( CONT ). Public comment and feedback from other agencies also indicated that an 1115 waiver would be needed because: Both counties and sister agencies perform targeted case management services. CMO or health home services to individuals in these programs would create an unnecessary duplication of services. It would also impact the current infrastructure and services that these agencies provided. Concerns were expressed about provider participation. Nevada needs to be able to develop creative payment models that would support incentives to providers to ensure additional services were provided and additional interactions between providers would be performed. 12

13. R ECIPIENT C RITERIA B ASED ON F EEDBACK Recipients must be Fee for Service (FFS) and not already enrolled in: managed care, waivered service eligibility, or in a category that already includes targeted case management (TCM) services. Selection Criteria Chronic Condition(s) High Utilization Rates (multiple ER visits, etc.) High Risk (potential for additional chronic conditions) Additional selection criteria may be chosen based on population and need. 13

14. C URRENT P LAN Develop Health Home(s) and Care Management program that integrates the medical/behavioral health and long term care needs for targeted Medicaid recipients Initially exclude persons who are receiving TCM, long-term care waiver (HCBW) services or are in the state or county child welfare and juvenile justice systems However, once the results of the initial program are determined, the State needs to create a long term plan to determine how and when this population would be able to be included in the CMO and/or health/medical homes program. 14

15. A N 1115 W AIVER IS N EEDED IN P HASE 1 TO : Use innovative care delivery and payment models, including PMPM provider payments, shared savings options, and pay for performance. Tailor some programs to specific populations or age groups (such as, health homes specific to children with cardiac conditions or adults with severe diabetes pre-end stage renal disease). Limit some programs to Medicaid and exclude the dual Medicaid/Medicare population. Mandatorily enroll or exclude specific groups. Act expeditiously when opportunities arise, without having to go through the CMS amendment process. 15

16. O VERALL T IMELINE AND W AIVER N EEDS OF 1115 W AIVER P HASE 1: 16 PHASE 1 (listed times contingent on CMS approval time frame) JUL 2012 Care Management Program Lock in. (Freedom of Choice, 1902(a)(23)) JUL 2012 Implement Medical Home pilots for high need/chronic condition enrollees. (Comparability 1902(a)(10)(B); Payment Reforms 1902 (a)(13)&1902(a)(30)) AUG 2012 Implement Care Management Organization (CMO) for high need enrollees where medical home not available or as alternative. (Comparability 1902(a)(10)(B)) AUG 2012 Expansion of Health Homes with CMO infrastructure support. SEP 2012 Implementation of Comprehensive Health Homes (integration of medical, behavioral health and long term supports).

17. A N 1115 W AIVER IS N EEDED IN P HASE 2 TO : Continue these Phase 1 needs: Using innovative care delivery & payment models Tailoring some programs to specific populations or age groups Mandatorily enrolling or excluding specific groups Act expeditiously when opportunities arise To implement meaningful benefit design changes (capped benefit unless participating in care management). Begin to incorporate previously excluded populations. 17

18. O VERALL T IMELINE AND N EEDS OF 1115 W AIVER P HASE 2: 18 PHASE 2 SEP 2013 Implementation of Integrated Care for Dual Eligible's (coordinate with Medicare for shared savings). (possible integration on 1915(c) waivers into the 1115 waiver) SEP 2013 Expansion of Managed fee for service for exempt populations (Severe Emotional Disturbed (SED), Severe Mental Illness (SMI), foster care). DEC 2013 If data indicates beneficial outcomes, implementation of Managed FFS for other populations not yet included.

19. C ARE D ELIVERY S YSTEM C HANGES There will be three primary delivery systems under the section 1115 waiver. DHCFP currently has (1) for the TANF/CHAP/CHIP populations and would require CMS approval of the 1115 waiver to implement (2) and (3): (1) HMOs, Managed FFS (2) health homes, and (3) care management organization/administrative service organization. 19

20. P OTENTIAL P ROGRAM P OPULATION BASED ON SFY 2011 C LAIMS DATA DefinitionCaseloadDollars Total Medicaid FFS (excluding those who have Medicare) population who have a diagnosis of Chronic Condition on a medical claim 66,379$808,752,072 Of those persons, the number of combined TCM, Child Welfare or Waiver patients 12,539$253, 738,669 The number of those with Chronic Conditions who are not in TCM, Child Welfare or the Waiver 53,840$555,013,403 20

21. T HANK Y OU If you have any additional questions, please visit our website: https://dhcfp.nv.gov/caremgmt.htm Or send an email: caremanagement.web@dhcfp.nv.gov 21