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Evercare Select Arizona Long Term Care System (ALTCS)

Published byMorris Clark Modified over 9 years ago

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Presentation on theme: "Evercare Select Arizona Long Term Care System (ALTCS)"— Presentation transcript:

1 Evercare Select Arizona Long Term Care System (ALTCS)

2 Arizona Long Term Care System (ALTCS)
Comprehensive Capitated Model Elderly and Physically Disabled (EPD) Population Developmentally Disabled Population

3 ALTCS Medicaid program designed to provide nursing facility and home based services to Arizona residents: Are at risk of institutionalization Have income and resources below the program limits Meet additional program requirements.

4 ALTCS Objectives Prepaid, capitated approach through public/private partnership. Integrate health services by bundling acute, long term care and behavioral health services. Pre-admission screening process to identify those who are at-risk for institutionalization. Full continuum of services: HCBS to NF Ensure members are placed in the least restrictive, most cost effective care. PCP/case managers coordinate care.

5 ALTCS Services Institutional Care Home and Community Based Services
Behavioral Health Acute Medical Care Services

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7 Elderly & Physically Disabled Population
85% of the EPD population are dual eligibles Average age of an EPD eligible member is 72 years of age. Approximately 2% of the EPD population are members under the age of 21. Largest growing EPD population segment Average length of time (duration) in the ALTCS Program years Less than 1% of the EPD population are ventilator dependent.

8 ALTCS Acute Care Services
Ambulatory Surgery & Anesthesiology Audiology Behavioral Health Chiropractic Services Dental Dialysis Early and Periodic Screening, Diagnosis and Treatment Emergency Services Eye Examinations/Optometry

9 ALTCS Acute Care Services
Family Planning Health Risk Assessment and Screening Hospital Immunizations Laboratory Maternity Medical Supplies, Durable Medical Equipment, Orthotics and Prosthetic Devices Physician

10 ALTCS Acute Care Services
Podiatry Prescription Medications Primary Care Provider Radiology and Medical Imaging Rehabilitation Therapy Respiratory Therapy Transplants Transportation Triage/Screening and Evaluation

11 ALTCS Long Term Care Services
Adult Day Health Care Attendant Care Behavior Management Services Emergency Alert System Environmental Modifications Group Respite Habilitation Home Delivered Meals Home Health Services

12 ALTCS Long Term Care Services
Homemaker Hospice Partial Care Personal Care Private Duty Nursing Respite Care

13 ALTCS Institutional Settings
Nursing Facility Institution for Mental Disease Inpatient Psychiatric Residential (members under 21)

14 ALTCS HCBS Alternative Residential Settings
Assisted Living Facilities Adult Foster Care Assisted Living Home Assisted Living Center Alzheimer’s Treatment Assistive Living Facilities

15 ALTCS HCBS Alternative Residential Settings
Behavioral Health Settings Behavioral Health Level I Behavioral Health Level II Traumatic Brain Injury Treatment Facility

16 Capitation AHCCCS pays program contractors prospectively on a capitated, per member per month basis. Capitation rates are blended rates which include: nursing facility, HCBS, acute medical services, behavioral health services, case management and administrative costs. Statewide average rate is $2,344 (as of October 1, 2000).

17 Development of ALTCS Capitation Rates
Information used in rate development: PC financial statements Encounters Inflation factor - Data Resource Institute (DRI) ALTCS Reinsurance covers partial reimbursement of acute inpatient services and limited outpatient services beyond an annual deductible ALTCS data sources (including PC reported financial information). Private sector data sources An independent actuarial firms establishes actuarially sound rates or rate ranges Competitive bids Rates/rate ranges are established each new bid year

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24 Risk Adjusters Geographic - by County Medicare - imbedded in the rate
Placement Nursing Facility HCBS - Community HCBS - Home

25 Risk Sharing HCBS Placement Reconciliation - annual
Placement - point in time Share of Cost

26 HCBS Placement Reconciliation
ALTCS recoups capitation if PC’s HCBS placement percentage exceeds estimate: HCBS % over budget Recoupment percentage pts. 0% of capitation overpayment percentage pts. 20% of capitation overpayment 2 or more percentage pts. 30% of capitation overpayment

27 HCBS Placement Reconciliation
ALTCS adds capitation if PC’s HCBS percentage is below estimated: HCBS % under budget Additional percentage pts. 0% of capitation underpayment percentage pts. 20% of capitation underpayment 2 or more percentage pts. 30% of capitation underpayment

28 Placement Adjustment Maricopa County Only
AHCCCS adjust placement percentages to provide incentives for appropriate placement in HCBS settings. AHCCCS adjust capitation prospectively on a quarterly basis. For every 1% increase/decrease in placement percentage: Acute Care will increase/decrease .5% Case Management will increase/decrease .85%

29 Share of Cost Members are required to contribute toward the cost of their care based on their income and type of placement. Monthly capitation payment incorporates an assumed deduction for the share of cost (SOC). Program Contractor is responsible for collecting the SOC or delegating to the nursing facilities. Assumed SOC is fully reconciled to actual SOC annually. AHCCCS will recoup or refund the difference.

30 Reinsurance Reinsurance is a stop-loss program provided for the partial reimbursement of covered medical services beyond an annual deductible. AHCCCS is self-insured for the reinsurance program.

31 Reinsurance Prior to Oct. 1, 2001
Regular Reinsurance - acute inpatient hospitalizations Statewide Plan Deductible Deductible Enrollment w/Medi A w/o Medi A Coinsurance 0 - 1,999 $ 5,000 $ 9, % 2, $12,000 $20, %

32 Reinsurance Prior to Oct. 1, 2001
Reinsurance Types without Deductibles and with Coinsurance Percentages Catastrophic Reinsurance Hemophilia - 85% vonWillebrand’s Disease - 85% Gaucher’s Disease - 85% Transplants - 85% High Cost Behavioral Health/Traumatic Brain Injury - 75%

33 Reinsurance Effective Oct. 1, 2001
Reinsurance will cover both inpatient and all outpatient services including pharmacy. Catastrophic reinsurance - limits program contractor’s expenses to $97,500 per catastrophic case.

34 Eligibility Mandatory v. Voluntary Eligibility Determination
Member Issues Adverse Selection Critical Mass Eligibility Determination Financial Medical / Functioning

35 Capitation Cohorts Actuarial Broad v. Narrow ABD At Risk Duals
Larger bands Movement between categories Risk Placement ABD At Risk Duals Actuarial Conservative approach Acute LTC Annual Change

36 Benefit Design Behavioral Health HCBS Facility COB Payer last resort
Health Plan updates CM advocacy

37 Risk Adjustment / Reconciliation
Placement SOC Reinsurance Duals Data Encounter / Utilization Financials Negotiation v. Bid

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