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THE NJ DEPARTMENT OF HUMAN SERVICES SEPTEMBER 2011 Comprehensive Waiver Application Overview.

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Presentation on theme: "THE NJ DEPARTMENT OF HUMAN SERVICES SEPTEMBER 2011 Comprehensive Waiver Application Overview."— Presentation transcript:

1 THE NJ DEPARTMENT OF HUMAN SERVICES SEPTEMBER 2011 Comprehensive Waiver Application Overview

2 What is a Comprehensive Waiver? 2 The Comprehensive Waiver is a collection of reform initiatives designed to: sustain the program long-term as a safety-net for eligible populations rebalance resources to reflect the changing healthcare landscape prepare the state to implement provisions of the federal Affordable Care Act in 2014 NJ-DHS 9-2011

3 Why Do We Need a Waiver? 3 Medicaid programs are matched – in part – with federal funding; all changes to the program must be approved before implemented NJ has 8 Medicaid waivers (including CCW) for various programs/services; need to consolidate to reduce administrative burden Medicaid grew in cost by 18% over 3 years; state must spend resources efficiently NJ-DHS 9-2011

4 Comprehensive Waiver Development 4 February 2011 - Governor Chris Christie calls for a Medicaid reform plan during FY12 budget address February 2011 to May 2011 – DHS, DHSS, DCF review every facet of the program, examine other states plans, look at every possible opportunity to improve and to reform May 2011 - Waiver concept paper is released May 2011 to August 2011 - Extensive public input process August 2011 to September 2011 – Input is reviewed/concept paper revised/waiver application drafted and finalized September 2011 - Waiver is submitted to CMS/posted on DHS website NJ-DHS 9-2011

5 Stakeholder/Public Input 5 Support for: Structural reform Enhanced services for underserved populations Preserving eligibility criteria Reinvestment of savings into community-based services Opposition to: Freezing AFDC/TANF+ parent population ER co-pay for non- emergency visits NJ-DHS 9-2011

6 Waiver Highlights 6 Model for reform and innovation Streamlines program administration and operation Preserves eligibility and enrollment Does not include ER co-pay Enhances and coordinates services to specialty populations Rewards efficiency in care NJ-DHS 9-2011

7 The details by category NJ-DHS 9-2011 7 WHAT DOES IT ALL MEAN?

8 What does Medicaid Waiver mean for Behavioral Health services? Integrates behavioral health and primary care Develops innovative delivery systems – MBHO, ASO Supports community alternatives to institutional placement Braids funding Provides opportunities for rate rebalancing No-risk model transitions to risk-based model Increased focus on children, SAI and consumers with developmental disabilities NJ-DHS 9-2011 8

9 Why the focus on BH/SA? The merger of DMHS and DAS into DMHAS lays the foundation to build a combined system that provides best practice treatments for individuals with co-occurring mental illness and substance use disorders. To improve access to appropriate physical and BH care services for individuals with MI/SA To better manage holistic care for individuals with co- occurring BH/PH conditions To improve health outcomes and consumer satisfaction NJ-DHS 9-2011 9

10 Eligibility Criteria Medicaid enrollees with MI/SA who meet the states definition of medical necessity for one or more covered BH service Two exceptions: Dual eligibles enrolled in a Special Needs Plan (SNP)/MCO Medicare BH benefits will be carved into the SNP/MCO Medicaid BH benefits will be carved out to the ASO/MBHO Coinsurance and deductibles associated with BH benefits are carved into the SNP Medicaid eligible members in a NF LOC or in a home and community-based waiver under managed LTC, administration of BH services will be carved into the LTC plan NJ-DHS 9-2011 10

11 Need for Care Integration Currently, BH care under Medicaid FFS is fragmented with an over-reliance on institutional, rather than community- based care Consumers receive care through managed care organizations (MCOs) with limited or no formal protocols for coordination between medical and behavioral health delivery systems Approximately two-thirds of Medicaids highest cost adult beneficiaries have MI and one-fifth have both MI and a substance use disorder. NJ-DHS 9-2011 11

12 Delivery System Innovations 12 Clinical Service Model: Uniform screening and assessment The SAMHSA 4-quadrant model ASO/MBHO clinical role Behavioral health homes, Accountable Care Organizations Special initiatives NJ-DHS 9-2011

13 Managed Behavioral Health Administrative services organizations (ASO) or managed behavioral health organizations (MBHO) provide improved access, quality outcomes, better distribution of services across the care continuum. These organizations have extensive experience with the BH population, including individuals dually diagnosed with intellectual and developmental disabilities (I/DD) and BH Coordinate services to the seriously mentally ill (SMI) and severely emotionally disturbed (SED) populations Integration of MH/SA services NJ-DHS 9-2011 13

14 MBHO/ASO Assignment The MBHO will be responsible for developing and managing the adult BH service delivery system The ASO will share responsibility with the state for developing and managing the childrens BH service delivery system Improved access Improved quality Greater value Sustainability NJ-DHS 9-2011 14

15 MBHO/ASO Member Services 24 hour toll free information and referral line MBHO will coordinate with the PERS system for adult consumers, including providing education and technical assistance to the crisis centers about consumer needs, model programs and best practices The childrens ASO will manage a 24-hour crisis response system, including dispatch of mobile crisis response teams consistent with the currently approved NJ State Plan The MBHO will be responsible for adjudication of all BH claims delivered by the specialty BH network, including contracted MBHO providers and out-of-network BH providers needed to meet the special needs of enrollees The MBHO may eventually be paid on an at-risk basis NJ-DHS 9-2011 15

16 MBHO/ASO Administrative Role Network Credentialing and Contracting – NJ will set reimbursement rates for BH network services until such time that the MBHO assumes full risk The MBHO/ASO will provide technical assistance to the state on reimbursement rates and appropriate use of financial and non-financial incentives for improved outcomes Network Development – the MBHO/ASP will assist the state with network development, including technical assistance to new providers regarding enrollment in Medicaid Management Information Systems (MIS) and Electronic Exchange Data - MBHO/ASO will establish and maintain a MIS that allows the MBHO and its subcontractors to collect, analyze, integrate and report data on service utilization, service costs, claim disputes, appeals and clinical and financial outcomes Financial Management and Reporting – establish a process for tracking service utilization and cost by funding source and provide regular reports in compliance with state and federal reporting requirements NJ-DHS 9-2011 16

17 Community vs. Hospital based Care Behavioral health care will be delivered through an administrative services organization (ASO) Begins January 2013 Uniform screening and assessment Behavioral health homes/case management/risk model Reliance on community-based settings Manage Medicaid funding, block grant and state-only dollars NJ-DHS 9-2011 17

18 Waiver Impact on Access, Quality, Outcomes State sets client outcome benchmarks for MBHO and performance measures for network participation Allows for consumer and family participation in the design and ongoing monitoring of access and quality outcomes Per the medical loss ratio provision, MBHO must spend majority of resources on care Sets minimum amount on services Limits maximum administrative spending Limits maximum profit to be earned Reinvestment in new capacity NJ-DHS 9-2011 18

19 Aspects of the Risk Model Non-entitlement services remain non-risk Increased opportunities for Medicaid reimbursement for the first 30-days of community-based residential treatment services - individuals age 22 to 64 Increased ability to capture savings generated from improved, coordinated BH services Greater assurance of meeting budget neutrality projections through capitation MBHO has more flexibility to develop new services Provides incentives for clients to be served in the least restrictive and least costly level of care NJ-DHS 9-2011 19

20 Bottom Line – Good News Integrated care SA/MH and BH/PH Opportunities for rate rebalancing Increase FFP Service expansion for SA services Reinvestment of some savings Reimbursement for community-based services instead of acute care Better access, enhanced quality, improved outcomes NJ-DHS 9-2011 20

21 Expected Challenges Timely communication Consumer involvement to ensure ease of access IT infrastructure Moving from non-risk to risk Managing eligibility and enrollment Coordination between MBHO and MCO Defining outcome measures to gauge performance NJ-DHS 9-2011 21

22 What are the next steps? 22 Federal review of the waiver application Informal and formal communications with CMS on waiver elements CMS submits waiver questions NJ responds to CMS questions CMS/NJ negotiations Waiver approval/denial NJ-DHS 9-2011

23 What is the tentative timeline for implementation? 23 January 2012 – SNPs offered, expanded support to I/DD July 2012 – managed LTC, streamlined eligibility for LTC support July 2012 – BH services to children expand January 2013 – managed BH organization implementation NJ-DHS 9-2011

24 More information 24 The full waiver application can be found online at: Comments can be emailed to NJ-DHS 9-2011

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