1. Frye 1 Judith Frye Director, Center for Delivery Systems Development Wisconsin Department for Family and Health Services

2. Frye 2 Community-based Care in Wisconsin zBegan state funded Community Options Program (COP) in 1981 zCOP waiver for elders in 1985 zWaiver for Community Integration Program in 1983 zWaiver for Brain-injured in 1995

3. Frye 3 Long Term Care System Redesign - 1997 zConcerns about access, complexity and institutional bias zProcess involving hundreds of consumer family members, providers, and advocates zProposed a new Medicaid managed long- term care model

4. Frye 4 What is Family Care? zAging and Disability Resource Centers zA flexible long-term care benefit zCare Management Organization

5. Frye 5 Aging and Disability Resource Centers zOne-stop shopping for information about LTC zInformation and assistance zFunctional eligibility screening zChoice counseling

6. Frye 6 A Flexible Long-Term Care Benefit zTraditional waiver services including care management, community support, home modifications, nutrition, supportive home care, transportation zTraditional state plan services related to LTC including: nursing facilities, therapies, medical equipment and medical supplies

7. Frye 7 Care Management Organization zReceives a capitated rate for each member enrolled zEnrollment is voluntary, but waiver services are only available through CMO zMust accept all eligible individuals: yelders, persons with physical or developmental disabilities yfunctional limitations requiring long-term care yfinancially eligible

8. Frye 8 Care Management Requirements zInterdisciplinary team - social worker, nurse, other health professionals, caregiver, member zAssessment that determines what is needed to meet the outcomes the member prefers zManage all health care services including acute and primary care zApply methods for meeting needs and preferences in most cost-effective manner

9. Frye 9 State’s Role zSet capitated rate zOversee eligibility and enrollment process zAssure quality in the care provided

10. Frye 10 Analyzed Cost of Services yHistorical cost of waiver participants yHistorical cost of fee-for-services long-term care yHistorical cost of “new” enrollees

11. Frye 11 Developed Prospective Rate zApplied managed care discount zAdded administrative allowance zBlended target groups into a single rate

12. Frye 12 Adjusted Rate Retrospectively

13. Frye 13 New Rate Setting Methodology zUses encounter data zUses individual’s functional status

14. Frye 14 Milwaukee County “Case Mix”

15. Frye 15 Final Rate zCost of service zAdministrative allowance zRisk adjustment

16. Frye 16 Increased Enrollment zWaiver enrollment zWaiting list

17. Frye 17 Savings to Medicaid zAcute and primary services - $33 per member per month 2001 zNursing home diversions