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

MLTSS – Current Situation MLTSS grew significantly between 2004 and 2012. 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

MLTSS – Pennsylvania Situation June 2015 - DHS released a “Managed Long-Term Services and Supports (MLTSS) Discussion Document This began the stakeholder input process September 2015 - 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

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.

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

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

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.

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

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

Questions?

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.

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

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)

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

Pennsylvania Medicaid Managed Care Zones

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

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

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

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

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

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).

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

Questions?

Organization Transformation An Opportunity to Grow and Diversify

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

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?

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

Perform SWOT Analysis

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

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

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!

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). 2014. Community-Based Organizations and MLTSS: An Issue Brief to Assess CBO Readiness. National Association of States United for Aging and Disabilities (NASUAD). 2014. www.dhs.pa.gov