1 University of Maryland Center on Aging Medicare/Medicaid Integration Program July 8, 2004 University of Maryland Center on Aging Medicare/Medicaid Integration Program July 8, 2004 The Arizona Long Term Care System (ALTCS)

2 AHCCCS’ Mission and Vision Mission: Reaching across Arizona to provide comprehensive, quality health care for those in need. Vision: Shaping tomorrow's managed health care from today's experience, quality, and innovation.

3 The Arizona Long Term Care System HistoryHistory CurrentSystem Current System FutureFuture

4History July 13, 1982: The Health Care Financing Administration (HCFA), which is now the Centers for Medicare & Medicaid Services (CMS) granted Arizona an 1115 Research Waiver. October 1, 1982: The Arizona Health Care Cost Containment System (AHCCCS) began serving people in its acute care program. Arizona was the first state to implement a statewide, Medicaid managed care system, based on prepaid, capitated arrangements with health plans.

5History The following long term care services were excluded with approval of the 1115 Waiver: –Skilled Nursing Facility Services to certain categorically needy individuals –Home Health Care Why wasn’t long term care covered in the initial Arizona 1115 Waiver? –Acute care was the main concern –Needed to stabilize acute care program first

6History Arizona in December 1986: –New Governor –Feds requested that AHCCCS add long term care or behavioral health services –Long term care was a responsibility of the counties –Home and community based programs existed –Opportunity to refinance

7History December 1988: AHCCCS began phasing-in long term care services for persons who were Developmentally Disabled (DD) January 1989: AHCCCS began serving the Elderly and Physically Disabled (E/PD) Home and community based services were limited to a maximum expenditure of 5% of the State’s long term care expenditures for long term care services.

8HistoryCounty Involvement: Then and Now In the Beginning: –Maricopa County –Pima County A Few Years Later: –Yavapai County –Pinal County –Cochise County  1 Plan per County, except Today: –Maricopa Long Term Care Plan –Pima Health System –Yavapai County Long Term Care –Cochise Health Systems –Pinal/Gila Long Term Care –Evercare Select –Mercy Care Plan  3 Plans in Maricopa County

Policy Eligibility (Special Populations) Contract for Care Monitor Care and Financial Viability Information Services Budget and Claims Processing Legal Intergovernmental Relations Payors ($2 Billion) HCFA State County Private º Foundation º Premiums Acute health plans LTC program contractors State Agencies º DHS · Behavioral Health · CRS º DES · DDD · Foster Children · Eligibility AHCCCS Administration Single State Agency FFS ° Indian Health Services ° Emergency Services (non-qualified immigrants) ° LTCS members enrolled with Tribes/NACH Payors: $2.8 Billion (Appropriated) $3.4 Billion (Appropriated & Non-Appropriated) Delivery System Product Lines Acute Care KidsCare Long Term Care Healthcare Group Premium Sharing Current System

10 Current System Who Does AHCCCS Serve?

Current System ALTCS Elderly and Physically Disabled (EPD) Only (3/01/2003) (Excludes Tribal Enrollment) Total: 21,969 NF: 38.6% Own Home: 44.7% Alt. Res.: 14.7% Other: 2.0%

12 Current System ALTCS Principles: –Prepaid, capitated approach through public/private partnerships. –Integrate all long term care services by bundling acute care, long term care, case management, and behavioral health services. –Pre-admission screening process to identify those at risk for institutionalization. –Full continuum of services to ensure members are placed in least restrictive, most cost-effective care. –Primary care physicians/case managers serve as gatekeepers to coordinate care.

13 Current System AHCCCS Health Plan Responsibilities: –Contract for Services –Develop and Ensure Adequate Network –Active Monitoring and Oversight –Case Management –Quality and Utilization Management –Integration of Medical Care –Member and Family Support –Pay Claims and Process Encounters –Grievance and Appeals

14 Current System What Makes ALTCS Work: –Pre-admission screening (PAS) –Integrated continuum of care / choice of community settings –Network standards –Ability for members to move between settings without interruption in services –Case management standards –HCBS financial incentives to health plans –State oversight (Contract, Network, Finance, QM, CM, Annual Reviews, Technical Assistance) –Good communication between State and health plans

15 ALTCS Health Plan DES-DDD EPD Contractors Maricopa LTC Plan Pima Health System Evercare Select Mercy Care Tribes Yavapai County LTC Pinal Gila LTC Cochise Health System Financial/Medical Eligibility 1.Citizen/Qualified Alien 2.AZ Resident 3.$2,000/$3,000 Resources 4.$1,692 Income Maximum 1 5.Transfer of Resources 6.SSN 7.Medical Eligibility/PAS PCP/ CASE MANAGER Covered Services Acute Care Services Nursing Facility ICF/MR Hospice Behavioral Health HCBS - Homemaker- Transportation - Personal Care- Adult Day Health - Respite Care- Home Delivered Meals - Attendant Care- DD Day Care - Home Health Nurse- Habilitation - Home Health Aide- Assisted Living Facilities Potential ALTCS Member 2,300 Applications/Month KEY EPD -Elderly & Physically Disabled (Age 65+, Blind or Disabled) DES/DDD Dept. of Economic Security, Div. Of Developmental Disabilities ICF/MR -Intermediate Care Facility for Mental Retarded NF -Nursing Facility PAS -Pre Admission Screening 1 Income Limit is 300% of SSI maximum and increases annually in January ALTCS Model Current System

16Future Future: –Coordination of care for dual eligibles. –Revamping of the Medicare and Medicaid programs. –A better system to help individuals understand and retrieve information on choices and options. –Ability to continue expansion of HCBS. This will create a need for more monitoring by plans. –Continued growth and impact on budget. –Federal law allowing people to shelter income and create annuities. –A closer look at including LTC insurance in employer benefit plans paid for by employees.