“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System AHCCCS Update Meeting September 19, 2012 Shelli Silver

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 2 CRS Medical Eligibility Determination  Effective October 1, 2013, AHCCCS will determine medical eligibility for CRS  AHCCCS adopted new Rules effective August 1, 2012, as directed by the Legislature - Chapter 13  Diagnoses that qualify for CRS did not change; attempted to clarify gray areas  Must be in active treatment for CRS condition

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 3 CRS Medical Eligibility Determination  Initial enrollment requires applicant/member under age 21  Option at 21 to remain with CRS; one chance  Member will be enrolled with CRS Contractor the day the medical eligibility is determined positive for CRS  Enrollment with CRS will NOT be delayed until after discharge from inpatient stay

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 4  AHCCCS will manage all communication/ processes related to eligibility determination  AHCCCS will not: Locate staff at clinics Assign members to clinics Assist with scheduling Assist with initial service plan Etc. CRS Medical Eligibility Determination

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 5 Capitation Rate Notes  All cap rates to be amended effective 1/1/13: PCP Medicare rate parity Part D changes  DDD & BHS to be amended effective 4/1/13: State mandated provider rate increase  EPD – new rate to be added in CYE 13: NF provider assessment supplemental payments

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 6 Capitation Rate Notes (continued)  Acute cap rates include a $6.6 million downward adjustment to recognize savings generated by transitioning procedures performed in hospital outpatient settings to more cost-effective Ambulatory Surgical Centers (ASC)  Savings are achievable by increasing ASC service utilization by 20% statewide

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 7  Laws 2012, Chapter 213 created a Nursing Facility (NF) provider assessment effective 10/1/2013  Tax revenues will be used as State match to draw down Federal funds  AHCCCS and its Contractors will make supplemental payments to NFs based on calculations performed by AHCCCS Nursing Facility Provider Assessment/ Supplemental Payments

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 8  Pending CMS approval, EPD Contractors will receive quarterly capitation payments under a newly created rate code  The new rate code will only be used to make NF supplemental payments  AHCCCS will provide supplemental payment information to Contractors Nursing Facility Provider Assessment/ Supplemental Payments (continued)

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 9  Contractors will provide confirmation of payments to AHCCCS  Supplemental payments may have to be reconciled; if that occurs: AHCCCS will establish a new reconciliation with Contractors Contractors will pay to/recoup from NF providers Nursing Facility Provider Assessment/ Supplemental Payments (continued)

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 10 Reconciliations – CYE 13  Acute Care: PPC reconciliation continues Non-MED reconciliation continues Prospective Tiered reconciliation continues  CRS Tiered reconciliation is added  EPD – no change

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 11 PCP Rate Parity  Affordable Care Act (ACA) requires Medicaid to reimburse certain primary care providers who provide primary care and vaccine admin services at specified rates  Mandate is effective January 1, 2013, though the final Federal regulation is not expected until November 2012  AHCCCS is currently working to implement provisions of May 2012 draft rule

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 12 PCP Rate Parity (continued)  Providers must be board certified in one of the specialties or sub-specialties, or must bill at least 60% of specified services for AHCCCS members  Providers without board certification and/or new to AHCCCS (with no utilization history) will either have to be paid at the new rates and reconciled later if they don’t meet the standard, or paid at the current rates and reconciled later if they do meet the standard

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 13 PCP Rate Parity (continued)  Per the draft rule, physician extenders practicing independently do not qualify for rate parity  Certain codes not covered by Medicare will be eligible for rate parity  Outstanding questions on codes TBD  Final rule could make significant changes, or not, jeopardizing ability to meet effective date

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 14 Medicare Part D Changes  Also effective January 1, 2013, Medicare Part D will cover: benzodiazepines for any condition, and barbiturates used for the treatment of epilepsy, cancer or chronic mental health conditions  Contractors will no longer be permitted to pay for these drugs/uses for dual members even if a dual member is not enrolled in a Part D plan

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment System 15 Medicare Part D Changes (continued)  Contractors will also be prohibited from making cost-sharing payments for dual eligible for these medications/uses  Contractors shall: Notify affected members of this change in coverage 30 days prior to January 1, 2013 (using AHCCCS-provided notices) Evaluate requests for these medications/uses and, when denied, notify members of appeal rights