1. New Jersey’s Health System Advancing Integration for Dual Eligibles
Karen L. Brodsky
Chief of Managed Care Contracting
Division of Medical Assistance & Health Services
New Jersey Department of Human Services
October 1, 2013

2. NJ FamilyCare Enrollment
Total Medicaid/SCHIP – 1.3 m
Dual enrollment – 173,920 (13%)
Medicaid managed care enrollment – 1.2 m (90%)
D-SNP enrollment – 26,213 (12% of duals in managed care)
Dual enrollment – 140,464 (81% of all duals in NJ)
September 2013

3. Medicaid Managed Care Plans Serving Duals
Amerigroup 16,807
Healthfirst NJ 9,026
Horizon NJ Health 52,385
UnitedHealthcare 36,033
TOTAL ,251
September 2013

4. NJ D-SNP Plans Serving Duals
Amerigroup 2,435
Healthfirst NJ 4,693
Horizon NJ Health 9,473
UnitedHealthcare 9,612
TOTAL 26,213
September 2013

5. NJ Developments for Duals
Voluntary managed care enrollment
Sept 2011
Mandatory managed care enrollment
October 2011
Dual SNPs
January 2012
Managed long term services and supports
July 2014

6. Regulatory Steps
1915b waiver for mandatory enrollment of duals into managed care
Medicaid managed care contract amendment
MIPPA contract to provide Medicaid wrap services in the D-SNP, approval
Comprehensive Medicaid Waiver (1115) approval

7. TPL issues that surfaced with mandatory managed care
Provider selection
Who is the member’s PCP?
Referrals for Medicaid-only benefits

8. TPL Issues, continued Balance billing Crossover claims process
Medicaid obligation
When is balance billing a dual okay?
Minimizing a beneficiary’s out-of-pocket costs
Medicare provider options

9. Clear Communications with mandatory managed care for duals
TPL Guide
Client notification letters
Client and Provider FAQs
Focused flyers
Medicaid HMO mailings
Public forums with stakeholders
Website

11. Member ID Card Issues Which Member ID card should a dual use?
What PCP name should be printed on the Member ID card?

12. Strategic Dual Integration Opportunities (Slide 1)
Readiness reviews for D-SNPs, MLTSS, behavioral health
Passive enrollment from MMC to D-SNP
Eliminate cost shifting for costliest services
Medicare Advantage SNP-specific Star Ratings

13. Strategic Dual Integration Opportunities (Slide 2)
Include Medicare deeming in Model of Care to avoid hidden EQRO costs to state
Overlap of MMC/D-SNP contract time periods and State/Federal budget years
Remove EOC conflict between Rx copay and LIS rider
SNP Star Ratings

14. Operational Dual Integration Opportunities (Slide 1)
Eligibility & Enrollment/Disenrollment Procedures
Marketing review
Care management
Streamlining the appeals process and integrated denial notice

15. Operational Dual Integration Opportunities (Slide 2)
Quality standards & monitoring
Provider network analysis
Ensuring members get one EOB and member handbook
Integrate provider manual
Close-out procedures

18. Contact Information
Karen L. Brodsky
Chief of Managed Care Contracting
Division of Medical Assistance and
Health Services
New Jersey Department of Human Services
Elizabeth Wood
Director of Dual Integration
Division of Medical Assistance and Health Services