1. 1Part 2

2.  Enrollment  Benefits  Usage  Cost sharing (co-pays)  Access  Quality  Accountability 2Part 2

3.  Dental  Medications  Transport  Behavioral health 3Part 2

4. 4

5. …bringing the biggest change in Medicaid since it began. 5Part 2

6. 6

7. 7

8.  Increase access  Control costs  Add benefits & protections  Address many smaller issues 8Part 2

9. 1. Insurance reform  Individual mandate 2. Exchanges + subsidies  Subsidies for those at 100% -400% of FPL 3. Medicaid expansion  For adults < 138% of FPL 9Part 2

10. Family of 1: $11,670x 133% =$15,521 Family of 4: $23,850x 133% =$31,721 2014 Federal Poverty Limit (FPL) 10Part 2

11. 11Part 2

12. 12Part 2

13. 13Part 2

14. 14Part 2

15. 15 “Old Eligibles”: FMAP = 50% “New Eligibles”: FMAP = 100%  90% Part 2

16. Change in Coverage in NJ under ACA (ages 0-64) 16Part 2

17. 17

18. 18Part 2

19. US0.72 WY1.43 AK1.40 DE1.00 PA0.73 CA0.56 NY0.43 NJ0.37 19Part 2

20. US0.72 WY1.43 AK1.40 DE1.00 PA0.73 CA0.56 NY0.43 NJ0.37 20Part 2

21. % doctors accepting 21Part 2

22. But…  For PCPs only  Family practitioners  Internists  Pediatricians  = 1.00!  Only for 2013, 2014  Also for managed care 22Part 2

23.  “Accountable Care Organization” 23Part 2

24.  Why?  Eligibility changes  Service benefit additions  Payment criteria changes  Waivers for…?  Medicaid ACOs ▪ Define scope ▪ Define new roles ▪ Build capacity ▪ Include high-cost groups ▪ Multi-payer alliances  Payment models  Measurements 24Part 2

25. Getting it all together 25Part 2

26.  “Division of Medical Assistance and Health Services”  $11 billion (federal and state)  500 people  Director: Valerie Harr  (“NJ FamilyCare”) 26Part 2

27.  Required by Section 1902(a) (30)(A)  71 elements  Rates  Methodology  Comment periods 27Part 2

28.  Section 1115  Research and demonstration  Section 1915(b)  Managed Care  Section 1915(c)  Home and Community Based  Concurrent 1915(b) & (c) …for more “flexibility” 28Part 2

29.  Health homes  2010: NJ Public Law 2012, Chapter 74  3 year Medicaid Medical Home demonstration project  Section 2703 of ACA  Accountable Care Organizations (ACO)  2011: NJ Public law 2011, Chapter 114  Medicaid Accountable Care Organization demonstration project. 29Part 2

30. KEEP…  Mandated services  Choice of plans  “Actuarially sound” rates ADD…  …“Risk-based” payments 30 LOSE… Part 2

31. 31Part 2

32.  Section 1115  Research and demonstration  Section 1915(b)  Managed Care (Mandatory)  Section 1915(c)  Home and Community Based  Concurrent 1915(b) & (c) 1. Childless adults 2. Family coverage (SCHIP)  ACOs 3. NJ Care 2000+ 4. NJ Family Care  BH ASO 5. Global Options (LT care) 6. Renewal Waiver 7. Community Resources 8. Community Care Alternatives 32Part 2

33.  Section 1115  Research and demonstration  Section 1915(b)  Managed Care (Mandatory)  Section 1915(c)  Home and Community Based  Concurrent 1915(b) & (c) 1. Childless adults 2. Family coverage (SCHIP)  Accountable Care (ACO) 3. NJ Care 2000+ 4. NJ Family Care  Behavioral Health (ASO) 5. Global Options (LT care) 6. Renewal Waiver 7. Community Resources 8. Community Care Alternatives 33Part 2

34.  Section 1115  Research and demonstration  Section 1915(b)  Managed Care (Mandatory)  Section 1915(c)  Home and Community Based  Concurrent 1915(b) & (c) 1. Childless adults 2. Family coverage (SCHIP)  Accountable Care (ACO) 3. NJ Care 2000+ 4. NJ Family Care  Behavioral Health (ASO) 5. Global Options (LT care) 6. Renewal Waiver 7. Community Resources 8. Community Care Alternatives 34Part 2

35.  Section 1115  Research and demonstration  Section 1915(b)  Managed Care (Mandatory)  Section 1915(c)  Home and Community Based  Concurrent 1915(b) & (c) One Comprehensive Waiver 35Part 2

36.  One already exists!  In DCF: “CSOC”  40,000 kids  Phase in risk-based over 5 years Administrative Services Organization 36Part 2

37. 37Part 2

38. 38Part 2

39. 39 “Benchmark” coverage under ACA Part 2

40. 40 “Benchmark” coverage under ACA Excludable for newbies under ACA Part 2

41. 41Part 2

42. US0.72 WY1.43 AK1.40 DE1.00 PA0.73 CA0.56 NY0.43 NJ0.37 42Part 2

43. % doctors accepting 43Part 2

44.  100%!  …for PCPs and those they supervise…  …even in managed care…  …even for dual eligibles.  Result: 10-24% increase in accepting PCPs? BUT:  Not for specialists (e.g., psychiatrists)  Only for 2013 and 2014  Extend? Measurement will be key… 44Part 2

45.  Overlap!  Medicaid: < 138% FPL.  Exchanges: > 100% FPL.  Partial expansion? All > 100% to exchanges, where no state funding needed…  HHS: 100% FMAP if states do partial? NO! 45Part 2

46.  Overlap!  Medicaid: < 138% FPL.  Exchanges: > 100% FPL.  Partial expansion? All > 100% to exchanges, where no state funding needed…  HHS: 100% FMAP if states do partial? NO! 46Part 2

47.  Overlap!  Medicaid: < 138% FPL.  Exchanges: > 100% FPL.  Partial expansion? All > 100% to exchanges, where no state funding needed?…  NO! HHS: no 100% FMAP if states do partial 47Part 2

48. Wages  Medicaid  Exchanges: 35% of all adults below 200% FPL  Exchanges  Medicaid: 28 million p.a.? 48Part 2

49. 234,000 total eligibles FMAP = 100% New eligibles vs. old eligibles not enrolled 49 Part 2

50.  HEDIS: measure behavioral health?  Healthcare Effectiveness Data and Information Set  System metrics, not consumer metrics 50Part 2

51.  Publicity hurdles  150 different languages in NJ  Cultural differences  Application hurdles  Multipage application  Documentation of income and residency  Tracking hurdles  ACA does not apply to incomes < IRS tax filing threshold ($9,350 for singles, $18,700 for joint)  = 50% of eligible uninsureds 51Part 2

52. South Carolina’s IT Enterprise Strategy Map 52Part 2

53.  ASO: July 1, 2014!  “Managed care”, but…  Fee for service  “Live”: January 1!  Medicaid Expansion  Exchanges 53Part 2

54.  Reporting  Documentation  Audits  Clawbacks  Penalties 54Part 2

55.  Reduced fees  Increased costs  New investments  EMR  Compliance  Training 55Part 2

56. 56Part 2

57. 57Part 2

58. 58Part 2

59. Access Availability Quality Cost Innovation 59Part 2

60. 60 EnrolledTo be enrolledNot enrolled Access Availability Quality Cost Innovation   Part 2

61.  To the System  To Providers  To PsyR services  (To Insurance…) 61Part 2

62.  Of basic care  Of specialty care  Of emergency care  Of evidence-based practices 62Part 2

63.  Provider  What level?  What training?  What experience?  What supervision?  Process  Simpler?  Smoother? 63Part 2

64.  Co-pays  Deductibles  Premiums  (Work incentives?) 64Part 2

65.  Practices  Medications  Technology  Management 65Part 2

66. 66Part 2

67. 67 EnrolledTo be enrolledNot enrolled Access   Availability  Quality   Cost    Innovation      Part 2

68. 68Part 2

69. 69Part 2

70. 70Part 2

71. 71Part 2