Managed Care Organizations (MCO’s):

Partners in a State PASRR Program

The Delaware Experience

Presented by: Mary Murabito, RNNursing Supervisor, PASRR Unit

Delaware Division of Medicaid and Medical Assistance

Frank L. Tetrick, III, MAPASRR Technical Assistance Center

November 18, 2014

Webinar Focus Areas

Growth in Managed Care Organizations (MCO) in LTSS

Impact of MCO role on PASRR partnership model

The Delaware experience

History

Goals and objectives

MCO engagement strategies

Delaware lessons learned

Moving forward strategies

Fee for Service

Health care providers are paid for each service (like an office

visit, test, or procedure). States may develop their payment

rates based on:

The costs of providing the service

A review of what commercial payers pay in the private

market

A percentage of what Medicare pays for equivalent services

Managed Long Term Services

and Supports

(MLTSS) refers to the delivery of long term services and

supports through capitated Medicaid managed care

programs.

MLTSS offers States a broad and flexible set of program

design options, and may be used as an overarching structure

to promote initiatives such as Money Follows the Person,

participant-directed services, the Balancing Incentive

Program, etc.

MCO’s: A Growing Force in LTSS Care

• Growth of MCO in LTSS

• States including NF’s in the capitation

• Likely continued shift to NF’s in a comprehensive capitation managed care model

• Broader role of MCO’s in all areas: Resource CMS 2012 Managed Care Enrollment Report http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/medicaid-managed-care/medicaid-managed-care-enrollment-report.html

AZ

NC

WI NY

CA

21 States Had MLTSS as of 9/14

N

M

M

N

MI

IL

WA

KS

TN

TX

PA

FL

DE

MA

HI

RI

Contractors include private plans

Contractors are government- or provider-based

AZ

NC

WI NY

CA VA

OHIL

PA

TX

MN

MI

N

M

KS

TN

FL

NJ

Truven Health Analytics: October 1, 2014 Presentation to AHIP Conference on Medicaid.

MLTSS Programs Operating as of 10/7/14: Selected Characteristics

State and Program NF in Cap Rate?Persons in ICF or IDD waiver Enrolled? ICF/IID in Cap Rate? IDD Waiver in Cap Rate?

IDD Capitated Services Contractor

AZ ALTCS Yes Yes Yes Yes (1115) State IDD agencyCA MediConnect (duals) and MLTSS (Medicaid-only) Yes No

DE Diamond State Health Plan-Plus Yes No No NoFL LTC Managed Care Yes NoHI QUEST Integration Yes Yes No No

IL Integrated Care Program Yes No

IL Medicare-Medicaid Alignment Initiative Yes NoKS KanCare Yes Yes Yes Yes Health PlansMA Senior Care Options Yes NoMA One Care Yes No

MI Medicaid Managed Specialty Support and Services Yes Yes Yes Yes

County-based contractors with exclusive service areas.

MN Senior Health Options Yes, for the first 180 days (then FFS)No

MN Senior Care Plus Yes, for the first 180 days (then FFS)No

NJ FamilyCare MLTSS

Yes, for people newly eligible for NF after 7/1/14. (People in NFs on 7/1/14 remain FFS for 2 years) No

NM Centennial Care Yes Yes No No

NY MLTC Partial CapPending, subject to agreement with CMS No

NY MA Plus Yes No

NC MH/DD/SAS Waiver No Yes Yes YesQuasi-govt. entities with exclusive service areas.

OH MyCare Yes NoPA Adult Community Autism Program (ACAP) No Yes Yes Yes Autism providerRI Medicaid Integrated Adult Care in Rhody Health Options Yes NoTN CHOICES Yes No

TX Star+Plus Pending. Will be added 3/15. No

VA Commonwealth Coordinated Care Yes No

WI Family Care Yes Yes Yes YesCounty-based contractors.

WI Family Care Partnership Yes Yes Yes YesProvider-based contractors.

Data provided by Truven Health Analytics – permission required for any other use

LTSS Users in MLTSS Projected to

Double this Year

Year StatesLTSS

Enrollees

2004 8 105,000

2012 16 389,000

2013 19 554,000

2014 (projected) 21 1,170,000

Sources: 2004 and 2012: The Growth of MLTSS Programs: A 2012 Update

(Truven Health for CMS)

2013 and 2014: Truven Health estimates.

PASRR Partnership Roles and

Responsibilities – Then & Now

Traditional models suggest a hierarchical and silo’s approach to managing a process that is highly interdependent.

The emergence of MCO’s creates an opportunity to redefine the extended network that makes PASRR work.

PASRR Roles & Responsibilities

A Traditional Model

PASRR Technical Assistance Center -

PTAC

An Extended Network Model for

State PASRR Programs

PASRR Technical Assistance Center -

PTAC

The Individual

The Delaware Experience

Capitalizing on the MCO movement

to expand the PASRR Partnership

Where We Started

Prior to MLTSS

• Fragmented - Carved out of Managed Care

• Heavily institutional

• Limited options and choices

• Fee for Service

• Customer dissatisfaction

13

Community

Waivers,

3000

Nursing

Home

Populations,

3500

The Delaware MLTSS

Objectives

• Increase options for those who need Long Term Care

(LTC) by expanding access to Home and Community

Based Services (HCBS)

• Increase coordination of care and supports

• Create a budget structure that allows resources to shift

from institutions to community-based services

• Give consumers more choice and a greater voice

14

History: A Fast Timeline

2011 Start

February

• Kick Off

• Initial Steering Committee Meeting

March

• Program Design

• Communication Plan

April

• Governor's Commission

• System Design

15

2011 Steps

16

May

• MCO Discussions

June

• Application Submitted to CMS

• Stakeholder Communications thru December

Dec• CMS Waiver Approval

2012 – The Final Stretch

17

Jan

• Notification and enrollment of members

Mar• MCO Readiness Review

April• Program Implementation

The MCO’s

United Health Care

4/1/2012

Delaware Physician’s Care Inc. (Aetna)

4/1/12 – 12/31/14 (Participation ends on 12/31/14)

Highmark Blue Cross Blue Shield – Healthy Options

1/1/15

Managed / Integrated Long Term Care

Integrates Nursing Facility (NF) services and Home and

Community Based Services (HCBS) for the elderly and

adults with physical disabilities into the existing managed

care delivery system

What is Diamond State

Health Plan Plus?

19

Included Populations

• Nursing Home Residents

• Elderly and Disabled Waiver Participants

• AIDS Waiver Participants

• Other Full Duals (Medicaid / Medicare)

20

Benefit Comparison

Diamond State Health Plan• Acute Care Services• Inpatient Hospitalization• Outpatient visits• 30 day institutional care• Behavioral health• Limited case management• Limited durable medical

equipment

DSHP - Plus• Case management services• Nursing facility care• Assisted living care• Personal care services• Respite care• Day habilitation• Cognitive services• Consumer directed attendant

care• ADL Services• Nutritional supplement• Specialized durable equipment• Transition services• Behavioral health

MCO Engagement:

Delaware Division of Medicaid and Medical

Assistance MCO Strategies

Primary areas of interest that drove strategy

Avoid further silo of entities

Address providers concerns of managed care process and MCO’s

Reinforce existing efforts to improve the States PASRR process

Build greater collaboration amongst the extended PASRR network

Enhance specialized services efforts

PASRR Technical Assistance Center -

PTAC

Engagement Strategy:

Avoiding Silos and Hierarchical Model

Road show activities - Targeted to specific audiences (providers/NF/Hospitals/Physicians)

History

Direction

Opportunity to engage MCO’s

Q&A

PTAC consultant meetings with SMA/MHA/IDA/MCO’s

Focus on common objectives

Quarterly Pre-admission screening / MCO meetings

PASRR Technical Assistance Center -

PTAC

Engagement Strategy:

Reinforcing PASRR Activities and

Collaboration

Statewide PASRR Workgroup Meetings

• SMA/SMHA/SIDA/Division of LTC

Residents Protection

• Plan to move to quarterly calls

• New focus on “targeted strategic meetings”

PASRR Technical Assistance Center -

PTAC

New contract language is more specific to

specialized services:1. Emphasis on MCO coordination with SMHA,SIDA, NF,

providers on SS that are identified within the contract.

2. Emphasis on MCO “coordination” of SS that are not provided in

the benefit package.

3. MCO case manager ensures that PASRR is completed prior to

admission and RR addressed on significant change of status.

Emphasizing A Shared Commitment to

Specialized Services

Lessons Learned

Early engagement

Emphasis on partnership

Model the partnership

Bridge silos – shared ownership

Continued emphasis on quality reviews

Moving Forward in Delaware:

Strengthening PASRR

1. Several key principles for

strengthening the new PASRR

partnership.

2. Continued engagement with PTAC to

support Delaware efforts.

A Common PASRR Agenda

Work towards partnership developing a

common agenda for change, including a

shared understanding of the problem and

a joint approach to solving it through

agreed upon actions.

Common PASRR Progress Measures

Look for ways for consistent data collection

and measuring efforts across all the

participants and use data to help each entity

succeed in their unique efforts.

That we understand what’s working, what’s not

working, and most importantly: why?

Mutually Reinforcing Activities

That we maintain continuous

engagement and open dialogue that

creates a mutual support culture for all

PASRR partners.

Communications

That we maintain open and continuous

communication to build trust, assure

mutual objectives, and create common

motivation.

Backbone Organization

That we maintain a core of

knowledgeable and skilled people to help

us maintain our focus on continuous

improvement in our PASRR process.

Summary

1. MCO role in LTSS growth will continue

and early engagement in PASRR is

valuable.

2. Silo partnership model no longer represents

PASRR reality.

3. Addition of MCO’s creates opportunity to

strengthen all relationships and improve

states ability to divert and serve PASRR

eligible populations.

Contact Information

Mary Murabito: Mary.Murabito@state.de.us

PASRR Office: 302-424-7120

Frank L. Tetrick Frank.tetrick@pasrrassist.org

Cell:804-436-5836

Questions / Recommendations