Lynn A. Kovich, Assistant Commissioner
Raquel Mazon Jeffers, Deputy Director
March 27, 2012
The Comprehensive Waiver Application Overview &
Health Care Reform
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Why Do We Need a Waiver?2
Medicaid programs are matched – in part – with federal funding; all changes to the program must be approved before implemented
NJ has 8 Medicaid waivers (including CCW) for various programs/services; need to consolidate to reduce administrative burden
Medicaid grew in cost by 18% over 3 years; state must spend resources efficiently
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The Patient Protection and Affordable Care Act (PPACA), signed into law by President Obama in
March 2010, reshapes the nation’s health system. The law requires coverage of mental
health and substance use disorders in the minimum benefit package and the new Medicaid
expansion provision for childless adults up to 133% of Federal Poverty Level (FPL).
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The Patient Protection and Affordable Care Act
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Mental health and substance use disorder benefits must be “no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan…” and “there are no separate cost sharing requirements than are applicable only with respect to mental health or substance use disorders benefits.”
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Mental Health Parity and Addiction Equity Act
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What is a Comprehensive Waiver?
The Comprehensive Waiver is a collection of reform initiatives designed to:
sustain the program long-term as a safety-net for eligible populations
rebalance resources to reflect the changing healthcare landscape
prepare the state to implement provisions of the federal Affordable Care Act in 2014
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Comprehensive Waiver Development6
February 2011 - Governor Chris Christie calls for a Medicaid reform plan during FY’12 budget address
February 2011 to May 2011 – DHS, DHSS, DCF review every facet of the program, examine other states’ plans, look at every possible opportunity to improve and to reform
May 2011 - Waiver concept paper is released May 2011 to August 2011 - Extensive public input process August 2011 to September 2011 – Input is reviewed/concept
paper revised/waiver application drafted and finalized September 2011 - Waiver is submitted to CMS/posted on
DHS website January 25, 2012 – Final draft of Standard Terms and
Conditions submitted to HHS
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Waiver Highlights7
Model for reform and innovation
Streamlines program administration and operation
Preserves eligibility and enrollment
Does not include ER co-pay
Enhances and coordinates services to specialty
populations
Rewards efficiency in careThe full waiver application can be found online at:
www.state.nj.us/humanservices/dmahs/home/waiver.html
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The Details by Category8
WHAT DOES IT ALL MEAN?
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Need for Care Integration
Currently, BH care under Medicaid FFS is fragmented with an over-reliance on institutional, rather than community-based care
Consumers receive care through managed care organizations (MCOs) with limited or no formal protocols for coordination between medical and behavioral health delivery systems
Approximately two-thirds of Medicaid’s highest cost adult beneficiaries have MI and one-fifth have both MI and a substance use disorder
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Need for Care Integration (cont)10
Individuals with untreated substance use disorders have higher medical costs than those without such disorders, especially for emergency department visits and hospitalizations.
Generally, these individuals use about 8 times more healthcare services.
Similarly, families of untreated individuals with substance use disorders also have significantly higher medical costs than other families; up to 5 times more health care driven by hospitalizations, pharmacy costs and primary care visits. for example: children of alcoholics who are admitted to the
hospital average 62 percent more hospital days and 29 percent longer stays
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Some Interesting Facts11
National studies estimate that during a 1 year period up to 30% of the US adult population meets criteria for one or more MH problems, particularly mood (19%), anxiety (11%, and substance use (25%)
MH problems are 2 to 3 times more common in patients with chronic medical illnesses such as diabetes, arthritis, chronic pain, headache, back and neck problems and heart disease
Left untreated, MH problems are associated with considerable functional impairment, poor adherence to treatment, adverse health behaviors that complicate physical health problems and excess healthcare costs
Most MH treatment is provided in primary care settings, and the percentage provided solely in these settings is rapidly growing
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What Does Medicaid Waiver Mean for Behavioral Health Services?
Integrates behavioral health and primary care
Develops innovative delivery systems – MBHO, ASO
Supports community alternatives to institutional
placement
Braids funding
Provides opportunities for rate rebalancing
No-risk model transitions to risk-based model
Increased focus on SAI and consumers with
developmental disabilities
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Managed behavioral health systems are typically organized around the following processes or core functions
The state, providers, members, and the MBHO each have specific roles and responsibilities within these processes
These may vary based on what the state opts to delegate to the MBHO and what it retains
Some processes may not be delegated to the MBHO; (ie, verification of Medicaid eligibility)
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Roles and Responsibilities in a Managed Behavioral Health System
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Eligibility Network Development and ManagementAssessment and ReferralUtilization ReviewClaims AdministrationData AnalyticsCare ManagementQuality ManagementFinancial Management
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Roles and Responsibilities in a Managed Behavioral Health System
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Aspects of the Risk Model
Non-entitlement services remain non-risk
Advantages of going risk Greater budget predictability Greater flexibility
Rates Services Reinvestment
Aligned incentives
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Safeguards of the Risk Model
Federally mandated consumer protections in a risk model grievance procedures fraud and abuse civil and monetary penalties enrollee rights and must be informed and re-informed of rights quality assurance programs mandatory external Quality review prohibition against provider incentive to decrease care or tie
compensation to utilization decisions Other protections could include:
consumer bill of rights Post-stabilization requirements
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Waiver Impact on Access, Quality, Outcomes
State establishes policy and standards for: MBHO mission/vision to serve BH consumers MBHO performance Provider network participation and performance Consumer outcome indicators and related process measures
Allows for consumer and family participation in the design of access and quality standards and ongoing monitoring of performance and outcome
Per the ‘medical loss ratio’ provision, MBHO must spend majority of resources on care Sets minimum amount on services Limits maximum administrative spending Limits maximum profit to be earned Reinvestment in new capacity
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Delivery System Innovations
Uniform screening and level of care determination
Tiered care management
Behavioral health homes
Special initiatives MATI and DDD
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Bottom Line – Good News
Integrated care SA/MH and BH/PH
Opportunities for rate rebalancing
Increase FFP
Service expansion for SA services
Reinvestment of some savings
Reimbursement for community-based services
instead of acute care
Better access, enhanced quality, improved outcomes
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Stakeholder Involvement20
Stakeholder Involvement
DMHAS, in partnership with NJ Medicaid, have developed a stakeholder input process to: Inform the Department of Human Services’
values and vision regarding the design and implementation ASO/MBHO
Elicit broad stakeholder input regarding the design and development of the various components of the ASO/ MBHO
Initiate a targeted workgroup process to inform more detailed level components of the ASO/MBHO
Identify and leveraging opportunities under Health Care Reform to support a transformed system
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The Steering Group meets March 30, 2012 to discuss the Workgroup reports and advance it’s recommendations to DMHAS and DMAHS
The final Steering Committee report and recommendations will be completed and posted in April 2012
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Stakeholder Involvement
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What are the Next Steps?22
July 2012 – ASO/MBHO RFP Posted
January 2013 – RFP Awarded
January –April 2013- ASO/MBHO
Readiness Review
July 2013 – ASO/MBHO implementation
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Stakeholder Involvement23
Updates on the development of the MBHO and the Steering group can be found at: www.state.nj.us/humanservices/dmhs/home/mbho.html
To provide comment to DMHAS on the proposed changes to behavioral health services under the Waiver, email:[email protected]
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