NJ FamilyCare Update

Transcription

1 NJ FamilyCare Update Valerie Harr Deputy Commissioner New Jersey Department of Human Services Home Care and Hospice Association of New Jersey June 22, NJ FamilyCare Covered Populations Parents/caretakers and their dependent children Pregnant women Single Adults Childless Couples Aged, Blind, Disabled 2 1

2 1998 6/15/2017 History of Managed Care /2017 s Since 1982, DMAHS has provided a voluntary managed care program as an alternative to the traditional fee-for-service (FFS) program. Mandatory managed care for AFDC/TANF and AFDC-related (low-income) Medicaid eligibility categories (SOBRA expansion groups), (Section 1915(b) waiver) County phase-in for non-institutionalized Aged, Blind or Disabled (ABD) beneficiaries without Medicare 95.3% of NJ FamilyCare beneficiaries are enrolled in managed care SCHIP mandatory managed care. Children enrolled in Parents and adults without dependents began enrollment in 2001 NJ FamilyCare Health Plans 4 2

3 NJ Total Population: 8,935,421 1,784,347 Total NJ FamilyCare Enrollees (May, 2017) 862, % % of New Jersey Population Enrolled (May, 2017) Children (Age <21)Enrolled (about 1/3 of all NJ children) Sources: Total New Jersey Population from U.S. Census Bureau 2016 population estimate at NJ FamilyCare enrollment from monthly eligibility statistics released by NJ DMAHS Office of Research available at 5 May 2017 Eligibility Summary Expansion Adults 561, % Other Adults 108, % Medicaid Children 702, % CHIP Children 113, % Aged/Blind/Disabled 299, % Source: Monthly eligibility statistics released by NJ DMAHS Office of Research available at Notes: Expansion Adults consists of ABP Parents and ABP Other Adults ; Other Adults consists of Medicaid Adults ; Medicaid Children consists of Medicaid Children, M- CHIP and Childrens Services ; CHIP Children consists of all CHIP eligibility categories; ABD consists of Aged, Blind and Disabled. 6 3

4 Millions 6/15/2017 NJ FamilyCare Overall Enrollment May May May May May Dec ACA Expansion Baseline 1.2 Jan-13 Jan-14 Jan-15 Jan-16 Jan-17 Source: Monthly eligibility statistics released by NJ DMAHS Office of Research available at Note: Includes all recipients eligible for NJ DMAHS programs at any point during the month 7 NJ FamilyCare Enrollment Breakdowns Total Enrollment: 1,779,971 By Program By Plan By Age By Gender By Region M-CHIP XXI Aetna WellCare FFS Ameri- Group United Male South Central XIX HZN 0-18 Female North Source: NJ DMAHS Shared Data Warehouse Snapshot Eligibility Summary Universe, run for December Notes: By Region: North= Bergen, Essex, Hudson, Morris, Passaic, Sussex & Warren. Central= Hunterdon, Mercer, Middlesex, Monmouth, Ocean, Somerset & Union. South= Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester & Salem. Region does not add up to total enrollment due to small unknown category that is not displayed. *M-CHIP: Individuals eligible under Title XIX, but paid with CHIP (Title XXI) federal funds. 8 4

5 New Jersey Demographics: Age 60 and Older 9 Basic Demographics in 2014 New Jersey s population was 8,938,175 in 2014 with 1,843,602 (20.6%) age 60 and older Women accounted for 56% of the population, aged 60 years and older and 67% of the population, age 85 and older Between 2010 and 2014, people aged 60 years and over exceeded 28% of Ocean County s population and 31% of Cape May s population. Hudson County had the smallest share of this demographic at just 15.3%. Source: US Census Bureau 10 5

6 Age Groups by County Source: US Census Bureau Summary File 1 (2010) 11 Older Adults (60+) as a Percentage of County Population Cape May Ocean Salem Bergen Atlantic Warren Monmouth Burlington Morris Hunterdon Camden Sussex Mercer Gloucester Cumberland Union Somerset Middlesex Passaic Essex Hudson 0% 5% 10% 15% 20% 25% 30% Source: US Census Bureau Summary File 1 (2010) 12 6

7 Age Structure Population pyramids Age groups represented by horizontal bars wider bars = more people Youngest at base Females on left Note the Baby Boom, Baby Bust, Echo Boom, contraction, gender imbalance beginning in 60 year olds < 5 New Jersey Gender/Age Group Distribution (2010) Baby Boom Boomers were 46 to 64 years old in Shockwave or Pig in the Python. Gen X: Born 60 s 80 s (30-50). Gen Y or Millennials: Born Late 70 s to early 2000 s (Age 10-30). (400,000) (300,000) (200,000) (100,000) - 100, , , ,000 Source: US Census Bureau Summary File 1 (2010) 13 Variation from County to County Hudson County Gender/Age Group Distribution (2010) Ocean County Gender/Age Group Distribution (2010) Cape May County Gender/Age Group Distribution (2010) < 5 (40,000) (20,000) - 20,000 40, < 5 < 5 (40,000) (20,000) - 20,000 40,000 (6,000)(4,000)(2,000) - 2,000 4,000 6,

8 Comprehensive Medicaid Waiver Renewal Update 15 WHAT IS AN 1115 WAIVER AND WHY DOES NEW JERSEY NEED TO SUBMIT A RENEWAL? The New Jersey 1115 Comprehensive Medicaid Waiver Demonstration is a Research and Demonstration waiver granted by the Centers for Medicare and Medicaid Services (CMS) under Section 1115(a) of the Social Security Act (SSA). Demonstrations under Section 1115 of the SSA give states flexibility to design and improve their programs using innovative ideas that are typically not allowed under Medicaid and CHIP rules. The Comprehensive Waiver gives NJ the authority to operate most of the NJ FamilyCare program, including: Mandatory Managed Care Managed Long Term Services and Supports (MLTSS) Supports Program Children s Home and Community Based Services (HCBS) Programs Delivery System Reform Incentive Payment (DSRIP) The Comprehensive Waiver expires on June 30,

9 Key Concepts For Renewal Move to an integrated, coordinated, and organized behavioral health delivery system, that includes a flexible and comprehensive substance use disorder (SUD) benefit; Increase access to services and supports for individuals with intellectual and developmental disabilities; Further streamline NJ FamilyCare eligibility and enrollment; Develop an uninterrupted re-entry system for incarcerated individuals; Include reinvestment dollars targeting housing support services for individuals who are homeless or at-risk of being homeless; Enhance access to critical providers and underserved areas through alternative provider development initiatives; Expand and enhance population health partnerships with community and faith-based organizations, public health organizations, healthcare providers, employers, and other stakeholders to improve health outcomes for Medicaid-eligible individuals. 17 Waiver Renewal Process To Date The amended application was submitted to CMS on Friday, September 16, CMS completed its review of the application and forwarded clarifying questions to DMAHS on October 4, DMAHS revised the application to address these questions and resubmitted a draft application to CMS on November 22, DMAHS incorporated feedback from CMS in the amended draft application, and posted for an additional 30 days of public comment from January 9 to February 10, DMAHS presented and solicited public feedback on the amended application at the MAAC meeting on January 23, The revised renewal application was submitted to CMS on March 2, CMS posted New Jersey s Waiver application for a 30-day federal public comment period (March 10 April 10, 2017). The current Waiver period ends June 30, New Jersey is engaging with CMS on the Waiver Renewal. 18 9

10 Renewal Information The Renewal application, and waiver updates, can be found on the Division s website at: Updates and ways of participating in workgroups will be announced through stakeholder forums like the MLTSS Steering Committee and the MAAC. Waiver comments can always be sent to dmahs.cmwcomments@dhs.state.nj.us 19 MLTSS Update 20 10

11 Long Term Care Recipients Summary April 2017 Total Long Term Care Recipients * 50,516 Managed Long Term Support & Services (MLTSS) 34,736 MLTSS HCBS 18,519 MLTSS Assisted Living 3,070 MLTSS HCBS/AL (unable to differentiate) 33 MLTSS NF 12,901 MLTSS Upper SCNF 133 MLTSS Lower SCNF 80 Fee For Service (FFS/Managed Care Exemption) PACE 14, 858 FFS pending MLTSS (SPC 60-64) 722 FFS Nursing Facility (SPC 65) 10,517 FFS SCNF Upper (SPC 66) 175 FFS SCNF Lower (SPC 67) 115 FFS NF Other (Jan 2017)** 3,329 Source: NJ DMAHS Shared Data Warehouse Regular MMX Eligibility Summary Universe, accessed 5/5/2017. Notes: Information shown includes any person who was considered LTC at any point in a given month and includes individuals with Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, & 88499, Special Program Codes 03, 05, 06, 17, 32, 60-67, Category of Service Code 07, or MC Plan Codes (PACE). * FFS NF Other is derived based on the prior month s population with a completion factor (CF) included to estimate the impact of nursing facility claims not yet received. Historically, 90.76% of long term care nursing facility claims and encounters are received one month after the end of a given service month. ** Includes Medically Needy (PSC 170,180,270,280, ,570&580) recipients residing in nursing facilities and individuals in all other program status codes that are not within special program codes or capitation codes 79399, 89399, 78199, 88199, 78399, 88399, & Long Term Care Population by Setting 60,000 6-Month Intervals 50,000 41,575 41,483 44,171 46,752 49,576 50,516 40,000 11,640 12,741 14,965 17,439 19,757 21,897 30, ,000 29,096 27,897 28,332 28,410 28,872 27,697 10,000 0 Sep-14 Apr-15 Oct-15 Apr-16 Oct-16 Apr-17 Nursing Facility PACE HCBS Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed on 5/5/2017. Notes: All recipients with PACE plan codes ( ) are categorized as PACE regardless of SPC, Capitation Code, or COS. Home & Community Based Services (HCBS) Population is defined as recipients with a special program code (SPC) of 60 (HCBS) or 62 (HCBS Assisted Living) OR Capitation Code 79399,89399 (MLTSS HCBS) with no fee-for-service nursing facility claims in the measured month. Nursing Facility (NF) Population is defined as recipients with a SPC 61,63,64,65,66,67 OR CAP Code 78199,88199,78399,88399,78499,88499 OR a SPC 60,62 with a COS code 07 OR a Cap Code 79399,89399 with a COS code 07 OR a COS 07 without a SPC (Medically Needy). COS 07 count w/out a SPC 6x or one of the specified cap codes uses count for the prior month and applies a completion factor (CF) due to claims lag (majority are medically needy recipients). * Increase in overall LTC population indicative of the natural aging process. 11

12 Long Term Care Population: FFS-MLTSS Breakdown 60,000 6-Month Intervals 50,000 40,000 41,529 41, , , ,576 50, ,000 11,159 14,873 20,478 25,786 30,839 34,736 20,000 10,000 29,542 25,765 22,819 20,063 17,790 14,858 0 Jul-14 Apr-15 Oct-15 Apr-16 Oct-16 Apr-17 FFS MLTSS Pace Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed on 5/5/2017. Notes: Information shown includes any person who was considered LTC at any point in a given month based on: Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, & 88499, Special Program Codes 03, 05, 06, 17, 32, 60-67, Category of Service Code 07, or MC Plan Codes (PACE). All recipients with PACE plan codes ( ) are categorized as PACE regardless of SPC, Capitation Code, or COS. MLTSS includes all recipients with the cap codes listed above. FFS includes SPC and all other COS 07, which is derived using the prior month s COS 07 population with a completion factor (CF) included to estimate the impact of nursing facility claims not yet received. Historically, 90.76% of long term care nursing facility claims and encounters are received one month after the end of a given service month. 23 MLTSS Population by Setting 40,000 6-Month Intervals 35,000 30,839 34, ,000 25, ,901 25,000 20,000 15,000 10,000 5,000 11,159 12,072 14, , ,855 2,865 3,025 8,160 8,761 9,247 20, , ,150 11, , ,247 13,771 11, ,337 15, ,070 18,519 0 Jul-14 Oct-14 Apr-15 Oct-15 Apr-16 Oct-16 Apr-17 HCBS AL HCBS/AL (no 6x SPC) NF SCNFs Source: DMAHS Shared Data Warehouse Monthly Eligibility Universe, accessed 5/8/2017. Notes: Includes all recipients in Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, 78499, at any point in the given month and categorizes them considering both their cap code and their SPC. 12

13 HCBS Population s LTC Services Utilization $35,000,000 Top 6 Services $30,000,000 $25,000,000 $20,000,000 $15,000,000 $64,042 $72,754 $277,577 $272,609 $746,694 $592,312 $850,651 $906,005 $96,061 $316,894 $627,542 $1,584,004 $4,638,367 $123,793 $420,565 $566,741 $2,155,900 $5,056,694 $142,556 $557,705 $729,756 $3,499,794 $5,072,969 $220,640 $680,988 $745,643 $4,389,357 $4,891,720 $10,000,000 $5,000,000 $4,735,187 $4,827,651 $8,293,376 $8,207,519 $10,551,310 $12,610,734 $15,609,614 $18,504,499 $0 Jul-14 Jan-15 Jul-15 Jan-16 Jun-16 Dec-16 PCA/Home-Based Support Care Assisted Living Medical Day Services TBI Habilitative Therapies Home-Delivered Meals PERS Set-up & Monitoring Source: NJ DMAHS Share Data Warehouse MLTSS Services Dictionary, accessed on 5/25/17. Notes: Claims represent encounters paid through the date that the SDW was accessed. Subcapitations are not included in this data. Data not shown for services whose claims represent 5% or less of total claims. LTC Services not shown include: Adult Family Care, Assisted Living Program, Caregiver Training, Chore Services, Cognitive Therapy (Group/Indiv.), Community Transition Services, Home- Delivered Meals, Medication Dispensing Device (Monitoring), Medication Dispensing Device (Setup), Occupational Therapy (Group/Indiv.), PERS Monitoring, PERS Setup, Physical Therapy (Group/Indiv.), Residential Modifications, Respite (Daily/Hourly), Social Adult Day Care, Speech/Language/Hearing Therapy (Group/Indiv.), Structured Day Program, Supported Day Services, TBI Behavioral Management, and Vehicle Modifications. HCBS Population s LTC Services Utilization, SFY16 Top LTC Services Utilized by HCBS Population, SFY16 PERS Set-up & Monitoring $1,469, % PCA/Home-Based Support Care $152,930, % Home-Delivered Meals $5,163, % TBI Habilitative Therapies $7,687, % Medical Day Services $28,113, % Assisted Living $58,646, % Source: NJ DMAHS Share Data Warehouse MLTSS Services Dictionary, accessed on 5/25/17. Notes: Claims represent encounters paid through the date that the SDW was accessed. Subcapitations are not included in this data. Data not shown for services whose claims represent 5% or less of total claims. LTC Services not shown include: Adult Family Care, Assisted Living Program, Caregiver Training, Chore Services, Cognitive Therapy (Group/Indiv.), Community Transition Services, Home-Delivered Meals, Medication Dispensing Device (Monitoring), Medication Dispensing Device (Setup), Occupational Therapy (Group/Indiv.), PERS Monitoring, PERS Setup, Physical Therapy (Group/Indiv.), Residential Modifications, Respite (Daily/Hourly), Social Adult Day Care, Speech/Language/Hearing Therapy (Group/Indiv.), Structured Day Program, Supported Day Services, TBI Behavioral Management, and Vehicle Modifications. 13

14 LTC Services Cost: Pre & Post MLTSS Top 8 services SFY14: Pre-MLTSS Average Monthly LTC Recipients: 41,722 Nursing Facility Services $1,772,869,385 PCA/Home-Based Support Care Assisted Living Services/Program $114,690,739 $64,530,979 Private Duty Nursing $31,760,567 Community Residential Services $13,495,242 Medical Day Services $207,974 Home-Delivered Meals $4,369,414 PERS Set-up & Monitoring $1,426,558 Grand Total $2,003,350,858 SFY15: Post-MLTSS Average Monthly LTC Recipients: 41,686 Nursing Facility Services $1,639,616,921 PCA/Home-Based Support Care Assisted Living Services/Program $101,186,530 $56,539,879 Private Duty Nursing $20,492,850 Community Residential Services $12,657,279 Medical Day Services $11,905,925 Home-Delivered Meals $3,286,744 PERS Set-up & Monitoring $892,922 Grand Total $1,846,579,050 SFY16: Post-MLTSS Average Monthly LTC Recipients: 45,402 Nursing Facility Services $1,623,523,496 PCA/Home-Based Support Care Assisted Living Services/Program $153,291,944 $59,141,940 Private Duty Nursing $26,563,525 Community Residential Services $12,725,629 Medical Day Services $28,270,914 Home-Delivered Meals $5,187,098 PERS Set-up & Monitoring $1,484,307 Grand Total $1,910,188,853 Source: NJ DMAHS Share Data Warehouse MLTSS Services Dictionary, accessed on 1/13/17. Notes: Dollars represent encounters and FFS claims paid through the date that the SDW was accessed. Subcapitations are not included in this data. 27 MLTSS Population s LTC Services Cost PCA/Home-Based Support Care NF/SCNF Services Assisted Living Private Duty Nursing Community Residential Services Medical Day Services TBI Habilitative Therapies Home-Delivered Meals Structured Day Program PERS Set-up & Monitoring Supported Day Services Other Respite Social Adult Day Care SFY15 $20,521,241 $12,687,329 $11,856,318 $8,205,726 $3,286,879 $2,510,431 $892,892 $518,427 $479,100 $374,673 $259,264 $56,675,083 $100,718,559 $97,558,385 $0 $100,000,000 $200,000,000 NF/SCNF Services PCA/Home-Based Support Care Assisted Living Medical Day Services Private Duty Nursing Community Residential Services TBI Habilitative Therapies Home-Delivered Meals Structured Day Program PERS Set-up & Monitoring Respite Social Adult Day Care Supported Day Services Source: NJ DMAHS Share Data Warehouse MLTSS Services Dictionary, accessed on 5/25/17. Notes: Dollars represent encounters paid through the date that the SDW was accessed. Subcapitations are not included in this data. Other Includes: Adult Family Care, Caregiver Training, Chore Services, Community Transition Services, Medication Dispensing Device (Monitoring), Medication Dispensing Device (Setup), Residential Modifications, TBI Behavioral Management, Non-Medical Transportation, and Vehicle Modifications. Other SFY16 $28,242,776 $27,127,326 $12,944,899 $7,762,342 $5,199,203 $3,457,511 $1,490,554 $1,143,743 $973,997 $358,527 $24,603 $59,248,808 Monthly Average Number of Recipients Monthly Avg (SFY15) Monthly Avg (SFY16) HCBS/AL 11,990 15,694 NF/SCNF 1,427 7,058 Grand Total 13,417 22,752 $154,224,532 $435,078,604 $0 $300,000,000 $600,000,000 14

15 MLTSS Rebalancing 6 Month Intervals 100% 80% 60% 70.6% 67.2% 64.1% 60.8% 58.2% 54.8% 40% 2.0% 2.0% 2.0% 1.9% 1.9% 1.8% 20% 27.4% 30.7% 33.9% 37.3% 39.9% 43.3% 0% Jul-14 Apr-15 Oct-15 Apr-16 Oct-16 Apr-17 HCBS% PACE % NF% Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed on 5/5/2017. Notes: All recipients with PACE plan codes ( ) are categorized as PACE regardless of SPC, Capitation Code, or COS. Home & Community Based Services (HCBS) Population is defined as recipients with a special program code (SPC) of 60 (HCBS) or 62 (HCBS Assisted Living) OR Capitation Code 79399,89399 (MLTSS HCBS) with no fee-for-service nursing facility claims in the measured month. Nursing Facility (NF) Population is defined as recipients with a SPC 61,63,64,65,66,67 OR CAP Code 78199,88199,78399,88399,78499,88499 OR a SPC 60,62 with a COS code 07 OR a Cap Code 79399,89399 with a COS code 07 OR a COS 07 without a SPC (Medically Needy &/or Rehab). COS 07 count w/out a SPC 6x or one of the specified cap codes uses count for the prior month and applies a completion factor (CF) due to claims lag (majority are medically needy recipients). 29 A Look at the June 30, 2014 Waiver Population Today All Waivers (6/30/14 = 12,040) MLTSS HCBS 6, % MLTSS NF 1, % No Longer Enrolled 4,502* 37.4% Other (Non-MLTSS NJ FamilyCare) % Source: DMAHS Shared Data Warehouse Monthly Eligibility Universe, accessed 5/22/17. Notes: Includes all recipients who were in a waiver SPC (03, 05, 06, 17 or 32) on 6/30/14. Where they are now is based on capitation code or PSC. Those without a current capitation code or PSC are determined to be No Longer Enrolled. Of the total number no longer enrolled, 93.8% (3,102) have a date of death in the system (current through ). 15

16 Home Care Regulations 31 N.J.A.C 10:60 Current Regulations Contains requirements for home health care services and home and community-based services provided under the previous Waiver programs. Proposed Amendments Addresses the following areas: Comprehensive Waiver MLTSS Accreditation of health care service firms Certification requirements for physical /medical personal care assistant services Private duty nursing services Industry commented during the advanced notice period: November 14 December 15, 2016 Once approved, the Division of Law will publish the final proposed rule for an additional comment period 16

17 Nursing Facility Any Willing Qualified (AWQP) Provider Provisions 33 Nursing Facility Quality Indicators Initiative 1 Move from MLTSS AWP to Any Willing Qualified Provider (AWQP) 2 Improve quality of care in nursing facilities for all residents 3 Set the stage for Value Based Purchasing between MCOs and Nursing Facilities, moving from strictly state-based rates to negotiated rates 34 17

18 AWQP General Provisions 1. Begin with seven measures, but retire measures and add others as the initiative evolves. 2. Begin July 1, 2017 with a phase-in of NF performance metrics: Allow NFs to meet 4/7 measures in Year One as the performance threshold. 3. MCOs will focus their NF care management on working with the NFs to improve their quality measures. 35 AWQP General Provisions, cont. 4. MCOs may not contract with a NF for new admissions that do not meet 4/7 measures. 5. A NF will be able to enter into a corrective action plan with the State if it doesn t meet 4/7 measures. 6. NFs will be able to appeal to the State for reconsideration of network exclusion. Exceptions may be for NFs that have a population with disproportionate needs, etc

19 AWQP General Provisions, cont. 7. Standards will be outlined in the MCO contract with DMAHS and policy guidance. 8. DoAS may grant the following exceptions: To meet geographic access To maintain family cohesion Because of a nursing home appeals network exclusion due to the unique features and population of that NF 37 Phase One in a Multi-Year Process Letter and chart to inform you how your NF is meeting the Minimum Data Set (MDS) performance metrics Will provide baseline data so you will know where you need to improve on the 5 MDS metrics before the initiative goes LIVE State contracting with national expert Dr. Nick Castle to conduct and analyze CoreQ surveys and NFs that track hospitalizations First CoreQ survey to be mailed this summer with data collected and finalized by this coming September MDS data will be collected and analyzed in coordination with survey mailing AWQP Provision to begin fall

20 Future of Medicaid 39 House Republicans Plan for Repeal and Replace: Medicaid American Health Care Act Passed in the House of Representatives on May 4, 2017 Repeals enhanced match for expansion population effective 1/1/2020. After 1/1/2020 states could only enroll newly eligible individuals at the state s traditional matching rate. Proposes redeterminations every 6-months for the expansion population beginning 10/1/2017. Eliminates the 3-month retroactive eligibility period. Disproportionate Share Hospital (DSH) cuts would be repealed. Converts Medicaid to a per capita cap funding starting FY

21 Current Medicaid Financing Structure Federal money is guaranteed as a match to State Spending 50% match for New Jersey State s must follow federal rules, or waiver special terms and conditions to receive this funding Medicaid is the largest source of federal revenue to New Jersey Federal Medicaid funding accounts for more than $9.4 billion, or 17% of New Jersey s general revenue. 41 For more information, visit our website: