Managed Long Term Services and Supports (MLTSS) A Forum for Consumers, their Families and Caregivers, Advocates and Community-Based Agencies 1
Background To give you an update on the implementation of MLTSS focusing on: Access to services Person-centered care approach Provider relations Today s Agenda Quality management and monitoring To have an open discussion for you share your thoughts about the new MLTSS program with Department of Human Services (DHS) Leadership. 2
Background Ground Rules for Today There are representatives here from the following four managed care organizations (MCOs) who you can reach out to at the end of the meeting about your particular issues: Amerigroup New Jersey Horizon NJ Health UnitedHealthcare Community Plan WellCare of New Jersey 3
Background NJ Comprehensive Medicaid Waiver (CMW) NJ CMW demonstration 1115 (a) was approved effective 10/1/12-6/30/17 to: Implement statewide health reform and expand current managed care programs to include managed long term services and supports (MLTSS) and expand home and community based services (HCBS) to some populations. Consolidate four existing HCBS waiver programs Provide a care manager to help coordinate medical, long term services and supports, behavioral health services and NJ FamilyCare State Plan services, through an individualized plan of care. 4
Background Array of Services under MLTSS Sample of Waiver Services Available: Respite Personal Emergency Response System (PERS); Home and Vehicle Modifications; Home Delivered Meals; Assisted Living; Behavioral Health Services; Community Residential Services, and Nursing Home Care. 5
Background Exclusions to MLTSS on July 1, 2014 About 27,000 Medicaid fee-for-service (FFS) beneficiaries in long-term care facilities: FFS Medicaid beneficiaries who are in custodial nursing home care on or before 7/1/14 Medicaid beneficiaries living in Special Care Nursing Facilities (SCNFs) as of 7/1/14 will remain in the current FFS for two years (until 7/1/16) PACE Program beneficiaries People enrolled in Dual Eligible Special Needs Plans (D-SNP) 6
Background Exclusions to MLTSS on July 1, 2014 Division of Developmental Disabilities CCW (Community Care Waiver) or Supports Program beneficiaries People with Pervasive Developmental Disabilities (DD) Intellectual/DD Beneficiaries in out-of-state HCBS settings People receiving inpatient services for intellectual or developmental disability and mental health illness in a psychiatric hospital 7
Background PACE The PACE organization coordinates and provides ALL services including nursing facility care, if needed. Applicant must be 55 or older, able to live safely in the community at the time of enrollment and have care needs at the nursing home level. Currently there are four PACE organizations in seven counties serving a total of 876 individuals. Applicant must live in the PACE provider service area to be eligible to enroll. 8
Background PACE LIFE at Lourdes Serving most of Camden County Lutheran Senior LIFE Serving parts of Hudson County LIFE St. Francis Serving Mercer County and parts of northern Burlington County Inspira LIFE Serving Cumberland and parts of Gloucester and parts of Salem counties 9
Background MLTSS Stakeholder Process Steering Committee was launched in 3/12 and still meets quarterly: At onset, four workgroups were created to address policies/processes. These groups met until a final report was done in 6/12: 1. Assessment to appeals 2. Assuring access 3. Provider transitions 4. Quality management Recommendations became contract language for MCOs, quality strategy and other policies. 10
Background MLTSS Guiding Principles HCBS is the preferred service delivery method for people receiving MLTSS. Consumer choice and participation in selecting service providers and living settings, to the maximum extent feasible, are a priority of NJ s MLTSS. Participation of all stakeholders in the planning and implementation of MLTSS. 11
Background Workgroup: Assessment to Appeals 1. Aging and Disability Resource Connection (ADRC) partnership shall serve as the single entry/no wrong door system for consumers to access MLTSS. 2. NJ CHOICE Assessment Tool will be used by the MCOs and PACE as the standardized functional assessment to determine clinical eligibility. 3. DHS, its Division of Aging Services, shall be responsible for conducting clinical eligibility for consumers not yet on NJ FamilyCare. 12
Background Workgroup: Assuring Access 1. Adopt consolidated service definitions 2. Perform activities that inform Network Adequacy development 3. Develop criteria to establish network requirements and require at least 2 providers of each service 4. Work with MCOs, PACE and DOBI to identify ways to streamline credentialing process 13
Background Workgroup: Provider Transitions 1. An Any Willing Provider (AWP) provision should be enacted for nursing homes and assisted living providers. 2. Nursing home and assisted living reimbursement rates should be paid for custodial residents at a minimum using existing case mix methodology during the two-year AWP period. 3. Special Care Nursing Facilities (SCNFs) should be paid at a minimum at current FY12 Medicaid rate for a period of two years from the launch of MLTSS. 14
Workgroup: Quality Management 1. Transparency 2. Accountability 3. Consistent approach 4. Monitoring quality 5. Benchmarked metrics 6. Quality of Life/Quality of Care 6. Avoid duplication in data definitions and collection 8. Consumer empowerment and choice 9. System rebalancing 10. Prevention, wellness and independence 15
Background In Summer 2013, State and MCOs submitted a request for information (RFI) to assess MLTSS readiness. Tracking progress took place from 4-6/14, including: MCO and State Readiness Review Development and fine tuning of existing policies; Creation of a staffing plan; Creation of a training plan, and Evaluation/development of IT systems and infrastructure. MCOs had to be ready for testing by 4/15/14. Weekly calls held between State and the MCOs discuss progress, on site-visits with MCOs, obstacles and successes. 16
MLTSS Implementation Strategy Weekly calls between DHS and MCOs Weekly calls between the Office of Community Choice Options and Care Management Supervisors Webinars focused topics 17
Background July 1, 2014 MLTSS Launch 11,138 1915 c waiver participants were transferred from 100+ community-based care management agencies to four MCOs. Division of Aging Services (DoAS) database provided MCOs with demographic information; identification of high risk members; authorized services/hours and provider agencies. DoAS database provides a benchmark for QA audits to monitor changes in members new plans of care. 18
Reevaluations for Former Waiver Participants Contract requires MCOs to maintain continuity of care for all former waiver participants until a face-to-face assessment is completed. Contract requires MCOs to conduct face-to-face comprehensive assessments for high risk members within 90 days and the remaining members within 180 days. Upon approval of assessment, MCO care manager must complete the new Plan of Care within 30 days. 19
MCO Revaluation Assessments July 1,990 August: 2,614 September: 3,104 Total MLTSS Submitted: 7,708 Focus is on High Risk individuals who require reassessment within the first 90 days of implementation All MCOs have completed high risk pool prior to 90 days 20
MLTSS Plans of Care Person-centered approach Collaborative process between the member, family and MCO care manager to develop goals and build on members strengths Formal & informal supports Informed by the NJ Choice assessment and options counseling 21
Background Behavioral Health Services under MLTSS These behavioral health services are included in MLTSS through the NJ FamilyCare MCOs: Acute Partial Hospitalization, Partial Hospitalization and Partial Care Adult Mental Health Rehabilitation (Group Homes A+ thru D) Independent Practitioner (Physician, APN, Psychologist) Mental Health Outpatient Clinic/Hospital Services Opioid Treatment Services Private Stand-Alone Psychiatric Hospital Inpatient/Acute Care Unit in a General Hospital (STCF) Under MLTSS MCOs are required to cover most behavioral health services covered under the current state plan as FFS. *PACT and ICMS/TCM are not covered by MCOs in MLTSS since they are duplicative care management services and remain in the NJ FamilyCare fee-for-service program. However, the MCOs must coordinate these services for MLTSS members, as needed. 22
MCO Member Services: Top Questions The MCOs handled a total of 29,674 calls on MLTSS as of September 24, 2014 The majority of calls centered on these issues: Benefits; Primary care providers/specialists; ID cards; Care management inquiries: appointments, etc., and Durable medical equipment questions. 23
Resource for Providers Office of Managed Health Care (OMHC) Managed Provider Relations Unit The OMHC, Managed Provider Relations Unit addresses Provider Inquires and/or Complaints as it relates to MCO contracting, credentialing, reimbursement, authorizations, and appeals. Conduct complaint resolution tracking/reporting. Provides Education & Outreach for MCO contracting, credentialing, claims submission, authorizations, appeals process, eligibility verification, TPL, MLTSS transition and other Medicaid program changes. Address stakeholder inquiries on network credentialing process, hospital turnover, network access, and payment compliance. 24
Provider Inquiries The Managed Care Provider Relations Unit will work with necessary staff at DMAHS, Molina, DOBI, other state Departments and/or HMO to address inquiry. Prior to contacting the State directly individuals should contact Member and/or Provider Relations Office at the Managed Care Organization (MCO) If matter is unresolved state staff will review and assist as necessary Provider inquiries should be e-mailed to the State Office of Managed Health Care at: MAHS.Provider-Inquiries@dhs.state.nj.us
Top Reasons for Claim Denials by MCOs Primary carrier information required DDuplicate claim Disallow is not allowed under contract Explanation of benefit (EOB) needed from commercial carrier Incorrect billing Place of service Multiple procedure reduction Procedure or modifier not in fee schedule 26
MLTSS Claims Processing by MCOs Data as of September 18, 2014 Submitted Paid Denied Pending Discrepancy 93,828 69,430 (74%) 12,035 (13%) 12,363 (13%) 0 27
NJ Family Care Managed Care Reference Information Below is the link where MCO contract is posted on line: http://www.state.nj.us/humanservices/dmahs/info/resources/care/ The link below will provide connection to individual MCO sites. The phone number for Member and Provider Relations for MCO s are listed as well http://www.state.nj.us/humanservices/dmahs/info/resources/hmo/ 28
State Resources for MLTSS Department of Human Services NJ FamilyCare Member 1-800-356-1561 Division of Aging Services Care Management Hotline 1-866-854-1596 Division of Disability Services Care Management Hotline 1-888-285-3036 NJ FamilyCare Health Benefits Coordinator (HBC) (Enrollment Issues) NJ FamilyCare Office of Managed Health Care, Managed Provider Relations Website Address 1-800-701-0710 MAHS.Providerinquiries@dhs.state.nj.us www.state.nj.us/humanservices/ 29
Provider Resources for MLTSS NJFC Health Plan Provider Relations MLTSS Contact Amerigroup New Jersey, Inc. 1-800-454-3730 1-800-454-3730 Horizon NJ Health 1-800-682-9091 1-877-765-4325 UnitedHealthcare Community Plan 1-888-362-3368 1-888-362-3368 WellCare of New Jersey 1-888-453-2534 1-888-453-2534 or 1-888-588-9769 30
Discussion 31
Access to Services 32
Person-Centered Care Planning 33
Provider Relations 34
Quality Assurance & Monitoring 35