Health Plans and LTSS NASUAD April 20,2011 Mary Kennedy, ACAP Medicare Vice President 1
Agenda ACAP Background Health Plan Interest in LTSS Developing Plan Capacity Relationship Building What should states consider before moving LTSS to health plans? Current State Initiatives Discussion 2
ACAP Mission Statement To represent and strengthen not-for-profit, safety net health plans as they work with providers and caregivers in their communities to improve the health and well-being of vulnerable populations in a cost-effective manner.
ACAP has 55 member plans representing close to 8 M Medicaid lives in 26 States 25% of all Medicaid managed care lives 4
ACAP Plans Affinity Health Plan (NY) Alameda Alliance for Health (CA) AlohaCare (HI) AmeriHealth Mercy Health Plan (PA) Amida Care (NY) Boston Medical Center HealthNet (MA) CalOptima (CA) CareOregon (OR) CareSource Michigan (MI) CareSource (OH) CenCal Health (CA) Children s Community Health Plan (WI) Children s Mercy Family Health Plan (KS) Children s Mercy Family Health Plan (MO) Colorado Access (CO) Commonwealth Care Alliance (MA) Community Health Choice (TX) Community Health Group (CA) Community Health Network of Connecticut (CT) Community Health Plan (WA) Contra Costa Health Plan (CA) Cook Children s Health Plan Denver Health Medical Plan (CO) Driscoll Children s Health Plan (TX) Elderplan & Homefirst (NY) El Paso First Health Plans (TX) *Associate Member ** Incubator Plan Family Health Network (IL) Gold Coast Health Plan (CA) Health Plan of San Mateo (CA) Health Plus (NY) Health Services for Children with Special Needs (DC) Horizon NJ Health (NJ) Hudson Health Plan (NY) Inland Empire Health Plan (CA) LA Care Health Plan (CA) Maine Primary Care Association (ME) ** MD Community Health Systems (MD) * MDwise (IN) Metropolitan Health Plan (MN) Monroe Plan for Medical Care, Inc. (NY) Neighborhood Health Plan (MA) Neighborhood Health Plan of Rhode Island (RI) Network Health (MA) Prestige Health Choice (FL) Priority Partners (MD) San Francisco Health Plan (CA) Santa Clara Family Health Plan (CA) Texas Children s Health Plan (TX) Total Care (NY) Univera Community Health (NY) University Physicians Health Plans (AZ) UPMC For You (PA) 5 Virginia Premier Health Plan, Inc (VA) VNS CHOICE (NY)
Health Plan Interest : Integrating LTSS with Acute Care Continuity of care for persons enrolled in the plan prior to need for LTSS Continuity of care across transitions and settings Affiliation of plan and care system Affiliation of plan to local government Opportunity to make the greatest improvement in health status, prevent or slow decline and support independence Response to state initiatives 6
Developing Capacity: Plan Staff Hire staff with disability and aging experience and competence Train other staff The obvious ones- customer service, marketing, web site staff, provider relations, care managers, pharmacy And the less obvious ones- Chief Financial Officer, claims processing, fraud and abuse staff Hear from consumers Engage counties, ADRC, Centers for Independent Living, AAAs etc in training 7
Developing Capacity : Network Hire care management teams Contract with key community resources Establish core of primary care practitioners with skill and interest in aging and/or disability; monitor for true accessibility Expand network of specialty providers, therapists, durable medical equipment Align payment practices to support needs and goals of LTSS Longer appointment times Non traditional providers Self directed models for personal care Integration with behavioral health Authorization aligned with care plan and care manager 8
Developing Capacity : Quality Adopt and train on the Model of Care Develop ongoing consumer input and feedback Develop a culture of Risk management vs. safety Risk adjust the quality metrics Develop measures that support independence and functioning at highest possible level 9
Building Relationships Start now Person-centered thinking and planning nothing about me without me Recognize stakeholder interests and stakeholder capacity Governance matters Board membership Meaningful Advisory groups 10
What should states consider in moving to an integrated system? When can we start? Phase in by population, by geography, by service? Voluntary or inclusive? What state and federal authority is needed? What is the Medicare strategy for duals? Buy experience in LTC integration or build capacity locally? Competitive bid or all qualified plans? Should existing managed care carve- outs (pharmacy, behavioral health ) remain? 11
What should states consider in moving to an integrated system? Will payment to plans be by setting, eligibility group or blended with incentives to re-balance? Is there sufficient money for the expected services and expected standards? Do we have the fortitude to endure the change? Unmet need identified initially will reduce expected savings Better management of transitions will reduce use of ER, Hospitals and Nursing homes Is there the capacity for LTSS rate-setting and for oversight? What risk adjustment capacity is needed for LTSS? Who will assess for the level of care? What payments will be pass-through to providers? 12
Does this initiative improve on the current weaknesses or failures ---in terms of health outcomes, personal impact and costs to public and private payers --- of the current system? Adapted from Making the Connection Community Catalyst and Boston Center for Independent Living 13
States Selected for Demonstrations to Integrate Care for Duals California Colorado Connecticut Massachusetts Michigan Minnesota New York North Carolina Oklahoma Oregon South Carolina Tennessee Vermont Washington Wisconsin. See: http://www.cms.gov/dualeligible 14
Other state initiatives Active discussions in Ohio, Rhode Island, etc Arizona ALTCS RFP for 5 years Kentucky RFP for all populations not HCBS/LTC Massachusetts RFI for Persons with Disabilities Texas Star Plus RFP and expansion for 7 years 15
Discussion 16
Contact: Mary Kennedy Phone: 202.701.4749 Email: mkennedy@communityplans.net 1015 15 th St. NW, Suite 950 Washington, DC 20005 Fax: 202.204.7517 Web: www.communityplans.net 17