Medicaid and You Yesterday and Tomorrow: How Medicaid and Payment Reforms Impact Assisted Living Providers Ohio Assisted Living Association November 5, 2012 Suzanne J. Scrutton Vorys, Sater, Seymour and Pease LLP www.vorys.com Daphne K. Saneholtz Vorys Health Care Advisors, LLC www.voryshcadvisors.com Maureen M. Corcoran Vorys Health Care Advisors, LLC www.voryshcadvisors.com
Agenda Medicaid Basics Evolving Federal Context and Health Care Reform Managed Care and Other Ohio Initiatives Opportunities and Other Implications for Assisted Living Providers 2
Medicaid Basics Joint federal/state program Feds pay 64%, state pays 36% (Ohio, FY2013) Medicaid must: Be statewide and uniform Ensure access to services Ensure recipients have free choice of provider 3
Medicaid and Long-Term Care Approximately 2.2 million Ohioans enrolled in Medicaid; 51% children, 25% ABD (FY09) Ohio Medicaid eligibility and long term care Aged, blind, disabled are approximately one quarter of total Medicaid population but more than 65% of cost Increasing fiscal pressures to find alternate ways to serve high cost population 4
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Quick Summary: Medicaid Services and Coverage State Plan: Medically necessary services E.g., physical health, community mental health (AKA card services ) Includes fee-for-service and managed care Administration & specialty delivery systems (ODMH, ODADAS) Waivers: Require an institutional LOC NF: AL, Passport, Choices, JFS Transitions NF ICF-MR: I/O, Level One, JFS Transitions ICF-MR NON-Medicaid funded services (including GRF, levy) 7
Evolving Federal Context On our way to 2014 Supreme Court decision Individual mandate upheld Medicaid expansion optional Impact of the Presidential and Congressional elections Federal budget and deficit reduction Sequestration/fiscal cliff Entitlement reform and block grants 8
Evolving Federal Context (cont d) Benefit design with new demand and budget pressures: Likely changes for current and reduced benefits for new eligibles. ACA provides some opportunities integrated, coordinated care (ACOs, health homes, dual eligible initiatives, etc.); positions providers for payment reform. 9
A Balanced Approach to ACA Implementation Per Alan Weil, Executive Director, NASHP Delivery System Improvement Provider Capacity Insurance Exchanges Eligibility Systems 10
Coordinated Care Equation Integration of Care + Enhanced Care Coordination + Payment Reform = Accountability System Reform Better Outcomes Lower Cost 11
CMS Perspective Stampede to managed care Overwhelming use of 1115 and some 1915(b) waivers Dual planning grants Health homes CMMI (ACA 3021) Payment reform is the goal 12
Ohio Initiatives Focused on Care Coordination Managed Care Single Waiver for NF LOC MH/SUD Elevation ACO & Pediatric ACO Integrated Care Delivery System for Medicare-Medicaid Enrollees Health Homes for those with SPMI 13
OHT SFY14-15 Budget Priorities Reform nursing facility reimbursement Expand HCBS Streamline health and human services, including budget and accounting system, eligibility system, shared services across local jurisdictions Coordinate housing programs, workforce programs, and programs for children 14
FROM LAST BIENNIAL BUDGET 15
Managed Care is Ohio s Platform Platform for Ohio s Medicaid delivery system Expansion with nearly 100% mandatory Today, most CFC and some ABD Medicaid consumers are mandatory. Certain CFC and ABD consumer are excluded from Medicaid managed care or are not required to enroll in a MCP It s changed/matured in last 5 years Stampede to managed care 16
Ohio s Managed Care Policy Currently in CFC adults CFC kids EXCEPT those in foster care or other out-of-home placement, or receiving services through BCMH for certain diagnoses ABD adults who are not duals, not on a waiver, not in an institution, and not spenddown Coming in ABD kids (July 2013) 17
Ohio s Managed Care Policy (cont d) Integrated Care Delivery System Not in Medicare-Medicaid enrollees who do not have a developmental disability, are not <18 years old, are not spend-down Includes individuals on a NF waiver or in a NF Individuals in an ICF-MR or ICF-MR waiver BCMH exempted groups ICDS-eligibles who are not in an ICDS 18
Managed Care and LTC When someone in managed care is placed in a NF, the MCP is responsible for payment for NF services and all covered services until the last day of the month following the month of the member s NF admission, for a period not to exceed sixty-two calendar days. MCP members remaining in a NF after this period will be disenrolled; returned to FFS. (OAC 5101:3-26-03) 19
Managed Care Opportunities for AL Providers AL providers reimbursed by Medicaid should consider contracting with MCPs/becoming part of their networks Although MCPs responsibility for providing LTSS is limited, assisted living is a less costly option in which they should be interested 20
Managed Care Reprocurement Expanding those to be included. Result will be: 1.6 million in CFC 125,000 in ABD 37,000 children with special needs Reducing from 8 to 3 regions; approved 5 MCPs MCPs must serve both CFC and ABD Includes flexibility to add/change later without reprocurement Want to push MCPs to innovate 21
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Ohio s Dual Eligible Proposal Integrated Care Delivery System (ICDS) with managed care platform Target population = all beneficiaries fully enrolled in both Medicare and Medicaid (i.e., not QMBs, etc.) Accountable for providing access to all services covered by both Medicare and Medicaid Required to provide, at minimum, all HCBS provided under current 1915(c) waivers MCPs will be required to contract with AAAs to help seniors find appropriate care Providers of AL services to Medicare-Medicaid enrollees in the regions were the ICDS is implemented will have to contract with these plans to continue providing services to individuals enrolled in the ICDS 23
Ohio s Dual Eligible Proposal (cont d) ICDS plans will be expected to provide care management services to monitor and coordinate the care for individuals Care management model must incorporate individuals residing in all care settings, such as nursing facilities, hospitals, assisted living facilities, and at home Duals with SMI included Excluded: DD individuals on 1915(c) waiver or in an ICF-MR; individuals <18 years old Individuals can opt out 24
Ohio s Dual Eligible Proposal (cont d) 7 regions of 3-5 counties each Waiver not yet approved; goal is to begin enrollment in April 2013 NW SW WC C EC NEC NE Aetna Aetna Buckeye Aetna CareSource CareSource Buckeye Buckeye Molina Molina Molina United United CareSource United 25
Ohio s Integrated Care Delivery System Goals for MCP as central point of coordination: Eliminate waste of duplicative testing or procedures Avoid treatments or medications that could conflict dangerously with other care the patient has received Ensure that patients are cared for in the setting they prefer, which typically is the least intensive and least expensive 26
ICDS: Examples 1. Without care coordination, a patient who enters an ED in a health crisis might be placed in rehab care at the hospital. He could receive rehab much more cost effectively at a nursing home, but he might not know this. 2. Many seniors on Medicaid are placed in nursing homes, when they would be happier in an assisted living facility or at home with in-home care, either of which is far more costeffective than a nursing home. 27
How Will the Single Waiver and ICDS Work Together? Most individuals who received LTSS through Ohio s NF based HCBS waivers are Medicare Medicaid Enrollees. As ICDS is rolled out throughout the entire state, the ICDS will be the primary program model for providing all LTSS in Ohio (institutional and HCBS services). Persons who otherwise qualify for LTSS but who are not Medicare Medicaid Enrollees will receive their LTSS under the single waiver. 28
NF LOC Single WAIVER Currently the idea is on hold, pending other initiatives Combines PASSPORT, Choices, AL waivers (ODA), and Ohio Home Care and Transitions II Aging Carve-Out waivers (ODJFS) Home Care Waiver, which currently serves consumers up to age 59, will only serve children with a NF or hospital LOC Who? NF LOC ages 18-64 with a disability or age 65 and up; eligible for Medicaid; need at least one waiver service every month in addition to case management (46,000 Ohioans) 29
NF LOC Single Waiver (cont d) 1915(b)/(c) waiver Entities that operate existing waivers will be condensed into one provider per region Will separate case management from eligibility determination The state plans to contract with at least two case management agencies per region; consumer would have choice AAAs concerned 30
ACA: Highlights Improves access to preventive services Coordinated care options (ACOs, health homes, dual eligible programs) Fights fraud/cost containment 31
ACA: Potential Impact to AL Providers Medicaid LTC initiatives included in ACA could provide opportunities for AL providers Goal is to help states rebalance LTC systems with priority on HCBS over institutional care 32
ACA: Potential Opportunities for AL Providers Dual eligible initiatives (like ICDS) Expanded HCBS options, including 1915(i), (j) BIPP (Balancing Incentive Payment Program) Enhanced match to states that spent less than a certain percentage of their Medicaid LTC dollars on HCBS in 2009; runs through September 2015 Ohio not currently participating; if it did, it could spend Medicaid funds on AL in order to meet the required goal of expanding non-institutional LTSS Health homes (AL providers could participate) 33
ACA: Medicare Programs That Might Impact AL Providers Reducing avoidable hospital readmissions Encourages hospitals to develop relationships with high quality providers AL providers can partner with hospitals Challenge: because AL does not participate in Medicare, tracking outcomes is not generally part of their business model 34
ACA: Medicare Programs That Might Impact AL Providers (cont d) Shared Savings Program/ACOs AL providers not specifically designated as eligible participants NOW Ultimately, both post-acute and LTC will be fundamental components; AL providers could cultivate relationships with referral sources like hospitals and physicians Hospitals will have significant incentive to care what happens when their patients leave, as the ACO s goal is hitting quality targets and sharing in savings 35
About Vorys Health Care Advisors Vorys Health Care Advisors, LLC helps health care providers, business decision makers and professional associations to achieve their objectives in a constantly changing governmental and business health care environment and to assist them in making well informed, strategic and tactical decisions tailored to their individual goals, needs and aspirations. Contact Information Maureen Corcoran, MSN, MBA mmcorcoran@voryshcadvisors.com Daphne K. Saneholtz, JD dksaneholtz@voryshcadvisors.com Vorys Health Care Advisors 52 East Gay Street, Columbus, OH 614-464-5461 www.voryshcadvisors.com 36
About Vorys Sater Seymour and Pease Vorys health care attorneys are trusted and experienced professionals who counsel clients on the legal and regulatory issues facing the health care industry. Whether the matter involves the day-today operations of a health care facility or issues associated with regulatory compliance, complex litigation, corporate compliance, fraud and abuse, or payor and reimbursement arrangements, our attorneys are fully equipped to address client health care needs. Contact Information Suzanne J. Scrutton sjscrutton@vorys.com Vorys, Sater, Seymour and Pease LLP 52 East Gay Street, Columbus, OH 614-464-6400 www.vorys.com 37