MedicaidMedicaid
Division of Medicaid and Long-Term CareDivision of Medicaid and Long-Term CareDepartment of Health and Human ServicesDepartment of Health and Human Services
Long-Term CareLong-Term Care Managed CareManaged Care
What is Managed Care?Managed Care is a health care delivery system used by Medicaid agencies to manage:
CostUse/UtilizationQuality
Medicaid requirements not required of managed care:
ComparabilityFreedom of ChoiceAny Willing Provider
What is Managed Care? cont.
• Managed care has to cover the services in the Benefits package in the same amount, duration, and scope as Fee-For Service Medicaid
• Can place appropriate limits on a service based on medical necessity or utilization control
• What constitutes medical necessity cannot be more restrictive than what is used in the State Medicaid program
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What are Long-Term Care Services?
Nursing FacilityPersonal Assistance Service
HCBS waiver services *aged*physical disabilities*traumatic brain injuries
Home HealthThese are all examples
Why Manage LTC?
*Nebraska manages physical and behavioral health services for many Medicaid recipients…
Why should Nebraska manage long-term care services?
Let’s look at some data
Aged17,783 7.6%
Blind & Disabled34,708 14.7%
Children151,140 64.2%
ADC Adults31,723 13.5%
NEBRASKA MEDICAID AND CHIP AVERAGE MONTHLY
ELIGIBLE PERSONS BY CATEGORYFiscal Year 2011
Total: 235,353
Aged17,768 7.5%
Blind & Disabled35,736 15.0%
Children152,297 64.1%
ADC Adults31,742 13.4%
NEBRASKA MEDICAID AND CHIP AVERAGE MONTHLY
ELIGIBLE PERSONS BY CATEGORYFiscal Year 2012
Total: 237,543
Nebraska Medicaid Annual Report, Division of Medicaid & Long-Term Care, December, 2012.
Aged$337,748,437
21.4%
Blind & Disabled$664,473,101
42.2%
Children$398,429,576
25.3%
ADC Adults$175,196,070
11.1%
NEBRASKA MEDICAID AND CHIP VENDOR EXPENDITURES BY ELIGIBILITY
Fiscal Year 2011Total: $1,575,847,184
Aged$341,670,694
21.3%
Blind & Disabled$711,031,873
44.4%
Children$378,940,580
23.6%
ADC Adults$170,704,198
10.7%
NEBRASKA MEDICAID AND CHIP VENDOR EXPENDITURES BY ELIGIBILITY
Fiscal Year 2012Total: $1,602,347,345
SFY2012 Medicaid Expenditures for Long-Term Care Services
Nebraska Medicaid Annual Report, Division of Medicaid & Long-Term Care, September, 2012
We manage recipients who are generally healthy, and have
much lower average monthly costs
We need to manage recipients who are require more services/benefits…
so they receive
RIGHT
• Right Serviceat the
Right Timein the
Right Amount
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CMS Principles for LTC managed care
•Adequate planning and transition strategies•Stakeholder engagement• Enhanced provision of HCBS• Alignment of payment structures with MLTSS programmatic goals
• Support for beneficiaries• Person-centered processes• Comprehensive and integrated
service package• Qualified providers• Participant protections• Quality
What has been done so far?
• Gathered data about clients, services, eligibility categories. We are analyzing it and determining what else we need to review.
• Posted a Request for Proposal (RFP) to procure an actuary to develop the managed care rates and rate methodology.
• Began conversations with interested parties, like you!
Some Next Steps
• Continue outreach with providers, advocates, clients, family members, other stakeholders to solicit input, hear concerns, answer questions.
• Develop RFP to post early 2014 to procure the long-term care managed care company
• Obtain federal approval for waivers and state plan as necessary
Now let’s hear from you