1Part 2.  Enrollment  Benefits  Usage  Cost sharing (co-pays)  Access  Quality  Accountability 2Part 2

  • Published on
    21-Dec-2015

  • View
    216

  • Download
    3

Embed Size (px)

Transcript

  • Slide 1
  • 1Part 2
  • Slide 2
  • Enrollment Benefits Usage Cost sharing (co-pays) Access Quality Accountability 2Part 2
  • Slide 3
  • Dental Medications Transport Behavioral health 3Part 2
  • Slide 4
  • 4
  • Slide 5
  • bringing the biggest change in Medicaid since it began. 5Part 2
  • Slide 6
  • 6
  • Slide 7
  • 7
  • Slide 8
  • Increase access Control costs Add benefits & protections Address many smaller issues 8Part 2
  • Slide 9
  • 1. Insurance reform Individual mandate 2. Exchanges + subsidies Subsidies for those at 100% -400% of FPL 3. Medicaid expansion For adults < 138% of FPL 9Part 2
  • Slide 10
  • Family of 1: $11,670x 133% =$15,521 Family of 4: $23,850x 133% =$31,721 2014 Federal Poverty Limit (FPL) 10Part 2
  • Slide 11
  • 11Part 2
  • Slide 12
  • 12Part 2
  • Slide 13
  • 13Part 2
  • Slide 14
  • 14Part 2
  • Slide 15
  • 15 Old Eligibles: FMAP = 50% New Eligibles: FMAP = 100% 90% Part 2
  • Slide 16
  • Change in Coverage in NJ under ACA (ages 0-64) 16Part 2
  • Slide 17
  • 17
  • Slide 18
  • 18Part 2
  • Slide 19
  • US0.72 WY1.43 AK1.40 DE1.00 PA0.73 CA0.56 NY0.43 NJ0.37 19Part 2
  • Slide 20
  • US0.72 WY1.43 AK1.40 DE1.00 PA0.73 CA0.56 NY0.43 NJ0.37 20Part 2
  • Slide 21
  • % doctors accepting 21Part 2
  • Slide 22
  • But For PCPs only Family practitioners Internists Pediatricians = 1.00! Only for 2013, 2014 Also for managed care 22Part 2
  • Slide 23
  • Accountable Care Organization 23Part 2
  • Slide 24
  • Why? Eligibility changes Service benefit additions Payment criteria changes Waivers for? Medicaid ACOs Define scope Define new roles Build capacity Include high-cost groups Multi-payer alliances Payment models Measurements 24Part 2
  • Slide 25
  • Getting it all together 25Part 2
  • Slide 26
  • Division of Medical Assistance and Health Services $11 billion (federal and state) 500 people Director: Valerie Harr (NJ FamilyCare) 26Part 2
  • Slide 27
  • Required by Section 1902(a) (30)(A) 71 elements Rates Methodology Comment periods 27Part 2
  • Slide 28
  • Section 1115 Research and demonstration Section 1915(b) Managed Care Section 1915(c) Home and Community Based Concurrent 1915(b) & (c) for more flexibility 28Part 2
  • Slide 29
  • Health homes 2010: NJ Public Law 2012, Chapter 74 3 year Medicaid Medical Home demonstration project Section 2703 of ACA Accountable Care Organizations (ACO) 2011: NJ Public law 2011, Chapter 114 Medicaid Accountable Care Organization demonstration project. 29Part 2
  • Slide 30
  • KEEP Mandated services Choice of plans Actuarially sound rates ADD Risk-based payments 30 LOSE Part 2
  • Slide 31
  • 31Part 2
  • Slide 32
  • Section 1115 Research and demonstration Section 1915(b) Managed Care (Mandatory) Section 1915(c) Home and Community Based Concurrent 1915(b) & (c) 1. Childless adults 2. Family coverage (SCHIP) ACOs 3. NJ Care 2000+ 4. NJ Family Care BH ASO 5. Global Options (LT care) 6. Renewal Waiver 7. Community Resources 8. Community Care Alternatives 32Part 2
  • Slide 33
  • Section 1115 Research and demonstration Section 1915(b) Managed Care (Mandatory) Section 1915(c) Home and Community Based Concurrent 1915(b) & (c) 1. Childless adults 2. Family coverage (SCHIP) Accountable Care (ACO) 3. NJ Care 2000+ 4. NJ Family Care Behavioral Health (ASO) 5. Global Options (LT care) 6. Renewal Waiver 7. Community Resources 8. Community Care Alternatives 33Part 2
  • Slide 34
  • Section 1115 Research and demonstration Section 1915(b) Managed Care (Mandatory) Section 1915(c) Home and Community Based Concurrent 1915(b) & (c) 1. Childless adults 2. Family coverage (SCHIP) Accountable Care (ACO) 3. NJ Care 2000+ 4. NJ Family Care Behavioral Health (ASO) 5. Global Options (LT care) 6. Renewal Waiver 7. Community Resources 8. Community Care Alternatives 34Part 2
  • Slide 35
  • Section 1115 Research and demonstration Section 1915(b) Managed Care (Mandatory) Section 1915(c) Home and Community Based Concurrent 1915(b) & (c) One Comprehensive Waiver 35Part 2
  • Slide 36
  • One already exists! In DCF: CSOC 40,000 kids Phase in risk-based over 5 years Administrative Services Organization 36Part 2
  • Slide 37
  • 37Part 2
  • Slide 38
  • 38Part 2
  • Slide 39
  • 39 Benchmark coverage under ACA Part 2
  • Slide 40
  • 40 Benchmark coverage under ACA Excludable for newbies under ACA Part 2
  • Slide 41
  • 41Part 2
  • Slide 42
  • US0.72 WY1.43 AK1.40 DE1.00 PA0.73 CA0.56 NY0.43 NJ0.37 42Part 2
  • Slide 43
  • % doctors accepting 43Part 2
  • Slide 44
  • 100%! for PCPs and those they supervise even in managed care even for dual eligibles. Result: 10-24% increase in accepting PCPs? BUT: Not for specialists (e.g., psychiatrists) Only for 2013 and 2014 Extend? Measurement will be key 44Part 2
  • Slide 45
  • Overlap! Medicaid: < 138% FPL. Exchanges: > 100% FPL. Partial expansion? All > 100% to exchanges, where no state funding needed HHS: 100% FMAP if states do partial? NO! 45Part 2
  • Slide 46
  • Overlap! Medicaid: < 138% FPL. Exchanges: > 100% FPL. Partial expansion? All > 100% to exchanges, where no state funding needed HHS: 100% FMAP if states do partial? NO! 46Part 2
  • Slide 47
  • Overlap! Medicaid: < 138% FPL. Exchanges: > 100% FPL. Partial expansion? All > 100% to exchanges, where no state funding needed? NO! HHS: no 100% FMAP if states do partial 47Part 2
  • Slide 48
  • Wages Medicaid Exchanges: 35% of all adults below 200% FPL Exchanges Medicaid: 28 million p.a.? 48Part 2
  • Slide 49
  • 234,000 total eligibles FMAP = 100% New eligibles vs. old eligibles not enrolled 49 Part 2
  • Slide 50
  • HEDIS: measure behavioral health? Healthcare Effectiveness Data and Information Set System metrics, not consumer metrics 50Part 2
  • Slide 51
  • Publicity hurdles 150 different languages in NJ Cultural differences Application hurdles Multipage application Documentation of income and residency Tracking hurdles ACA does not apply to incomes < IRS tax filing threshold ($9,350 for singles, $18,700 for joint) = 50% of eligible uninsureds 51Part 2
  • Slide 52
  • South Carolinas IT Enterprise Strategy Map 52Part 2
  • Slide 53
  • ASO: July 1, 2014! Managed care, but Fee for service Live: January 1! Medicaid Expansion Exchanges 53Part 2
  • Slide 54
  • Reporting Documentation Audits Clawbacks Penalties 54Part 2
  • Slide 55
  • Reduced fees Increased costs New investments EMR Compliance Training 55Part 2
  • Slide 56
  • 56Part 2
  • Slide 57
  • 57Part 2
  • Slide 58
  • 58Part 2
  • Slide 59
  • Access Availability Quality Cost Innovation 59Part 2
  • Slide 60
  • 60 EnrolledTo be enrolledNot enrolled Access Availability Quality Cost Innovation Part 2
  • Slide 61
  • To the System To Providers To PsyR services (To Insurance) 61Part 2
  • Slide 62
  • Of basic care Of specialty care Of emergency care Of evidence-based practices 62Part 2
  • Slide 63
  • Provider What level? What training? What experience? What supervision? Process Simpler? Smoother? 63Part 2
  • Slide 64
  • Co-pays Deductibles Premiums (Work incentives?) 64Part 2
  • Slide 65
  • Practices Medications Technology Management 65Part 2
  • Slide 66
  • 66Part 2
  • Slide 67
  • 67 EnrolledTo be enrolledNot enrolled Access Availability Quality Cost Innovation Part 2
  • Slide 68
  • 68Part 2
  • Slide 69
  • 69Part 2
  • Slide 70
  • 70Part 2
  • Slide 71
  • 71Part 2