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