State Medicaid Advisory Committee (SMAC)archive.azahcccs.gov/archive/AHCCCS Info/Healthcare Advocacy/State Medicaid...Oct 22, 2014 · • SMAC Nomination Form • Bylaws and Federal

State Medicaid Advisory Committee (SMAC) Wednesday, October 22, 2014

AHCCCS Gold Room - 3rd Floor 701 E. Jefferson Street

9 a.m. – 11 a.m. Agenda

I. Welcome

Director Thomas Betlach

II. Introductions of Members

ALL

III. Approval of July 9, 2014 meeting summary

ALL

Agency Updates

IV. AHCCCS Update


V. CMS Update

Theresa Gonzales

Office of Intergovernmental Relations

VI. Membership • Term – Affirmation Statement • SMAC Nomination Form • Bylaws and Federal Regulations

ALL

Discussion

VII. Call to the Public • Suzanne Legander – S.T.A.R. Handout


VIII. Adjourn at 11:00 a.m.

ALL

2014 SMAC Meetings

Per SMAC Bylaws, meetings are to be held the 2nd Wednesday of January, April, July and October. All meetings will be held from 1 p.m.- 3 p.m. at the AHCCCS Administration

701 E. Jefferson, Phoenix, AZ 85034, 3rd Floor in the Gold Room:

January 8, 2014 April 9, 2014 July 9, 2014

October 8, 2014Rescheduled to October 22, 2014 with new time 9:00am to 11:00am

For more information or assistance, please contact Theresa Gonzales at (602) 417-4732 or [email protected]

July 2014 Meeting Summary

Janice K. Brewer, Governor Thomas J. Betlach, Director

801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 • 602-417-4000 • www.azahcccs.gov

State Medicaid Advisory Committee (SMAC) Meeting Summary

Wednesday, July 9, 2014, AHCCCS, 701 E. Jefferson, Gold Room 1:00 p.m. – 3:00 p.m.

Members in attendance: Beth Lazare Will Humble Kathy Waite Tara McCollum Plese Kevin Earle Phil Pangrazio Tomas Leon Vernice Sampson

Amanda Aguirre by phone Kathleen Collins Pagels Leonard Kirschner by phone Kathy Byrne by phone Peggy Stemmler Kim VanPelt Steve Jennings on behalf of David Mitchell

Members Absent: Tom Betlach Staff and public in attendance: Theresa Gonzales, Exe Const. III, AHCCCS Barb Fanning, Director, AzHHA Marcus Wilson, Policy & Planning, DES Scott Larson, SAM, BMS Terry Magden, Sr. P.M., AHCCCS Markay Adams, BH Coordinator, AHCCCS Eddie Sissons, MHA Arizona Lisa Schamus, Director of Program, AFHP

Charlie Collins, SAM, Gilead Anna Gulotta, Staff Attorney, CLS Melissa Higgins, Staff Attorney, CLS Sheila Sjolander, Assistant Director, ADHS Pam Perry, VP, Wellpoint Shannon Groppenbacher, Director Health Policy, JNT Gabriela Boyd, Self James Gauslad, PPLP, Self

AGENDA

I. Welcome & Introductions Beth Lazare II. Introductions of Members All

III. Approval of April 9, 2014 Meeting Summary/Minutes Unanimous

AGENCY UPDATES

IV. AHCCCS Updates Beth Lazare

• Medicaid Restoration • HEAplus Update • Prop 204 Adult Restoration • AHCCCS Adult Expansion • AIHP Adult Restored Coverage • Hospital Assessment & Litigation • Legislative Session • DHS Procurements

Page 2 of 2

AHCCCS Updates (continued)

• DHS Greater AZ Guidance • SIM Overview

AHCCCS Update Q&A’s Q: Include Primary Care Providers directly. A: This is part of the DHS Strategy. Q: How will Stakeholders be engaged? A: Stakeholders will be engaged re: structure of the framework.

• Proposed Arizona Strategy • Sovaldi

Other Q&A’s

Q: Any insight on Budget for next year due in a few weeks? A: Working with Governor’s office, but AHCCCS will provide on enrollment and cost information.

Comments:

o SLHI will share finding from their funded pilot projects re: SIM concept.

o Reauthorization of NF assessment. o Dental is a big issue. o Arizona is the only State without an open CHIP program.

V. Transition and Coordination with the Justice System Michal Rudnick

• Background • Eligibility and Enrollment • Pre-release Application Process • Care Coordination • Future Efforts

Q&A’s

Q: Issue for kids on medication who get enrolled in plan with different formulary.

A: Met with CMDP and need to explore; part of care coordination. Get information on what they’re on and look at best approach when gaps are identified. Comments:

o Grateful for the Justice Project. o Complex issues: AHCCCS doing amazing. o Want to look at data o Looking at SIM grant but recognize and sustainability plan is

needed. o Make sure information gets from plan to providers. o Expectation that something is done with information. o SLHI work with PCAP and Keogh for enrollment assistance, but

when expanding, how would it be funded in the long-term.

Page 3 of 2

VI. CMS Update Theresa Gonzales

• AZ Medicaid State Plan Amendments • SNCP and I.H.S./638 Extension Waiver Amendment Requests • Benefits Discussion

DISCUSSION VII. Call to the Public Beth Lazare

VIII. Adjourn at 3:00 p.m. All

AHCCCS Update

AHCCCS Update

Hospital Assessment & LitigationAssessment• Collaborating with stakeholders – model no negative system• Assessed $75 m in FY 2014 - $233 m in FY 2015• FY 15 estimates - Will wait for several more data points –

collaborate Litigation• Lawsuit brought by 36 Republican Legislators• Won at Superior Court – Standing• Court of Appeals - 4-22-14 rules legislature has standing • November 6th – State Supreme Court oral arguments

2

Medicaid Restoration

Reaching across Arizona to provide comprehensive quality health care for those in need

3

12/1/2013 9/1/2014 Change

Prop 204 Restoration 67,770 266,514 198,744

Adult Expansion 0 30,014 30,014

KidsCare 46,761 1,945 ‐44,816

Family Planning 5,105 0 ‐5,105

AHCCCS for Families & Children (1931) 672,135 746,715 74,580

All Other 505,379 596,228 90,849

Total Enrollment 1,297,150 1,641,416 344,266

AHCCCS Enrollment Growth

01000020000300004000050000600007000080000

Enrollment Growth

4Reaching across Arizona to provide comprehensive quality health care for those in need

Prop 204 Adult Restoration


‐

50,000

100,000

150,000

200,000

250,000

300,000

Actual FY15 Forecast FY16 Forecast

AHCCCS Adult Expansion


6

‐

10,000

20,000

30,000

40,000

50,000

60,000

70,000


Total AHCCCS Acute


‐

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000


Hospital Assessment Funding Levels• JLBC had estimated $204 m for FY 2015• AHCCCS levied $233 m for FY 2015• Current Estimate is $272 m for FY 2015

and $250 m for FY 2016• Many variables-options

o Enrollment o Health Plan Reconciliations o Payment Timing


Medicaid / CHIP Enrollment Millions of Enrollments per month


SOURCE: CMS Medicaid and CHIP: May 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report (published July 11, 2014)

Eligibility Update• Preparing for Nov 15th Open enrollment• New Interface requirements• Risks• Increased call center staff• Better Consumer experience??


10

AHCCCS/DES Call Volume

0

50000

100000

150000

200000

250000

300000

January February March April May June July August


Safety Net Care Pool (in millions)FFY2012

FFY 2013 FFY 2014 Totals

SNCP $267.2 $243.9 $28.4 $539.5

City of Phoenix

$322.8 $94.1 $416.9

I.H.S/638Uncomp care

$47.9 $102.2 $18.2 $168.3

Totals $315.1 $668.9 $140.7 $1,124.7


AHCCCS Funding by Source


73%18%

2%

3%3%1%

Fed Funds

Gen Fund

Tobacco

Assessments

County/Local

Presc Drug

Budget Update• FY 14 State revenues were ($113) m below

forecast – growth rate 2.8%• K-12 Superior Court ruling for $317 m in FY 2015


14

In Millions FY 2015 FY 2016

Adopted Budget Projection 130 (237)

Oct. JLBC Revenue Changes (189) (667)

Revenue + K‐12 Ruling (520) (1,002)

Budget Reduction Options1. Eligibility – Freezes not an option –

savings accrue to assessment2. Optional Services – None left3. Rate Reductions –4. Administration – still one-third less staff


Provider Rate Changes (2009-15) Provider Change Provider Change

Hospital IP ‐9.8% Emergency 29.5%

Hospital OP ‐8.7% NEMT ‐14.3%

NF (EPD) ‐1.6% ASC 5.6%

Behavioral Health OP

‐8.1% Dental ‐12.5%

Physician ‐12.9% FQHC 35.8%

PCP Parity 13.8% Hospice 12.3%


Average Annual Capitation Growth


6.73 6.49

-2.45-4.2

-7.6

1.42.8 2.0

-10-8-6-4-202468

CYE '08 CYE '09 CYE '10 CYE'11 CYE '12 CYE'13 CYE'14 CYE 15

AHCCCS Spending 2001-2015

1

3

5

7

9

11

13

FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY 16

Billion

s


General Fund for AHCCCS Programs

0

500

1,000

1,500

2,000

2,500

FY 09 FY 10 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16

DES/DHS GF2AHCCCS GF



Sovaldi• Have had 18,000 Hep C members past 2

years• Total approved 225• 165 12 week – 60 24 week• First 4 month 33.75 per month• Last 4 months 14.5 per month


21

Sovaldi Con’t.Low High

Treatment Cost –post Rebate

$52,500 $112,500

20% of Known HepC Population

117,119,520 250,970,400

Entire Known HepC population

585,597,600 1,254,852,000


Improving Federal Estimates


Payment Modernization• Shared Savings Requirement for 10-1-14

o 10% acute o 5% ALTCS – CRS

• New APR-DRG structure provides flexibility in future for more quality based payments

• New Requirement for plans to leverage payment incentives and other tools to increase E-prescribe o Current ranking for AZ – 42nd


Payment Modernization• Health Plan 1% Cap Withhold Competition

1. 30 day readmission2. ED Utilization3. Well Child visits – 15 months4. Well Child visits – 3-6 years5. Well Child visits – 12-21 years6. Children’s dental visit – ages 2-21


Program Integrity Avoidance and Recovery Savings (in millions)

0

200

400

600

800

1000

1200

FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014Note – calculation of savings has evolved over time


Fragmentation Initiatives• Members with Serious Mental Illness• Dual Eligible Members• American Indian Health Program• Justice System Transitions• CRS – 16,700 special needs kids

(10-1-13)


Greater AZ RBHA


North includes San Carlos Apache Tribe in Graham county with zip codes 85530 and 85550

Aligned Dual Members

0

10000

20000

30000

40000

50000

60000

70000

January 2006 January 2012 October 2014


American Indian Health Plan

Staffing & Resources Data

Care Coordination Model Relationships

AIHPCare Coordination

30

Justice Transition Initiatives• 18,000 + released DOC annually• 100,000 + released county jails annually• Estimated over half of those released require

treatment for mental health/substance abuse• DOC Spends $150 m annually • Counties spend approx $90 m • 60-70% for Both is BH/SA• In 2011 AHCCCS spent $187 m on members

incarcerated as some point during the year31Reaching across Arizona to provide comprehensive

quality health care for those in need

Justice Transition Initiatives• AHCCCS has in place process to cover

Inpatient costs for DOC - most county jails• AHCCCS has in place data interfaces to

suspend and reinstate enrollment • AHCCCS has in place manual process for

care coordination – enrollment for high cost cases

• Pursuing other opportunities


Other Issues• Federal uncertainty over increased

Physician Payments• Marketplace Consolidation

o Banner – UAHNo Accension – Tenet – Dignityo JLC - Scottsdale

• Transparencyo Public Spending – Performance – Costso Consumer info – Health plan report card


Arizona SIM VisionAccelerate the delivery system’s evolution towards a value-based integrated model that focuses on whole person health in all settings

regardless of coverage source.


SIM StrategiesStrategy Funding

Implement SHIP strategies to accelerate transformation $ 5 million

Accelerate use of HIT/HIE in delivery system – BH emphasis $ 10 m

Competitive grants to large provider systems that partner with community based behavioral health providers

$20 m

Workforce initiatives – training and best practices $7.5 m

EMS Partnerships for ED diversion $2 m

Accelerate care coordination for high need adults $6 m

QHP/Medicaid Care Coordination transition $2 m

Enhance and expand American Indian care coordination $3 m

Fund 4 regional care coordination models $10 m

American Indian Health Plan member education $1 m

Justice System Care Coordination $5 m

Value Based Payment Modernization $5 m 35

CMS Update

1

CMS Update State Plan Activity

The State Plan is a comprehensive written contract between AHCCCS and the Centers for Medicare and Medicaid Services (CMS) that describes the nature and scope of Arizona’s Medicaid program and assures that Arizona will administer its programs according to federal requirements under the provisions of the Social Security Act (SSA). The State Plan also provides a basis for Federal Financial Participation (FFP).

AHCCCS submits State Plan Amendments (SPAs) for CMS approval to reflect changes in federal and state laws, regulations, policy, or court decisions. The following is a summary of Arizona’s SPA activity over the past 3 years: 2014: 12 SPAs submitted; 6 approved; 6 pending 2013: 19 SPAs submitted; 18 approved; 1 pending; 2012: 15 SPAs submitted; 12 approved; 1 pending; 2 withdrawn 2011: 25 SPAs submitted; 24 approved; 0 pending; 1 withdrawn 2010: 17 SPAs submitted; 16 approved; 1 withdrawn 2009: 6 SPAs submitted; 5 approved; 1 denied More information can be found at: http://www.azahcccs.gov/reporting/PoliciesPlans/StatePlanAmendments.aspx Waiver Activity

The 1115 Waiver refers to section 1115 of the Social Security Act. AHCCCS has been exempt from specific provisions of the SSA, under an 1115 Waiver since Arizona first began participating in Medicaid on October 1, 1982. Arizona’s 1115 Waiver includes provisions in the SSA and corresponding regulations AHCCCS is exempt from; terms and conditions that AHCCCS must fulfill; approved federal budget amounts. AHCCCS submits waiver amendments to reflect changes in federal and state laws, regulations, policy, and court decisions. The following is a summary of Arizona’s Waiver activity:

- Pregnant Women and Hospital Presumptive Eligibility (HPE)

Currently, federal regulation limits services available to pregnant women under HPE to ambulatory prenatal care. AHCCCS is proposing to reimburse for the full array of services available to eligible Medicaid beneficiaries under the State Plan and 1115 waiver provided to pregnant women who are eligible under the Hospital Presumptive Eligibility program. Proposal to CMS 9/2/14 [PDF]

- Phoenix Children’s Hospital SNCP Extension and Uncompensated Care Payments to I.H.S. and 638s Extension On August 26, 2014, AHCCCS submitted a request to amend the waiver to extend the Phoenix Children’s Hospital SNCP and Uncompensated Care Payments initiatives for an additional year through December 31, 2015. For more background information on these requests, can be found on the AHCCCS website.

- Tuba City Regional Health Care Corporation On August 29, 2014, AHCCCS submitted a Waiver Amendment request to preserve access to care for a critical Medicaid population that is largely American

2

Indian living in rural and frontier areas; and collect data to establish a line item within the Indian Health Services budget as more of these facilities are built on reservation. Tuba City Regional Health Care Corp. Waiver Submittal 8/29/14 [PDF]

- Behavioral Health Integration

AHCCCS is proposing to expand integrated health care service delivery by allowing the Greater Arizona RBHAs to provide physical and behavioral health care services to individuals with Serious Mental Illness in order to maximize care coordination statewide. AHCCCS is accepting public comments through March 24, 2014 on the proposal at the link below. See the Public Comment section below for instructions on how to send comments on this proposal. Greater AZ RBHA DRAFT 2/20/14

- Medical Homes at I.H.S. and 638 facilities AHCCCS is requesting authority to support a Medical Home Program for the FFS population receiving services at Indian Health Services and 638 facilities. More information is included in the proposal below. REVISED Proposal to CMS 4-15-14 [PDF]

More information about waivers can be found at: http://www.azahcccs.gov/reporting/federal/waiver.aspx

3

2014 Amendments SPA 14-012 - GME Updates GME funding for the service period July 1, 2014 through June 30, 2015 for programs with submitted IGAs. Submitted 9/30/14 [PDF] SPA 14-011 - Third Party Liability Updates the State Plan to reflect changes to Third Party Liability. Submitted 9/30/14 [PDF] SPA 14-010 – Insulin Pumps Updates the ABP and State Plan to include insulin pumps as a covered benefit. Submitted 9/9/14 [PDF] SPA 14-009 – ARP-DRG Describes the All Patient Refined Diagnosis Relation Group hospital reimbursement methodology in the State Plan for Inpatient dates of service on and after October 1, 2014. Submitted 8/27/14 [PDF] Approved 10/21/14 SPA 14-008 – Presumptive Eligibility Describes Presumptive Eligibility by Hospitals in Arizona. Submitted 3/28/14 Presumptive Eligibility in Arizona SPA 14-004 – Therapies Revises the State Plan to reflect updates to therapies covered under the State Plan. Submitted 2/20/14 SPA 14-003 – Medically Preferred Treatment Options Revises the State Plan to reflect updates to the orthotic benefit. Submitted 1/31/14 SPA 14-001 – ADHS Licensure Changes Revises the State Plan to reflect updates to the licensing of health programs. Submitted 1/10/14

Membership

First Name Ex‐OfficioThomas

Will

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Term da

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Term: 2/2

Term: 2/2

Term: 4/2

Term: 7/2

Term: 4/2

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2014 – 2/2016

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STATE MEDICAID ADVISORY COMMITTEE

(SMAC) Nomination Form

Your Name: Nominee’s Name: Address:

City/State:

Zip Code:

Employer:

Position/Title:

Office Phone Number:

Fax:

E-Mail Address: What experience or skills does the nominee have that would be a benefit to the committee?

Please complete all fields. Mail, Fax, or E-Mail to: AHCCCS, Office of the Director 801 E. Jefferson St., MD 4100

Phoenix, AZ 85034 Phone: (602) 417-4711

Fax: (602) 256-6756 E-Mail: [email protected]

BYLAWS

For The

A. H. C. C. C. S.

STATE MEDICAID ADVISORY

COMMITTEE

(SMAC)

Arizona Health Care Cost Containment System Revised December 2005

BYLAWS

MISSION

The committee will participate in the consideration of AHCCCS policy and programs by reviewing policy, rules and administrative issues. The committee will advise the Director of AHCCCS of policy and administrative issues of concern to the committee member's constituency. To facilitate accomplishing this mission, the committee will recommend issues to be included on the agenda to allow deliberation of major policy issues prior to their implementation, as much as practicable; receive background information and policy papers prior to meetings, if available; and, have the opportunity to discuss issues with AHCCCS Senior Management.

AUTHORITY

The committee operates in accordance with 42 CFR 431.12 and the State Medicaid plan.

DEFINITIONS

“Administration” means the Arizona Health Care Cost Containment System (AHCCCS) as defined in Arizona Revised Statutes (A.R.S.) §§ 36-2901, 36-2931, 36-2971 and 36-2981. “Committee” means the State Medicaid Advisory Committee, as appointed by the Director. “Director” means the Director of AHCCCS as specified in A.R.S. §§ 36-2901, 36-2931, 36-2971 and 36-2981.

COMMITTEE COMPOSITION

The committee shall include the Director or a designee, the DHS Director or a designee, and the DES Director or a designee; six health care providers or professionals with a direct interest in the AHCCCS program; and six members of the public (such a Medicaid recipient, a consumer advocate, a representative of a tribal community, or a representative of the educational community).

APPOINTMENT PROCESS AND LENGTH OF TERM

The Director or a designee, the DHS Director or a designee, and the DES Director or a designee positions are ex-officio. The remaining 12 committee members shall be appointed by the Director for two, two year terms. The AHCCCS Director or a designee is the committee's chairperson and is responsible for setting meeting agendas. The chairperson can call special meetings. The chairperson shall preside at all meetings, and shall facilitate discussion by the members. The committee may submit to the Director a list of nominees for expiring terms. The Director may solicit or receive nominations from other sources.

STAFF ASSISTANCE Staff assistance from the Administration shall be available to the committee at the request of the chairperson or the full committee. The designated SMAC Manager shall provide staff assistance. The SMAC Manager can be reached by phone at (602) 417-4736 or 1-800-654-8713 ext. 4736. Independent technical assistance shall be available at the request of the full committee, if determined necessary by the Director and funds are available.

MEETINGS

Meetings shall be held quarterly on the 2nd Wednesday of February, April, July and October, or upon the call of the Director.

If a committee member is unable to attend a meeting, the member is requested to notify the SMAC Manager of their absence prior to the date of the meeting. Members are encouraged to send a representative to meetings they are unable to attend. Members are requested to notify the SMAC Manager with the name of the individual who will be attending on their behalf. The SMAC meetings are open to the public. MEETING MATERIALS When available, handouts for the current agenda will be mailed two weeks in advance of the meeting. Members shall bring all mailed handouts to the meeting to facilitate discussion. If a member is unable to attend the meeting and is sending a representative, please forward the handouts to the representative to bring to the meeting. FEDERAL FINANCIAL PARTICIPATION

Medicaid recipient members shall be reimbursed for necessary costs, such as transportation and childcare, to facilitate their attendance at committee meetings. If determined necessary and available by the AHCCCS Director, Federal financial participation at 50 percent shall be secured for expenditures for the participation of the Medicaid recipient members and for committee activities, including independent technical assistance costs. S:\Share\SMAC\SMAC Bylaws2000.doc

42 Code of Federal Regulations (CFR)

Part 431-State Administration Subpart A-Single State Medicaid Agency 42 CFR 431.12 § 431.12 Medical care advisory committee. (a) Basis and purpose. This section, based on section 1902(a)(4) of the Act, prescribes State plan requirements for establishment of a committee to advise the Medicaid agency about health and medical care services. (b) State plan requirement. A State plan must provide for a medical care advisory committee meeting the requirements of this section to advise the Medicaid agency director about health and medical care services. (c) Appointment of members. The agency director, or a higher State authority, must appoint members to the advisory committee on a rotating and continuous basis. (d) Committee membership. The committee must include -

(1) Board-certified physicians and other representatives of the health professions who are familiar with the medical needs of low-income population groups and with the resources available and required for their care;

(2) Members of consumers' groups, including Medicaid recipients, and consumer organizations such as labor unions, cooperatives, consumer-sponsored prepaid group practice plans, and others; and

(3) The director of the public welfare department or the public health department, whichever does not head the Medicaid agency.

(e) Committee participation. The committee must have opportunity for participation in policy development and program administration, including furthering the participation of recipient members in the agency program. (f) Committee staff assistance and financial help. The agency must provide the committee with -

(1) Staff assistance from the agency and independent technical assistance as needed to enable it to make effective recommendations; and (2) Financial arrangements, if necessary, to make possible the participation of recipient members.

(g) Federal financial participation. FFP is available at 50 percent in expenditures for the committee's activities.

Call to the Public

Documents

State Medicaid Advisory Committee (SMAC)archive.azahcccs.gov/archive/AHCCCS Info/Healthcare Advocacy/State Medicaid...Oct 22, 2014 · • SMAC Nomination Form • Bylaws and Federal