Transcript The Arizona Long Term Care System (ALTCS) University of Maryland Center on Aging
The Arizona Long Term Care System (ALTCS)
University of Maryland Center on Aging Medicare/Medicaid Integration Program July 8, 2004
1
AHCCCS’ Mission and Vision Mission:
Reaching across Arizona to provide comprehensive, quality health care for those in need
.
Vision:
Shaping tomorrow's managed health care from today's experience, quality, and innovation
.
2
The Arizona Long Term Care System
History Current System Future
3
History
•
July 13, 1982:
The Health Care Financing Administration (HCFA), which is now the Centers for Medicare & Medicaid Services (CMS) granted Arizona an 1115 Research Waiver.
•
October 1, 1982:
The Arizona Health Care Cost Containment System (AHCCCS) began serving people in its acute care program.
• Arizona was the first state to implement a statewide, Medicaid managed care system, based on prepaid, capitated arrangements with health plans.
4
History
•
The following long term care services were excluded with approval of the 1115 Waiver:
– Skilled Nursing Facility Services to certain categorically needy individuals – Home Health Care •
Why wasn’t long term care covered in the initial Arizona 1115 Waiver?
– Acute care was the main concern – Needed to stabilize acute care program first 5
History
•
Arizona in December 1986:
– New Governor – Feds requested that AHCCCS add long term care or behavioral health services – Long term care was a responsibility of the counties – Home and community based programs existed – Opportunity to refinance 6
History
•
December 1988:
AHCCCS began phasing-in long term care services for persons who were Developmentally Disabled (DD) •
January 1989:
AHCCCS began serving the Elderly and Physically Disabled (E/PD) • Home and community based services were limited to a maximum expenditure of 5% of the State’s long term care expenditures for long term care services.
7
History
County Involvement: Then and Now • •
In the Beginning:
– Maricopa County – Pima County
A Few Years Later:
– Yavapai County – Pinal County – Cochise County 1 Plan per County, except •
Today:
– Maricopa Long Term Care Plan – Pima Health System – Yavapai County Long Term Care – Cochise Health Systems – Pinal/Gila Long Term Care – Evercare Select – Mercy Care Plan 3 Plans in Maricopa County 8
Current System
•$2.8 Billion (Appropriated) •$3.4 Billion (Appropriated & Non-Appropriated) •
HCFA
•
State
•
County
•
Private
º º
Foundation Premiums Delivery System Single State Agency AHCCCS Administration
•
Policy
•
Eligibility (Special Populations)
•
Contract for Care
•
Monitor Care and Financial Viability
•
Information Services
•
Budget and Claims Processing
•
Legal
•
Intergovernmental Relations Product Lines
• Acute Care • KidsCare • Long Term Care • Healthcare Group • Premium Sharing •
Acute health plans
•
LTC program contractors
• •
State Agencies
º
DHS
· Behavioral Health · CRS º
DES
· DDD · Foster Children · Eligibility
FFS
° Indian Health Services ° Emergency Services (non-qualified immigrants) ° LTCS members enrolled with Tribes/NACH
Current System
Who Does AHCCCS Serve?
Program
Acute ALTCS (Long Term Care) KidsCare Healthcare Group
Enrolled Members Member Profile
853,206 38,886 (EPD – 23,329, DD – 15,557) 48,331 Primarily children and women with children. Individuals with developmental disabilities, physical disabilities, or over 65 years of age. Children through the age of 18. 10,969 Employees of small businesses.
Total 951,392
(April 2004) 10
Current System
ALTCS Elderly and Physically Disabled (EPD) Only (3/01/2003) (Excludes Tribal Enrollment) 0 to 21 3% 65 & Older 71% 21 to 64 26% Total:
21,969 NF: 38.6% Own Home: 44.7% Alt. Res.: 14.7% Other: 2.0%
Current System
•
ALTCS Principles:
– Prepaid, capitated approach through public/private partnerships.
– Integrate all long term care services by bundling acute care, long term care, case management, and behavioral health services.
– Pre-admission screening process to identify those at risk for institutionalization.
– Full continuum of services to ensure members are placed in least restrictive, most cost-effective care.
– Primary care physicians/case managers serve as gatekeepers to coordinate care.
12
Current System
•
AHCCCS Health Plan Responsibilities:
– Contract for Services – Develop and Ensure Adequate Network – Active Monitoring and Oversight – Case Management – Quality and Utilization Management – Integration of Medical Care – Member and Family Support – Pay Claims and Process Encounters – Grievance and Appeals 13
Current System
•
What Makes ALTCS Work:
– Pre-admission screening (PAS) – Integrated continuum of care / choice of community settings – Network standards – Ability for members to move between settings without interruption in services – Case management standards – HCBS financial incentives to health plans – State oversight (Contract, Network, Finance, QM, CM, Annual Reviews, Technical Assistance) – Good communication between State and health plans 14
Current System
Potential ALTCS Member
2,300 Applications/Month
ALTCS Health Plan
DES-DDD ALTCS Model
Financial/Medical Eligibility
1. Citizen/Qualified Alien 2. AZ Resident 3. $2,000/$3,000 Resources 4. $1,692 Income Maximum 1 5. Transfer of Resources 6. SSN 7. Medical Eligibility/PAS EPD Contractors Maricopa LTC Plan Pima Health System Evercare Select Mercy Care Tribes Yavapai County LTC Pinal Gila LTC Cochise Health System
PCP/ CASE MANAGER
KEY EPD Elderly & Physically Disabled (Age 65+, Blind or Disabled) DES/DDD Dept. of Economic Security, Div. Of Developmental Disabilities ICF/MR - Intermediate Care Facility for Mental Retarded NF Nursing Facility PAS Pre Admission Screening 1 Income Limit is 300% of SSI maximum and increases annually in January Covered Services Acute Care Services Nursing Facility ICF/MR Hospice Behavioral Health HCBS - Homemaker - Personal Care - Respite Care - Attendant Care - Home Health Nurse - Home Health Aide - Transportation - Adult Day Health - Home Delivered Meals - DD Day Care - Habilitation - Assisted Living Facilities 15
Future
•
Future:
– Coordination of care for dual eligibles.
– Revamping of the Medicare and Medicaid programs.
– A better system to help individuals understand and retrieve information on choices and options.
– Ability to continue expansion of HCBS. This will create a need for more monitoring by plans.
– Continued growth and impact on budget. – Federal law allowing people to shelter income and create annuities.
– A closer look at including LTC insurance in employer benefit plans paid for by employees.
16