balancing incentive program webinar (nov 2011)
TRANSCRIPT
Section 10202 of the
Affordable Care Act
Mission Analytics Group and HSRI in collaboration with
the Centers for Medicare and Medicaid Services (CMS)
November 2011
Presentation Outline
2
1. Overview of the Program
3. Reporting Requirements
2. Applying to the Program
4. Frequently Asked Questions
Ben
efi
ts o
f th
e P
rogra
m
3
• Support States in providing quality care in the most appropriate, least restrictive settings
Purpose
• +2% FMAP: States that spend less than 50% of Medicaid LTSS dollars on community LTSS
• +5% FMAP: States that spend less than 25% of Medicaid LTSS dollars on community LTSS
State Benefits
4
NWD/SEP System
Core Standardized Assessment
• Standard assessment instrument(s) used for a given population
• Captures domains & topics
Conflict-Free Case
Management
• Streamlined and
coordinated system
for eligibility
determination and
enrollment into
services
Three Structural Changes
• Separation between case
management & provision
of community LTSS
services
NW
D/SE
P S
yste
m
5
•State Medicaid AgencyOversight Agency
•Delegated by the Medicaid Agency
Operating Agency
• Aging and Disability Resource Centers
• Centers for Independent Living
• Area Agencies on Aging
• Non-profit organizations
NWD/SEP Network
NW
D/SE
P S
yste
m
6
• Composed of basic functional and financial questions
• Determines potential eligibility for community LTSS
Level I Screen
• Composed of a full functional and financial assessment
• Determines actual eligibility for community LTSS
Level II Assessment
Two-Stage Eligibility Determination
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Website
1-800 Number
• Links individual to a NWD/SEP for information and Level I screen
NWD/SEP Physical Location
• Contains information
about community
LTSS, 1-800 number,
and location of
NWD/SEPs
• Ideally, provides
Level I self-screen
Entry Points
• Staff conduct Level I
screen and coordinate
Level II assessment
NWD/SEP
System
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Determine eligibility
Determine support needs
Inform service
planning
Three Goals
Core
Standardized
Assessment
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Three Goals of the CSA
1. Activities of Daily Living
Eating ToiletingBathing MobilityDressing PositioningHygiene Transferring
2. Instrumental Activities of Daily Living
Preparing Meals TransportationHousework ShoppingManaging MoneyTelephone UseManaging Medication
3. Medical Conditions/Diagnoses
4. Cognitive Functioning/ Memory
Diagnoses tied to CognitiveFunctionMemoryJudgment/Decision-Making
5. Behavior Concerns
Injurious UncooperativeDestructive Other SeriousSocially Offensive
CSA Must Capture Domains and Topics
Conflict-Free Case Management
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Separation of case management from direct
service provision
Separation of eligibility determination from
direct service provision
Individuals performing evaluations, assessments, and plans of
care cannot be:
Related by blood or marriage to the individual or any of the
individual’s paid caregivers
Financially responsible for the individual
Empowered to make financial or health-related decisions on
behalf of the individual
Presentation Outline
11
1. Overview of the Program
2. Applying to the Program
3. Reporting Requirements
4. Frequently Asked Questions
12
Application
Work Plan
• States must submit a Work Plan six months after submitting the application
Technical Assistance
• CMS and contractors will provide technical assistance to States
Applying to the
Program
• States submit
applications on a
rolling basis though
August 1, 2014 or
$3 billion exhausted
Work Plan (Page 59 of Manual)
13
Category Major Objective / Interim TasksDue Date (from time
of Work Plan submission)
Lead Person Status of Task Deliverables
Gen
eral
NW
D/S
EP
Str
uct
ure All individuals receive standardized information and experience the same eligibility determination and enrollment
processes.Develop standardized informational materials that NWD/SEPs provide to individuals
3 months Informational materials
Train all participating agencies/staff on eligibility determination and enrollment processes
18 months Training agenda and schedule
A single eligibility coordinator, “case management system,” or otherwise coordinated process guides the individual through the entire functional and financial eligibility determination process. Functional and financial assessment data or results are accessible to NWD/SEP staff so that eligibility determination and access to services can occur in a timely fashion. (The timing below corresponds to a system with an automated Level I screen, an automated Level II assessment and an automated case management system. NWD/SEP systems based on paper processes should require less time.)
Design system (initial overview)
0 months (submit with Work Plan)
Description of the system
Design system (final detailed design)
6 months Detailed technical specifications of system
Select vendor (if automated) 12 months Vendor name and qualifications
Implement and test system 18 months Description of pilot roll-out
System goes live 24 months Memo indicating system is fully operational
System updates Semiannual after 24 months
Description of successes and challenges
Completing the Work Plan
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1. Review/modify tasks
2. Change # of months to actual dates
3. Add lead person
4. Add status (i.e., not started, in progress, finished)
Deliverables Due with Work Plan
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1. Initial Overview of NWD/SEP System
2. Name of Operating Agency and NWD/SEP types
3. Completed CDS Crosswalk
4. Description of case management and potential conflict
6. Data collection protocols
7. Sources of funding to implement structural changes
Presentation Outline
16
1. Overview of the Program
3. Reporting Requirements
2. Applying to the Program
4. Frequently Asked Questions
Quart
erl
y R
eport
s
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• Provides information on share of LTSS dollars spent on community LTSS
• Allows CMS to monitor progress toward community LTSS targets
Form CMS-64
• Submitted online
• Includes Work Plan deliverables with a summary sheet
• Allows CMS to monitor progress on structural changes and provide technical assistance
Progress Reports
Data
Coll
ecti
on
R
equir
em
en
ts
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• All community LTSS at the individual level
• States should already have mechanisms in place for collecting these data (e.g., claims/encounter data)
Services Data
• Clinical measures that capture the extent to which service providers are supplying comprehensive, quality care
• Example: Medicaid Adult Health Quality Measures
Quality Data
• Measures of beneficiary and family caregiver experience and satisfaction with providers
Outcomes Measures
Presentation Outline
19
1. Overview of the Program
3. Reporting Requirements
2. Applying to the Program
4. Frequently Asked Questions
Fre
quen
tly A
sked
Questi
on
s
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• How is a State’s eligibility for the Program determined? Question
• Share of Medicaid LTSS spent on community LTSS
Answer
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• How was this percent calculated for each State?Question
• State Medicaid expenditures reported on CMS-64 from FY 2009
• You may: Request information on your State
calculations
Propose your own calculations
Answer
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• When does the enhanced FMAP begin? Question
• The first day of the first full quarter after the application is approved
Answer
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• Do rural areas with few providers have to meet the conflict-free case management requirements?
Question
• If a rural area has very few providers, the State must have mechanisms to reduce conflict, e.g., administrative separation and State and consumer oversight
Answer
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• What about conflict-free case management in managed care environments?
Question
• If the managed care environment does not permit the complete separation between case management and service provision, the State must have mechanisms to reduce conflict, e.g., administrative separation and State and consumer oversight
Answer
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• How can my State fund the structural changes?Question
• Enhanced FFP for Eligibility and Enrollment (E&E) Systems
• Money Follows the Person (MFP) administrative and savings funds
• ADRC grantsSee p. 44 of the Manual for more
Answer
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• What can the enhanced FMAP be used for? Question
• “For purposes of providing new or
expanded offerings of non-
institutionally-based long-term
services and supports.”
Answer
TA
Resourc
es
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CMS
TA Contractors
• http://www.balancingincentiveprogram.org/
• https://www.cms.gov/smdl/smd/itemdetail.asp?itemid=CMS1252041
Websites