evercare select arizona long term care system (altcs)
TRANSCRIPT
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Arizona Long Term Care System (ALTCS)
Comprehensive Capitated Model
Elderly and Physically Disabled (EPD) Population
Developmentally Disabled Population
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ALTCS
Medicaid program designed to provide nursing facility and home based services to Arizona residents:
Are at risk of institutionalization Have income and resources below the program limits Meet additional program requirements.
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ALTCS Objectives
Prepaid, capitated approach through public/private partnership.
Integrate health services by bundling acute, long term care and behavioral health services.
Pre-admission screening process to identify those who are at-risk for institutionalization.
Full continuum of services: HCBS to NF Ensure members are placed in the least restrictive,
most cost effective care. PCP/case managers coordinate care.
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ALTCS Services
Institutional Care Home and Community Based Services Behavioral Health Acute Medical Care Services
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PotentialALTCSMember
Chart 3AARIZONA LONG TERM CARE SYSTEM
EligibilityFinancial
andMedical
ALTCSProgram
Contractor
PCP / CaseManager
HCBS
AlternativeResidential
Settings
Nursing Facility
ICF/MR(DD only)
Hospice
Acute CareServices
CaseManagement
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Elderly & Physically Disabled Population
85% of the EPD population are dual eligibles Average age of an EPD eligible member is 72 years of
age. Approximately 2% of the EPD population are members
under the age of 21. Largest growing EPD population segment - 19-64 Average length of time (duration) in the ALTCS
Program - 2.8 years Less than 1% of the EPD population are ventilator
dependent.
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ALTCS Acute Care Services
Ambulatory Surgery & Anesthesiology Audiology Behavioral Health Chiropractic Services Dental Dialysis Early and Periodic Screening, Diagnosis and
Treatment Emergency Services Eye Examinations/Optometry
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ALTCS Acute Care Services
Family Planning Health Risk Assessment and Screening Hospital Immunizations Laboratory Maternity Medical Supplies, Durable Medical Equipment,
Orthotics and Prosthetic Devices Physician
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ALTCS Acute Care Services
Podiatry Prescription Medications Primary Care Provider Radiology and Medical Imaging Rehabilitation Therapy Respiratory Therapy Transplants Transportation Triage/Screening and Evaluation
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ALTCS Long Term Care Services
Adult Day Health Care Attendant Care Behavior Management Services Emergency Alert System Environmental Modifications Group Respite Habilitation Home Delivered Meals Home Health Services
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ALTCS Long Term Care Services
Homemaker Hospice Partial Care Personal Care Private Duty Nursing Respite Care
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ALTCS Institutional Settings Nursing Facility Institution for Mental Disease Inpatient Psychiatric Residential
(members under 21)
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ALTCS HCBS Alternative Residential Settings
Assisted Living Facilities Adult Foster Care
Assisted Living Home
Assisted Living Center
Alzheimer’s Treatment Assistive Living Facilities
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ALTCS HCBS Alternative Residential Settings
Behavioral Health Settings Behavioral Health Level I
Behavioral Health Level II
Traumatic Brain Injury Treatment Facility
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Capitation
AHCCCS pays program contractors prospectively on a
capitated, per member per month basis.
Capitation rates are blended rates which include:
nursing facility,
HCBS,
acute medical services,
behavioral health services,
case management and administrative costs.
Statewide average rate is $2,344 (as of October 1, 2000).
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Development of ALTCS Capitation Rates
Information used in rate development: PC financial statements Encounters Inflation factor - Data Resource Institute (DRI)
ALTCS Reinsurance covers partial reimbursement of acute inpatient services and limited outpatient services beyond an annual deductible
ALTCS data sources (including PC reported financial information). Private sector data sources Inflation factor - Data Resource Institute (DRI)
An independent actuarial firms establishes actuarially sound rates or rate ranges
Competitive bids Rates/rate ranges are established each new bid year
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Nursing Facility $3,272.04 X 50.00% = $1,636.02
HCBS Home $1,043.74 X 36.50% = $380.97
HCBS Community $1,327.96 X 13.50% = $179.27
Acute Care $415.35
Case Management $74.97
Administration/Profit $189.95
Risk/Contingency* $38.46
Share of Cost* ($312.26)
*Set by AHCCCS. Share of Cost will be fully reconciled.
CRCS SUMMARY
Capitation Rate Components
Net Capitation $2,602.74
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Type of Placement% of
PlacementPer Diem
CostPer Diem Placement
Level One 44.0% X $99.02 = $43.57
Level Two 42.2% X $111.44 = $47.03
Level Three 5.2% X $135.44 = $7.04
Wandering Dementia 7.4% X $118.45 = $8.77
Subacute 1.2% X $245.00 = $2.94
Total (100%): 100.0% Subtotal: $109.34
Less Medicare/TPL Per Day: ($1.84)
Nursing Facility Per Diem-Net: $107.50
Conversion from Per Diem to Per Month:X 30.4375
Nursing Facility PMPM: $3,272.04
NURSING FACILITY
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Type of Service Annualized Units per
1000 Members Unit Cost PMPM Cost
Attendant Care 696,041 X $12.10 = $701.84
Homemaker 18,782 X $17.94 = $28.08
Personal Care 87,350 X $18.48 = $134.52
Home Delivered Meals 26,009 X $7.50 = $16.26
Respite 12,428 X $7.50 = $7.77
Adult Day Health Care 57,545 X $6.35 = $30.45
Home Health Nurse 17,882 X $77.19 = $115.03
Home Health Aide 3,493 X $33.67 = $9.80 $1,043.74
Less Medicare/TPL Per Day:Less Medicare/TPL: $0.00
Nursing Facility Per Diem-Net:HCBS Home PMPM: $1,043.74
HCBS HOME
Subtotal Home-based Services:
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Type of Service Annualized Units per
1000 Members Unit Cost PMPM Cost
Adult Care Home/Assisted Living Home 96,549 X $51.22 = $412.10
Assisted Living Centers 67,875 X $60.13 = $340.11
Adult Foster Care 118,853 X $50.11 = $496.31
TBI/Behavioral Health 11,981 X $350.00 = $349.43
$1,597.96Less Reinsurance: ($270.00)
Less Medicare/TPL Per Day:Less Medicare/TPL: $0.00
Nursing Facility Per Diem-Net:HCBS Community PMPM: $1,327.96
HCBS Community
Subtotal Community-based Services:
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Category of Service Annualized Units per 1000 Members Unit Cost
PMPM Cost
Hospital Inpatient Days 1,745 X $1,039.14 = $151.11Hospital Outpatient Visits 2,945 X $568.35 = $139.48Emergency Room Visits 739 X $345.69 = $21.29Primary Care 10,511 X $66.16 = $57.95Specialists 57,949 X $28.74 = $138.79Surgical Services 1,275 X $285.45 = $30.33Prescription Drugs 58,426 X $30.80 = $149.96Behavioral Health:
a. Inpatient 43 X $704.84 = $2.53b. All Other 3,450 X 77.63 = $22.32
Subtotal $713.75Other Costs
Laboratory, X-ray, Medical Imaging $7.73Hospice $3.18Durable Medical Equipment (DME) and Oxygen $23.90Therapy $4.58Transportation -- Emergency $15.92Transportation -- Non-Emergency $29.57Miscellaneous $0.00
Subtotal, Other Costs $84.88Less Reinsurance ($44.00)Less Medicare/TPL ($339.28)
Total Acute Care Capitation Rate PMPM: $415.35
ACUTE CARE
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Estimated Number of ALTCS Clients 315
Nursing Facility Placement Distribution (Set by AHCCCS) 50.00%
Case Manager Base Pay $36,490.00Case Manager Supervisor Base Pay $44,120.00Employee Related Expense % 25%Institutional Clients/Case Manager 120.0HCBS Clients/Case Manager 48.0Case Manager/Supervisor Ratio 7.0CM FTEs per Vehicle 1.0Vehicle Cost per Mile $0.345Vehicle Miles per Day 80Vehicle Days per Year 260
4.6$209,532.42
0.7 $36,192.19
Vehicles Required: 5.3
Vehicle Costs: $37,674.00
Total Annual Case Management Cost: $283,398.61Case Management PMPM: $74.97
Case Management Supervisor Salary and ERE:
CASE MANAGEMENT
Case Management FTEs Required:Case Management Salary and ERE:Case Management Supervisor FTEs Required:
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Risk Adjusters
Geographic - by County Medicare - imbedded in the rate Placement
Nursing Facility HCBS - Community HCBS - Home
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HCBS Placement Reconciliation
ALTCS recoups capitation if PC’s HCBS placement percentage exceeds estimate:
HCBS % over budget Recoupment0 - .5 percentage pts. 0% of capitation overpayment.51 - 1.99 percentage pts. 20% of capitation overpayment2 or more percentage pts. 30% of capitation overpayment
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HCBS Placement Reconciliation
ALTCS adds capitation if PC’s HCBS percentage is below estimated:
HCBS % under budget Additional0 - .5 percentage pts. 0% of capitation underpayment.51 - 1.99 percentage pts. 20% of capitation underpayment2 or more percentage pts. 30% of capitation underpayment
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Placement AdjustmentMaricopa County Only
AHCCCS adjust placement percentages to provide incentives for appropriate placement in HCBS settings.
AHCCCS adjust capitation prospectively on a quarterly basis. For every 1% increase/decrease in placement percentage:
Acute Care will increase/decrease .5% Case Management will increase/decrease .85%
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Share of Cost
Members are required to contribute toward the cost of their care based on their income and type of placement.
Monthly capitation payment incorporates an assumed deduction for the share of cost (SOC).
Program Contractor is responsible for collecting the SOC or delegating to the nursing facilities.
Assumed SOC is fully reconciled to actual SOC annually.
AHCCCS will recoup or refund the difference.
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Reinsurance
Reinsurance is a stop-loss program provided for the
partial reimbursement of covered medical services
beyond an annual deductible.
AHCCCS is self-insured for the reinsurance program.
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Reinsurance Prior to Oct. 1, 2001
Regular Reinsurance - acute inpatient hospitalizations
Statewide Plan Deductible Deductible
Enrollment w/Medi A w/o Medi A Coinsurance
0 - 1,999 $ 5,000 $ 9,000 75%
2,000 + $12,000 $20,000 75%
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Reinsurance Prior to Oct. 1, 2001
Reinsurance Types without Deductibles and with Coinsurance Percentages
Catastrophic Reinsurance Hemophilia - 85% vonWillebrand’s Disease - 85% Gaucher’s Disease - 85%
Transplants - 85% High Cost Behavioral Health/Traumatic Brain Injury -
75%
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Reinsurance Effective Oct. 1, 2001
Reinsurance will cover both inpatient and all
outpatient services including pharmacy.
Catastrophic reinsurance - limits program contractor’s
expenses to $97,500 per catastrophic case.
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Eligibility
Mandatory v. Voluntary Member Issues Adverse Selection Critical Mass
Eligibility Determination Financial Medical / Functioning
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Capitation
Cohorts Broad v. Narrow
Larger bands Movement between categories Risk Placement
ABD At Risk Duals
Actuarial Conservative approach Acute LTC Annual Change
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Benefit Design
Behavioral Health HCBS Facility COB
Payer last resort Health Plan updates CM advocacy