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Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid and CHIP Services Centers for Medicare & Medicaid Services Medicaid Managed Care Conference

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Page 1: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

Medicaid Managed Care:

Moving Forward

Barbara Coulter Edwards

Director

Disabled and Elderly Health Programs Group

Center for Medicaid and CHIP Services

Centers for Medicare & Medicaid Services

Medicaid Managed Care Conference

Page 2: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

Medicaid is a Major and Growing Part of Health

Coverage and Spending

Medicaid is a Major and Growing Part of Health

Coverage and Spending

2

Health Coverage, CY

2015

Health Expenditures, CY

2015

Other Private

(including

Marketplaces),

24 million

Employer

Sponsored

Insurance,

172.4 millionMedicare,

54.3 million

Medicaid

70.1 million

CHIP,

6.2 million

Uninsured,

27.3 million

Other Public,

$398 billion

Employer

Sponsored

Insurance,

$1,009 billion

Medicare,

$669 billion

Medicaid,

$531

billion

CHIP,

$15 billion

Other Private

(including

Marketplaces)

$91 billion

Total = $2.7 trillion

Source: CMS, Office of the Actuary, http://cms.hhs.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-

Reports/NationalHealthExpendData/Downloads/Proj2012.pdf

Page 3: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

55% of Medicaid Beneficiaries in Comprehensive Risk-

Based Managed Care Organizations

55% of Medicaid Beneficiaries in Comprehensive Risk-

Based Managed Care Organizations

3

Page 4: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

Medicaid Expenditures by Service, with DSH

Payments and Payments to Medicare

Medicaid Expenditures by Service, with DSH

Payments and Payments to Medicare

4Source: Medicaid Moving Forward, Kaiser Commission on Medicaid and the Uninsured, June 2014, http://kff.org/medicaid/fact-sheet/the-

medicaid-program-at-a-glance-update/

Page 5: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

Number of Enrollees Projected to RiseNumber of Enrollees Projected to Rise

5Source: Actuarial Report On The Financial Outlook For Medicaid, CMS, 2013

Page 6: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

Coverage Expansion

Expanding Medicaid

For 2014

Not expanding

Medicaid to date

DE

DC

So far, 26 states and DC are expanding Medicaid to low-

income adults in 2014 – discussions continue to evolve.

Page 7: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

Projected MLTSS Activity in 2014

7

Page 8: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

Demographics Driving Demand for

LTSS

8

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

2015 2020 2025 2030 2035 2040 2045 2050 2055 2060

Percent of US Population by Age or Severe Disability*

65 years and over 85 years and over 100 years and over Severe Disability under age 65

*US Census Bureau

Page 9: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

LTSS: We’ve Tipped the Scales!

Institutions

Community Settings9

Page 10: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

HCB Settings Challenge

Decreasing

Isolation

Increasing

Integrated

Life

10

Page 11: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

� Adequate planning and transition strategies

� Stakeholder engagement

� Enhanced provision of Home and Community Based Services

� Alignment of payment structures with MLTSS programmatic goals

(“most integrated community setting” for LTSS)

� Support for beneficiaries

� Person-centered processes

� Comprehensive and integrated service package

� Qualified providers

� Participant protections

� Quality

MLTSS Essential Elements

Page 12: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

�Quality management systems should include standards and

processes to ensure that:� Adequate safeguards are built into the design of the MLTSS to increase

the probability of good outcomes.

� Standard methods are used to define and measure the quality of

services and outcomes.

� Credible data and information are routinely collected and analyzed to

assess program performance and identify opportunities for improvement.

� Performance is improved based on the use of evidence-based practices.

Quality - MLTSS

Page 13: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

Coming soon:

Medicaid Managed Care

Notice of Proposed

Rulemaking (NPRM)

13

Page 14: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

Center for Medicare and Medicaid Innovation

State Innovation Model Focus Areas

Center for Medicare and Medicaid Innovation

State Innovation Model Focus Areas

EXPAND

VALUE BASED

PAYMENT

MODELS

TRANSFORM

HEALTHCARE

DELIVERY

IMPROVE

POPULATION

HEALTH

Page 15: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid
Page 16: Medicaid Managed Care: Moving Forward - HEOPS · Medicaid Managed Care: Moving Forward Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid

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