NJ FamilyCare Update

NJ FamilyCare Update

NJ FamilyCare Managed Care Update Joseph Bongiovanni Director, Managed Long Term Services and Supports & Contract Logistics Division of Medical Assistance and Health Services 1 NJ FamilyCare Interactive Public Applications Aged Blind Disabled Program On-line Application NJ FamilyCare Dashboards Available Summer 2018 2

Aged Blind Disabled Program Online Application Launched December 2017 (1,300 online applications to date) Applications managed online More online verifications (AVS and SSA Hub) Train and certify Assistors such as ADRC, SHIP agencies Worker Portal enhancements: documents attached and uploaded Implementing best practices with the CWAs 3 New! Data Analytics

NJ FamilyCare Dashboards Public Interactive Dashboards Mobile Friendly 4 Managed Care Contract Changes July Managed Care Contract Managed Care Rule and other CMS Requirements Highlights of the changes on the next few slides; Managed Care Contract available online at : http://www.state.nj.us/humanservices/dmahs/info/resources/care/hmo-contract.pdf 5

5 Highlights of MCO Contract Changes Article 4 Provision of Health Care Services In Lieu of Services may be provided to members outside of the Medicaid benefit. These require DMAHS and CMS approval. The following are included in the July 2017 approved contract. o OTC medications o Smoking Cessation o Residential BH/SUD treatment in an IMD for 15 days or less o LTAC treatment o Residential Modifications o Assistance with finding or keeping housing (not rent) 6 Article 4 Provision of Health Care Services,

continued Contract now states specific federal law requirements for Hospice Care provided in a NF or SCNF o at least 95% of the of the rate that would have been paid by the State for facility services in the facility for the individual. MCOs MLTSS Consumer Advisory Committee must include representation by MLTSS population participants or their representatives and case managers. Must address issues related to MLTSS. Must forward results and follow up items to DMAHS quarterly. 7 Article 4 Provision of Health Care Services, continued Appeals process changes resulting from new Managed Care Rule. Rule permits two levels of appeal, an Internal MCO appeal and once adjudicated, an appeal for

eligible members through the Fair Hearing Process. For some services, an appeal may be filed with the Independent Utilization Review Organization (IURO) at DOBI. A member has 60 days from the date of the initial denial to request an internal appeal. MCOS have 30 days (72 hours for expedited appeals) to reach a decision on internal appeals. Continuation of Benefits during a State Fair Hearing Appeal to have benefits continue, a member must make their request in writing within 10 calendar days of the Notification Letter following the internal appeal, on or before the last day of the original authorization whichever is later. The prior process allowed continuation of benefits to be requested within 20 calendar days, this is no longer permitted. As in the prior process, by CMS requirement, members may be required to pay for the cost of continued services if the Fair Hearing is not resolved in the members favor. 8

Article 4 Provision of Health Care Services, continued MCO must mail notice of adverse benefit determination to Member by date of action if: Member has died Member has requested, in writing, service termination/reduction Member has been admitted to an institution where he/she is no longer eligible for NJFC Members address is unknown mail returned without forwarding address Member is accepted for Medicaid services outside of NJ A change in LoC is prescribed by Members physician Notice involves adverse determination regarding preadmission screening (section 1919(e)(7) of the Act. Transfer or discharge from a facility will occur in an expedited manner MCO is not precluded from establishing measures to maintain quality of services and control costs, consistent with MCOs responsibilities to members 9

Article 4 Provision of Health Care Services, continued Managed Care Final Rule requires MCOs, when building Provider Networks, to consider: o How many NJ FamilyCare beneficiaries may enroll o The expected utilization of services, given the characteristics and health care needs of the specific populations enrolled with the Contractor o The numbers and types (their training, experience and specialization) of Providers required to provide the required services o The numbers of network Providers who are not accepting new NJ FamilyCare patients Article 4.11 provides DMAHS with authority to conduct enhanced readiness reviews for significant and material MCO changes impacting members or providers. MCOs were instructed on submission criteria, processing protocol, and review timeframes. MCOs are not permitted to implement a proposed change without DMAHS approval. 10

Article 7 - Terms and Conditions Required each MCO to establish a dedicated Housing Specialist responsible for: oIdentifying, securing and maintaining community-based housing for MLTSS Members oActing as a liaison with DMAHS to receive training and capacity building assistance 11 Article 9 Managed Long Term Services and Supports Expanded procedures for Member voluntary withdrawal from MLTSS and Disenrollment for non-compliance at MCO request. Defined MCO counseling responsibilities and risks to Members

Expanded procedures for screening potential MLTSS Members Expanded explanation to Member of MCO Care Management requirements and procedures Defined Essential Elements for person-centered plan of care: o Member demographics o Member Goals o Members assessed needs o Service and support needs o Medical review o Caregivers support needs

o Member rights and responsibilities o Special instructions/comments 12 Article 9 Managed Long Term Services and Supports, continued Changes to NJ FamilyCare Health Plan Benefit Coverage (effective with the July 1, 2018 Contract): o Behavioral Health coverage for BNJFC beneficiaries enrolled in Fully Integrated Dual Eligible Special Needs Plans (FiDE SNP) and DDD MCO members will be aligned with those for MLTSS members. The benefit plan for these groups will include all mental health benefits and will be expanded to include coverage for all NJFC covered substance use disorder (SUD) services for MLTSS, DSNP and DDD Managed Care members. o In addition, all admissions to a general acute care hospital including admissions to a psychiatric unit will and stand alone psychiatric hospital

will be the responsibility of the MCO. These changes are not limited to MLTSS, FIDE SNP and DDD members and are effective July 1, 2018. o Refer to Provider Newsletter Volume 28 Number 4 13 Continuity of Care Geralyn Molinari Director, Provider Relations Division of Medical Assistance and Health Services 14 Continuity of Care Definition: The plan of care for an enrollee that should assure progress without unreasonable interruption The Contractor shall ensure continuity of care and full

access to primary, behavioral, specialty, MLTSS and ancillary care as required under this contract and access to full administrative programs and support services offered by the Contractor for all its lines of business and/ or otherwise required under this Contract. Source: Article 2.B of the July 2017 NJ FamilyCare Managed Care Contract 15 Prior Authorization Guidelines for MLTSS New Member No Existing Plan of Care Member Transitions to MCO with Existing Plan of Care for LTC

MCO must prior-authorize service MCO must honor continuity of care parameter of contract Provider must be in Network MCO and Provider must set up with MCO and/or have a single SCA or join network. Approved case agreement (SCA) to serve services as per existing plan member will be reimbursed until new plan of care established 16 Cost Share Overview 17

Calculation of Cost Share At the time of eligibility determinations, annual renewals, and renewals based on changes in circumstance, the CWAs are required to create and send PR forms to LTSS providers and Medicaid LTSS beneficiaries, or their representatives, in order to notify them of their payment responsibilities. 18 NJ FamilyCare Cost Share Patient Pay Liability (PPL) County Welfare Agency (CWA) Calculates Cost share

PR- 1 Nursing Facility PR-2 Assisted Living PR-3 Currently paper forms are HCBS in private home used Cost Share is paid directly to state 19 Calculation of Cost Share

Cost Share/PPL payments begin with the first month that an individual receives LTSS regardless of whether they are a MCO member or Medicaid FFS enrolled. Cost Share/PPL amounts may temporarily be reduced to $0 during periods when a beneficiary is making payments for pre-eligibility medical expenses (PEME) or if the CWA determines there are allowable expenses for the month of admission or month of discharge. The CWA will temporarily update PR forms when these situations occur. If a provider has not received the PR information and the resident has been eligible for LTC for greater than 30 days, the provider should contact the states County Operation Unit. County Operation Unit: 609-588-2556 20 Deduction of Cost Share FFS member The Cost Share/PPL is collected monthly from the beneficiary by the provider. FFS claims submitted by an LTSS provider are reduced by the members Cost

Share/PPL. Nursing facilities: the state deducts the amount based on the PR-1 information identified on the claim. Assisted Living claims: the provider must manually deduct the Cost Share/PPL amount from the FFS claim based on the PR-2 form. MCO enrolled MLTSS member MCO enrolled members -State deducts PR amount from MCO capitation and the MCO reduces claim by amount of Cost Share identified in E-mevs MCO enrolled member not in MLTSS MCO enrolled members -PR amount is not deducted from MCO capitation. Provider must return Cost Share amount to State as MCO will not reduce PR amount 21 Reconciliation of Cost Share Overpayment

A Medicaid LTSS Members Cost Share/PPL may exceed the monthly amount billed by the facility. In situations where the cost share exceeds amount paid by Medicaid for LTC the following process should be followed by Provider to return funds to the state: Fee-for-Service Members Provider must return the Cost Share/PPL overpayment to the State of New Jersey. The provider must include a letter with a detailed explanation for the refund and contact information regarding refund. Managed Care MLTSS enrolled members: The MCO will adjust funds paid to the Provider if an overpayment is not addressed in MCO deductions, the Provider will submit refund to the State of New Jersey: Checks sent regular mail should be sent to: Payee: Treasurer, State of New Jersey Mail To: Division of Revenue Lockbox 656 200 Woolverton Avenue, Bldg. 20

Trenton, NJ 08646 22 Provider Resources Office of Managed Health Care, DMAHS Addresses provider inquiries and/or complaints related to managed care organization (MCO) contracting, credentialing, reimbursement, authorizations and appeals, and conducts complaint resolution tracking/reporting If the provider has a specific question regarding payment for a Medicaid managed care member, they must provide detail regarding the claim. E-mail detailed information securely to [email protected] If multiple claims are impacted, the information should be summarized using an Excel file. (Keep in mind, all information must be sent securely, if it includes Protected Health Information (PHI)). DMAHS Provider Relations Inquiry Information Provider Relations Inquiry Request form multiple cases 23

DHS Website Information Link to Individual MCO Sites: http://www.state.nj.us/humanservices/dmahs/info/resources/hmo/ -Contact phone number for Member and Provider Relations -Link to MCO Member Manuals -Provider Manual and Quick Reference Guides (see handout) Link to Human Services Website - MLTSS: http://www.state.nj.us/humanservices/dmahs/home/mltss_resources.html -Provider Frequently Asked Questions (FAQs) -Provider Education slide decks 24 Any Willing Qualified Provider Initiative (AWQP)

Elizabeth Brennan Assistant Division Director Division of Aging Services 25 Any Willing Qualified Provider (AWQP) The AWQP Initiative is a collaboration between the Department of Human Services (DHS) Division of Medical Assistance and Health Services (DMAHS) and Division of Aging Services (DoAS) The AWQP Initiative was developed in collaboration with the MLTSS Steering Committee Quality Workgroup which includes representatives from the NF providers, MCOs, and other long-term care stakeholders and advocates. The Quality Workgroup was involved with the initial development of MLTSS and then was reconvened to provide input into this initiative. The selection of the initial quality performance standards was a

collaborative process over the course of several meetings in 2016. 26 Any Willing Qualified Provider (AWQP) Three primary goals of the AWQP program: Set the stage for value-based purchasing: the AWQP program is aligned with value-based purchasing because its focus is on quality and outcomes of care Improve NF quality for long-stay residents (raise all ships): by providing regular feedback on performance to NFs, they can design and implement quality improvement plans to improve outcomes for all residents Provide MCOs with a pathway toward stronger network management: in addition to rewarding quality through higher reimbursement to quality providers, MCOs will be able to share provider performance with members so they have the knowledge base to select high value

service providers 27 Guiding Principles 1 Improved Resident Experience and Quality of Life 2 Transparency & Collaboration with the Stakeholder Community 3 Consistent approach to Quality Measurement 4

Quality Monitoring & Promoting Continuous Quality I Improvement 5 Oversight and Protections 28 Any Willing Provider (AWP) Policy New Jerseys goal has been to provide quality care, minimize disruption to NF residents and safeguard the NF industrys financial health and as the state moves from FFS to managed care under MLTSS. The AWP provision currently requires the MCOs to contract with the NFs at least at the approved state Medicaid rates. The AWP contracting policy for NFs was extended beyond its original two year period until 6/30/18.

NJ is developing NF provider network requirements and quality indicators that will be used in the contracting process between providers and the MCOs. 29 Quality Performance Standards (QPS) QPS Measures QPS 1 Is the percent of long-stay residents who are immunized against influenza annually at or above the statewide average? (calculated annually during influenza season) QPS 2* Is the facility at or below the statewide average for antipsychotic medication

use in the long-stay residents on a quarterly basis? QPS 3* Is the percent of long-stay, high risk residents with a pressure ulcer at or below the statewide average on a quarterly basis? QPS 4* Is the percent of long-stay residents who are physically restrained at or below the statewide average on a quarterly basis? QPS 5* Is the percent of long-stay residents experiencing one or more falls with major injury at or below the statewide average on a quarterly basis? QPS 6

Resident/family experience in the NF. QPS 7 Is the facility using INTERACT, Advancing Excellence tools, TrendTracker, or another validated tool to measure 30-day hospitalizations and hospital utilization so that it can share data with the MCOs? Data Source MDS CoreQ Composite Score Selfreported

*To meet any of these four individual standards, NFs must be at or below the DHS established benchmark for at least four out of six quarters for the most recently publicly available data. 30 Implementation Activities AWQP Initiative launched in January 2018 290 Medicaid certified NFs are included SCNFs, Private Pay, and small volume facilities are excluded Quality Performance Standards MDS data was released to providers in February Appeals and QPP Reports submitted to DHS in March/April DHS Website updated to post all relevant materials 31

Implementation Activities Webinars for NF providers including a comprehensive overview of the initiative and specific information on Core Q and Hospital Utilization Tracking Materials and information are available through NJ Hospital Association and DMAHS websites Resident/Family experience (Core Q) and Hospital Utilization Tracking surveys for the first data collection period of February through May are being calculated Dr. Nick Castle of University of Pittsburgh: states vendor for NFs that dont have a Core Q vendor 32 Timeline: 2018 Completed Activities Timeline February 2018 March 2018

April/May 2018 Key DMAHS and DoAS Activities Baseline QPS data is released to NFs Webinars conducted Webinars conducted DHS receives NF Quality Performance Plans (QPP) DHS receives and reviews NF appeals related to data Core Q/Hospital Utilization Tracking Survey Collection NF vendors or Dr. Castle

33 Timeline: 2018 Timeline June 2018 July 2018 August 2018 September 2018

Oct/Nov 2018 December 2018 Key DMAHS and DoAS Activities First report of Core Q and Hospital Utilization Tracking by Dr. Castle to DHS DHS prepares QPS data for distribution to NFs QPS baseline interim data is released to NFs NFs (without vendors) provide patient demographics to Dr. Castle for Core Q surveys DHS receives NF Quality Performance Plan Reports (QPP) from NFs

DHS receives and reviews NF appeals related to data Core Q survey distribution and collection continues Core Q survey distribution and collection continues DHS receives Core Q and Hospital Utilization Tracking report from Dr. Castle 34 Timeline: 2019 Timeline January 2019 March 2019

April 2019 February 2019 Key DMAHS and DoAS Activities DHS prepares QPS data for distribution to NFs NFs (without vendors) provide patient demographics to Dr. Castle for Core Q surveys

QPS baseline interim data is released to NFs Core Q survey distribution and collection begins DHS receives NF Quality Performance Plan Reports (QPP) from NFs DHS receives and reviews NF appeals related to data Core Q survey distribution and collection continues AWQP annual designation is provided to NFs for the first time Designation status shared with MCOs and posted publically Progressive Accountability action for non-designated facilities MLTSS member notification of facility designation by MCOs 35 AWQP Additional Information Website

http://www.state.nj.us/humanservices/dmahs/home/mltss_nhq.html Email [email protected] Leah Rogers, DoAS QA Coordinator 609-588-6510 36 Questions ? 37

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