Long Term Care (LTC) and Managed Long Term Services & Supports (MLTSS) Advisory, Consultative, Deliberative

Transcription

1 Long Term Care (LTC) and Managed Long Term Services & Supports (MLTSS) 1

2 August 015 MLTSS Headlines 35.4% of the NJ FamilyCare LTC Population is in Home and Community Based Services Highest Since MLTSS Implementation Nursing Facility Population Decrease is Getting Smaller; by Almost 1,500 Since June 014

3 Long Term Care Recipients Summary August 015 Total Long Term Care Recipients* 4,47 Managed Long Term Support & Services (MLTSS) 18,436 MLTSS HCBS 10,866 MLTSS Assisted Living 3,019 MLTSS HCBS/AL (unable to differentiate) 8 MLTSS NF 4,486 MLTSS Upper SCNF 35 MLTSS Lower SCNF Fee For Service (FFS/Managed Care Exemption) 3,811 FFS pending MLTSS (SPC 60-64) 594 FFS Nursing Facility (SPC 65) 18,50 FFS SCNF Upper (SPC 66) 33 FFS SCNF Lower (SPC 67) 165 FFS NF Other (Feb 015)** 3,733 PACE 836 Source: NJ DMAHS Shared Data Warehouse Regular MMX Eligibility Summary Universe, accessed 9/9/15 Notes: Information shown includes any person who was considered LTC at any point in a given month and includes individuals with Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, & 88499, Special Program Codes 03, 05, 06, 17, 3, 60-67, Category of Service Code 07, or MC Plan Codes 0-3 (PACE). * FFS NF Other is derived based on the prior month s population with a completion factor (CF) included to estimate the impact of nursing facility claims not yet received. Historically, 90.76% of long term care nursing facility claims and encounters are received one month after the end of a given service month. ** Includes Medically Needy (PSC 170,180,70,80, ,570&580) recipients residing in nursing facilities and individuals in all other program status codes that are not within special program codes or capitation codes 79399, 89399, 78199, 88199, 78399, 88399, &

4 Long Term Care Population by Setting 35,000 30,000 5,000 Aug-11 30,130 Aug-1 9,44 Aug-13 9,000 Aug-14 9,833 Aug-15 7,81 0,000 15,000 10,000 Aug-11 10,93 Aug-1 11,599 Aug-13 11,884 Aug-14 11,44 Aug-15 14,130 5,000 0 Aug Aug Aug-13 7 Aug Aug Nursing Facility HCBS PACE Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed on 9/9/015. Notes: All recipients with PACE plan codes (0-9) are categorized as PACE regardless of SPC, Capitation Code, or COS. Home & Community Based Services (HCBS) Population is defined as recipients with a special program code (SPC) of 60 (HCBS) or 6 (HCBS Assisted Living) OR Capitation Code 79399,89399 (MLTSS HCBS) with no fee-for-service nursing facility claims in the measured month. Nursing Facility (NF) Population is defined as recipients with a SPC 61,63,64,65,66,67 OR CAP Code 78199,88199,78399,88399,78499,88499 OR a SPC 60,6 with a COS code 07 OR a Cap Code 79399,89399 with a COS code 07 OR a COS 07 without a SPC (Medically Needy). COS 07 count w/out a SPC 6x or one of the specified cap codes uses count for the prior month and applies a completion factor (CF) due to claims lag (majority are medically needy recipients). 4

5 Percent of LTC Population in NF vs HCBS vs PACE 100%.0%.0%.0%.0%.1%.1%.0%.0%.0% 90% 80% 6.9% 9.4% 9.7% 30.0% 30.5% 31.1% 31.8% 33.0% 33.4% 70% 60% 50% 40% 30% 71.1% 68.6% 68.3% 68.0% 67.5% 66.8% 66.1% 65.0% 64.6% 0% 10% 0% Jul-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed on 9/9/015. NF % HCBS % Pace % Notes: All recipients with PACE plan codes (0-9) are categorized as PACE regardless of SPC, Capitation Code, or COS. Home & Community Based Services (HCBS) Population is defined as recipients with a special program code (SPC) of 60 (HCBS) or 6 (HCBS Assisted Living) OR Capitation Code 79399,89399 (MLTSS HCBS) with no fee-for-service nursing facility claims in the measured month. Nursing Facility (NF) Population is defined as recipients with a SPC 61,63,64,65,66,67 OR CAP Code 78199,88199,78399,88399,78499,88499 OR a SPC 60,6 with a COS code 07 OR a Cap Code 79399,89399 with a COS code 07 OR a COS 07 without a SPC (Medically Needy). COS 07 count w/out a SPC 6x or one of the specified cap codes uses count for the prior month and applies a completion factor (CF) due to claims lag (majority are medically needy recipients). 5

6 Nursing Facility Population 35,000 30,000 5,000 0,000 9,975 5, ,599 8,09 7,855 7,583 7,56 7,39 6,884 7,154 5,131 4,978 4,843 4,698 4,419 4,097 3,606 3,606 1,53 1,587 1,879 03,4,679 3, ,870 4, ,000 10,000 4,931,01 1,40 0,898 0,39 19,903 19,446 19,104 18,648 5,000 0 Jul-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 NF Grandfathered FFS NF FFS Pending MLTSS NF&SCNF-MLTSS NF FFS- Other Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed on 9/9/015. Notes: NF (Nursing Facility) Grandfathered FFS population is defined as recipients with Special Program Code (SPC) NF MLTSS population is defined as recipients with Capitation Code 78199, 88199, 78399, 88399, or NF FFS Pending MLTSS population is defined as recipients with a SPC 61,63,or 64 but not in Capitation Codes 78199, 88199, 78399, 88399, or OR recipients with SPC 60 or 6 and COS 07 but not in Capitation Codes or NF FFS- Other population is defined as all other recipients with COS code 07 that do not meet any of the previous criteria (most are medically needy recipients); most recent month: since claims have not been received yet, this category uses counts from the prior month with the same completion factor applied as in the prior month. NF-PACE is defined as recipients with a Plan Code 0-9 6

7 LTC Demographics (July 015*) Age Group Dual/Non-Dual ,64 3.4% , % , % ,81 3.9% Non-Dual 4, % Dual 37, % Source: NJ DMAHS Shared Data Warehouse Regular MMX Eligibility Summary Universe, accessed 9/9/15 Notes: Information shown includes any person who was considered LTC at any point in a given month, based on CAP Codes 79399, 89399, 78199, 88199, 78399, 88399, & 88499, Special Program Codes 60-67, Category of Service Code 07, or MC Plan Codes 0-3 (PACE). Uses count for the prior month due to claims lag in identifying medically needy (PSC 170,180,70,80, ,570&580) and other non-exempt fee-for-service nursing facility recipients. 7

8 Qualified Income Trust (QIT) /1/014 1/1/015 /1/015 3/1/015 4/1/015 5/1/015 6/1/015 7/1/015 8/1/015 FFS ABD MLTSS Source: NJ DMAHS Shared Data Warehouse Regular MMX Eligibility Summary Universe, accessed 9/1/15. Notes: A recipient is considered QIT if they had a QIT recipient id at any point in time since the start of the program (1/1/014). The chart indicates their status in the given month, based on cap code alone (or lack thereof), at the point in time at which the data was accessed. As of 9/1/15, there have been a total of 40 recipients found eligible for QIT. 8

9 MLTSS Population by Setting 0,000 18,000 16,000 14,000 1,000 10,000 January 015: New MLTSS recipients with NF indicators on their PAS now default to NF (SPC 61) instead of HCBS (SPC 60). 11, ,898 13,93 13, ,9 1, ,941 1,861,840,87,999, ,458 10, ,63 0,659 39,948 16, ,35 1 3,040 17, ,87 8 3,036 18, , ,019 8,000 6,000 4,000 8,186 9,188 9,133 9,054 9,14 9,597 9,840 10,46 10,866,000 0 Jul-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 HCBS AL HCBS/AL (no 6x SPC) NF SCNFs Source: DMAHS Shared Data Warehouse Monthly Eligibility Universe, accessed 9/9/15. Notes: Includes all recipients in Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, 78499, at any point in the given month and categorizes them considering both their cap code and their SPC. 9