Home Care Association of Washington Conference. MaryAnne Lindeblad, State Medicaid Director Washington Health Care Authority

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1 Home Care Association of Washington Conference MaryAnne Lindeblad, State Medicaid Director Washington Health Care Authority April 25, 2013

2 Overview Overview of Health Care Authority Public Employees Benefits Washington Medicaid program The changing face of health care Affordable Care Act or the ACA Medicaid programs to improve care and services Health Homes HealthPathWashington Role of home care in new models of service delivery 2

3 Health Care Authority HCA purchases health care services for: 300,000 Washington government employees, retirees and dependents 1.2 million Washington low-income citizens Children birth to 20 years of age Pregnant women Blind and disabled Dually eligible clients (Medicare/Medicaid) duals Basic Health And more... 3

4 Medicaid Insurance Programs 4

5 Delivery Systems for Medicaid Services Just over 1 million beneficiaries receive their full medical coverage from Medicaid (excludes duals, partial duals, family planning-only and alien emergency medical.) 5

6 Affordable Care Act What Congress Did Retained a private insurance marketplace for individual and small group insurance coverage, AND Created a new marketplace, a health insurance exchange that at minimum: facilitates the offer of qualified health plans to individuals and small groups provides a place for administering subsidies to Washington citizens who would otherwise find coverage unaffordable provides incentives to hold down premiums and compete based on value enables easier comparison among apples-to-apples plan offerings 6

7 Status of the Exchange Washington State s exchange became a quasigovernmental entity in 2012 IT systems are being built to enroll Washington citizens into health plans Insurance plans qualification process under way thru Office of Insurance Commissioner Washington HealthPlanFinder (Call Center) will be operational this fall Enrollment begins October 1, 2013, with coverage beginning on January 1,

8 Enrollment Impacts Exchange enrollment Anticipated enrollment - 280,000 in 2014 Enrollment grows to 471,000 by 2017 Medicaid enrollment next year Increased enrollment due to changes in Medicaid eligibility (to 138% of poverty level) Welcome mat (currently eligible, newly enrolled: 77,913) Newly eligible and enrolling: 250,308 Who are the newly eligible Medicaid enrollees? Childless adults with incomes below 138% of the FPL Parents with incomes between ~40% and 138% of the FPL 8

9 Federal Poverty Level Federal Poverty Levels and annual income Annual Income: Individual Annual Income Level: Family of 3 100% $11,170 $19, % $14,856 $25, % $15,415 $26, % $22,340 $38, % $33,510 $57, % $44,680 $76,360 (*) FPL figures are based on federal 2012 calculations 9

10 Integrated Care Vision Systems must: Be based in organizations that are accountable for costs and outcomes Be delivered by teams that coordinate medical, behavioral and long-term services Be provided by networks capable of meeting the full range of needs Emphasize primary care and home and community-based service approaches 10

11 New Program Offered by the ACA: Health Homes Section 2703 of the Affordable Care Act Health home services for Medicaid enrollees with chronic conditions 2011 Senate Bill 5394 Promoted primary care health homes and chronic care management Required the state to make application for health homes 11

12 Is a health home the same thing as a medical home? Health homes may or may not be within the walls of a primary care practice Health homes expand on the traditional medical home models Health homes are designed to be person-centered systems of care that facilitate and coordinate all care Primary and acute physical health services, behavioral health care, longterm community-based services and supports Both models aim to improve clinical outcomes and patient experience while reducing costs Medical homes can be but don t have to be the foundation for a health home 12

13 ACA Section 2703 Allows state to incorporate health home services for Medicaid patients 90% federal matching rate for eight quarters Focus on high-need, high-cost patients with chronic conditions, including behavioral health concerns Focus on reducing hospital readmissions, avoiding Emergency Room visits and reducing reliance on long-term care facilities 13

14 Six Health Home Services under Section 2703 Six newly reimbursable services: Comprehensive care management Care coordination and health promotion Comprehensive transitional care/follow-up; Patient and family support Referral to community and social support services HIT to link services, if applicable Services may or may not be incorporated into a primary care clinic 14

15 Who can receive 2703 health home services? Medicaid beneficiaries with: Two or more chronic conditions (mental health, substance abuse, asthma, diabetes, heart disease, being overweight) One chronic condition and at risk for a second or serious and persistent mental health condition Dual eligibles (both Medicare/Medicaid eligible) Target individuals geographically or within a subset of specific chronic conditions 15

16 Who can provide 2703 health home services? Designated provider: May be physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, others Team of health professionals: Linked to a designated provider such as primary care provider, nurse care coordinator, nutritionist, social worker, behavioral health professional Health team: A team of health care professionals may include a nurse care coordinator, nutritionist, social worker, behavioral health professional, community health worker or other professionals deemed appropriate by the state and approved by HHS 16

17 Washington s approach to health homes Health homes are the bridge to integrating services across Medicaid silos Physical health care Behavioral health care (clients with substance use disorder and serious and persistent mental illness) Long-term care Assigned care coordinator plays key role in facilitating services and engaging the client in self-care activities 17

18 Why health homes? They address fragmented service delivery and lack of overall accountability (medical and non-medical) Service needs and risk factors overlap in high-risk populations Incentives not aligned to achieve outcomes Current model is not sustainable High-risk populations receive poorly coordinated and managed care Federal and state legislative direction 18

19 Dual Eligible Program State received $1 million federal grant to support planning and stakeholder engagement Goal is to develop a care management program for individuals enrolled in both Medicare and Medicaid The project, known as HealthPathWashington is designed to better integrate primary and specialty care, behavioral health, and long-term services and support for individuals eligible for both Medicare and Medicaid ( duals ) 19

20 Building program: Recommendations from stakeholders Make changes to improve beneficiaries ability to function in their home and community and their selfcare abilities Slow the progression of disease and disability Access the right care, at the right time, right place Successfully transition from hospital to other care settings and get necessary follow-up care 20

21 Building program, continued Make changes to improve clients ability to function in their home and community and their self-care abilities Slow the progression of disease and disability Access the right care, at the right time and right place Successfully transition from hospital to other care settings and get necessary follow-up care 21

22 Duals demonstration projects Testing two different models Strategy 1: Health home model delivered to the eligibles throughout the state (except King and Snohomish) Strategy 2: Fully integrated capitated managed care program in both King and Snohomish counties Individuals are enrolled in Strategy 2 if the cost of their care is likely to be 50 percent higher than for other enrollees 22

23 More about the duals Strategy 1 will be implemented in July 2013 Uses health homes to achieve program goals; roughly 40,000 duals meet the criteria for referral statewide Seven geographic areas defined as health home service areas Strategy 2 will be launched in April Selection of health plans will be done competitively Health plans to provide same coordinated approach to the delivery of health home services as managed fee-for-service through their unique plan networks. 23

24 24

25 Role of home care in new models of service delivery Greater insurance coverage through the Affordable Care Act will result in greater need for all services including home care Home care has a unique role in providing homebased rehabilitation services, designed to optimize function and keep a client in their home setting Care coordination is a typical activity provided by home care nurses and social workers in a home care environment 25

26 Questions? MaryAnne Lindeblad State Medicaid Director Phone:

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