What s New in Long-Term and Post Acute Care Just About Everything. AHLA Annual Meeting June 30, 2014 New York Hilton Midtown. Mark Reagan, Esq.

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1 What s New in Long-Term and Post Acute Care Just About Everything AHLA Annual Meeting June 30, 2014 New York Hilton Midtown Mark Reagan, Esq. Hooper Lundy and Bookman PC San Francisco, CO Note: The majority of the slides were developed by Mark E. Reagan and Chris Puri. Mr. Puri practices with Bradley Arant Boalt Cummings, LLP in Nashville, Tennessee. Overview & Outline 2 Growth in the Medicare Advantage Program Where States Are Going with Medicaid Managed Care Big Picture Global Issues in Plan/State/Provider Set Up Provider Contracting In A Managed Care Environment 2 1

2 Medicare Advantage Nationwide 14 Million Medicare beneficiaries in Medicare Advantage = 28% Approximately 30% growth since Million Medicare beneficiaries in a Medicare Advantage Special Needs Plan ( SNPs ) Approximately 80% of those in Dual Special Needs Plans ( D SNPs ) Most MA plans are HMOs (65%) but there are still viable PPO platforms KFF, Medicare Advantage 2013 Spotlight: Enrollment Market Update June MA Variations By State Percentage of Medicare beneficiaries in MA plans 14 states have at least 30% 6 states have less than 10% 9 states have D SNP enrollment of at least 20% (dual eligibles) 17 states have no D SNP enrollment at all (dual eligibles) KFF, Medicare Advantage 2013 Spotlight: Enrollment Market Update June

3 MA Variations By State KFF, Medicare Advantage 2013 Spotlight: Enrollment Market Update June MA Variations By Locality Florida More than 50% of beneficiaries in Miami Dade County are enrolled in MA plans while 35% in Palm Beach County California Almost 50% enrolled in Orange County (CA), while less than 15% in Santa Barbara County Urban vs. Rural More than 30% MA enrolled in metropolitan areas, while less than 20% in non metropolitan areas. KFF, Medicare Advantage 2013 Spotlight: Enrollment Market Update June

4 MA Market Concentration All Others Aetna Kaiser United Humana BCBS 5 Health Plans cover nearly 65% of all MA plans enrollees United (21%) 70% in HMO BCBS (17%) 50% HMO Humana (17%) 50% HMO Kaiser Permanente (8%) 94% in HMO Aetna (4%) KFF, Medicare Advantage 2013 Spotlight: Enrollment Market Update June Challenges to the MA Program ACA contains significant reimbursement changes MA Demonstration has tempered impact ends in 2014 Payment increasingly tied to MA s CMS quality rankings (i.e., 5 star system) Provider s relationships are very important to MA plan success 8 4

5 Medicaid LTSS Nationwide 389,390 Nationwide Enrollment in Medicaid LTSS 284,000 Change in service population in 8 years (2004 to 2012) from 105K to 389K 8 to 16 Doubling of State Programs from 2004 to 2012) Market Concentration Like MA Plans, 44% Share of MLTSS Market for Private belongs to for profit contractors Source: Saucier et al., The Growth of Managed Long-Term Services and Supports (MLTSS) Programs: A 2012 Update, CMS, July Source: Cheek at al., The Transformation of Long Term Services and Supports, AARP Public Policy Institute, February,

6 Managed LTC System Used instead of FFS Capitated MMLTC Medicaid agency and contractors enter into agreement under which contractor accepts risk of providing defined Medicaid LTC services Alternative types of MMLTC capitation packages: Medicaid covered LTC services only All Medicaid covered acute and LTC services All Medicare and Medicaid covered services (additional plan contract with CMS required for Medicare portion State Medicaid Agency Capitated Payment Managed Care Contractor Negotiated Payments (FFS, Per Diem, etc.) Providers Source: Cheek, Mike - American Health Care Association 11 States Are Increasing HCBS Waiver Caseload, While Expecting Medicaid NF Census to Be Flat or Decline HCBS Caseload HCBS Caseload to 2012 NF Census Increased Same Decreased Source: Cheek at al., The Transformation of Long Term Services and Supports, AARP Public Policy Institute, February,

7 Duals Demonstration Update Capitated Demonstrations 9 MOUs signed California Illinois Massachusetts Minnesota New York Ohio South Carolina Virginia Washington 13 Duals Demonstration Update: 11 MOUs pending Colorado Connecticut Idaho Iowa Michigan Missori North Carolina Oklahoma Rhode Island Texas Vermont 14 7

8 Duals Demonstration Update: 3 Way Contracts California Massachusetts Managed Fee For Service Washington 15 Duals Demonstration Update: Variety of Issues re Structures/Populations of dual eligibles Rates Medicare& Medicaid rate floors Any Willing Provider, Credentialing & Network Adequacy Enrollment Rights to Opt Out of Medicare Portion 16 8

9 Issues and Challenges Greater financial risk, operational efficiency Information Technology Preservation of FFS Medicare and Medicaid rates as "floors? Timing of Payment and EFT Network Composition Utilization Changes Impact on Medicare and Medicaid both in acuity and Length of Stays 17 Impacts Referral sources/patterns Tracking of metrics, marketing strategies Financial incentives, efficiencies Better physician coordination Lack of Experience by Health Plans Shifting of Market Share within the SNF Profession/Advantages for Multi Facility/Integrated Organizations and Movement Out of SNFs Expansion of HCBS and impact on Medicaid days Moving towards integration of Medicare/Medicaid under Health Plans 18 9

10 MA vs. Medicaid MC Payment Methods Medicare Advantage Regulatory framework of noninterference with Plan rate setting MA contracts can be negotiated on completely different methodologies than full Part A FFS Carve out components of Part A Ancillary Drugs Stop losses Medicaid Managed LTC Often a statutory rate framework and/or rates set by State not Plans Legislation may limit plan negotiation Medicaid Rates Often a less robust payment bundle Harder to vary costs / rates within per diem Risk sharing can be more difficult in some cases 19 Key Issues for LTC Network Participation Contractual Provisions Rates/Risk Sharing Authorizations and Eligibility Timing of Payment Denials/Appeals Covered Services, Ancillary Services Share of Cost Bedholds 20 10

11 Key Issues for LTC Crossover claims Transfer/discharge Audit rights Waivers of three day stay requirements Reimbursement for services other than traditional Medicare/Medi Cal 21 Strategies Marketing your facility Metrics Reduced acute admissions and re admissions Better outcomes Elimination of acquired conditions Reduce/eliminate medication errors Improved care transitions Patient centered care Reduced Costs Physician involvement 22 11