Nebraska DHHS Medicaid and Long-Term Care

Transcription

1 Nebraska DHHS Medicaid and Long-Term Care Implementation of Managed Long-Term Services and Supports (MLTSS) Steve Schramm Tim Doyle, FSA, MAAA Zach Aters, ASA, MAAA Optumas February 18, 2014 Discussion Outline Care Management Overview Four Determinants of Risk Actuarial Considerations for Managed Long Term Care Rate Setting Overview Lessons Learned Questions? 2 Care Management Overview What is Care Management? Service delivery system in which Managed Long Term Services and Supports Organizations (MLTSSOs) receive a monthly capitated (per member) payment to provide services to members Goals of Care Management Promote client choice in services and settings Better coordinate all health care services Increase access to care in all settings Efficiently use financial resources 3 1

2 Four Determinants of Risk Program Design How? How is the program structured? Target Population Who? Who will enroll in the program? Benefit Package What? What type of services will be offered? Service Delivery Network Where? Where will services be delivered? 4 Actuarial Considerations Recognize the goal of the Nebraska program Right Services in Right Location at the Right Time Best Outcome for Members Define eligible populations Aged, Blind, and Disabled Nursing Facility Population Waiver Population Katie Beckett Program Population Community Well (non-nursing home certifiable) 5 Actuarial Considerations Include necessary waivers Consider waiver wait lists Determine rate structure Blended vs. Tiered ADL Considerations Develop annual rates Review and adjust rates each year to reflect most up-to-date experience, trend, and programmatic changes Important in the first few years of a new program to rebase at least every year until the risk of the population is reflected in the program data 6 2

3 Actuarial Considerations How will the MLTSS program interact with current programs? Physical Health Behavioral Health Two MLTSSOs for clients to choose from MLTSSOs are required to accept any willing provider of LTSS during first year of the program MLTSSOs will be held to quality and performance standards, and rewarded as such 7 Lessons Learned Set rates consistent with how the program will be operationalized Identifying Nursing Facility population Identifying Waiver population How will members transition into different populations? 8 Rate Setting Overview Base Medical Policy/ Medical Trend Program Claims + + Changes + Costs Non- Medical Loading = Final Capitation Midpoint Rate 9 3

4 Rate Setting Overview: Base Data CMS Checklist states that base data for utilization and cost should be relevant to the Medicaid population and only include services covered under the State Plan Multiple years utilized to establish credibility and stability Data adjusted for large claims and outliers Benchmark summarized data to State reports 10 Rate Setting Overview: Base Data Data adjusted for Incurred But Not Reported (IBNR) claims Data adjusted for copays Review age/sex rating cohorts for appropriateness CMS requires cohorts established to group similar risk and enhance predictability Data review to observe relationships between cost, age and sex Rebase every year until the program is mature and constantly reviewing the experience 11 Rate Setting Overview: Medical Trend Estimates change in service cost over time due to differences in practice patterns, technology, utilization, case mix and inflation Used to project costs from the midpoint of the base period to the midpoint of the contract period Analysis performed by major category of service 12 4

5 Rate Setting Overview: Medical Trend Several sources used to determine trend Health care economic indices, such as Consumer Price Index and Global Insight Trends exhibited in the encounter, FFS, and financial data Trends in other state Medicaid programs (adjusted for Nebraska) 13 Rate Setting Overview: Policy/Program Changes Historical Changes Changes in benefits, eligibility or fee schedule captured in the historical base data Prospective Changes Changes in the program that were not captured in the base data but will be implemented prior to or during the contract period Nursing Facility fee schedule changes are typically one of the more impactful program changes 14 Rate Setting Overview: Non-Medical Loading Non-Medical Load (NML) 2 Major Components Administration Review requirements in contract Review financial administrative experience Leverage our experience in other Medicaid programs Profit/Risk/Contingencies/Reserves Discuss profit objective with State Leverage our experience in other Medicaid programs Also Need to Ensure NML complies with State Medical Loss Ratio (MLR percent spent on claims) requirements 15 5

6 Rate Setting Overview: Other Adjustments CMS requires the actuary to review the data regionally to determine if rates should be specific to locality Will perform a regional analysis to compare to current regions 16 Rate Setting Overview: Sample Rate Structure Cohort Nursing Facility 1 Nursing Facility 2 HCBS Waiver 1 HCBS Waiver 2 Community Well Community Well Dual Status Utilization Unit Cost PMPM Dual Non-Dual Dual Non-Dual Dual Non-Dual 1 The Nursing Facility Dual and HCBS Waiver Dual cohorts will be blended together 2 The Nursing Facility Non-Dual and HCBS Waiver Non-Dual cohorts will be blended together 17 Questions? 18 6