IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM

Transcription

1 The New Jersey Department of Human Services Division of Deveopmenta Disabiities 1 IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM Eizabeth M. Shea Assistant Commissioner Thomas S. Papa Chief of Staff

2 Quick Review: Background Shift from a Contract Reimbursement System to a Standardized Fee-for-Service System Comprehensive Rate Study from 1/2013 7/2014 Fina Rate Report & Rate Schedue reeased 7/2014 The new system is buit on a Medicaid patform: Individua, Provider & Service The new FFS mode requires much greater attention to service definitions; Providers wi be reimbursed for units of biabe service as opposed to sots of a bunded service package 2

3 Quick Review: How wi the new system work? New Jersey Comprehensive Assessment Too (NJ CAT) Enroment onto one of two waivers (CCW/Supports Program) Support Coordination mode Individuaized Service Pan: Person Centered Panning Too (PCPT) Prior authorization of services Amended as needed through-out year; re-done annuay Service Provision Fee for Service Quaity Monitoring Provider quaifications, approva, disenroment if needed Provider, Service, & individua outcome monitoring Support Coordination quaity monitoring 3

4 What is the purpose of tiering in the new mode? 4 A individuas, as part of the New Jersey Comprehensive Assessment Too, wi be assigned into a tier based on their assessed eve of need. Five base tiers: A, B, C, D & E Five acuity differentiated ( a ) tiers: Aa, Ba, Ca, Da & Ea There is aso an exception tier avaiabe if needed in extremey rare cases. Individuas are assigned to one tier; and that tier assignment impacts: The rate providers get paid to provide Individua Supports in icensed residentia settings; The rate providers get paid to provide Day Habiitation; and The individua s budget amounts

5 Tiers At A Gance 5 Tota D Acuity 5.01% E 7.16% E Acuity 2.60% A 18.78% D 21.04% C Acuity 3.33% A Acuity 0.12% B Acuity 1.16% B 15.64% A A Acuity B B Acuity C C Acuity D D Acuity E E Acuity C 25.16%

6 Rates by Tier: Individua Supports 6 Individua Supports: sef-care and habiitation-reated tasks performed and/or supervised by service provider staff or an approved individua caregiver in an individua s own home or famiy home or in other community-based settings, in accordance with approved Service Pans. Assistance to, as we as training and supervision of, individuas as they earn and perform the various tasks that are incuded in basic sef-care, socia skis, activities of daiy iving and behavior shaping wi be provided Service avaiabe to individuas on the Community Care Waiver (CCW) Essentiay, this service is the staffing supports for peope in icensed residentia settings, or the in-home staff supports needed for peope in unicensed settings An individua s assigned tier wi determine the daiy rate that a provider gets paid for providing this service in a icensed residentia setting; Providers of this service in an unicensed setting get reimbursed at the houry Individua Supports rate.

7 Rates by Tier: Individua Supports Remember: When the provider gets reimbursed a daiy rate for Individua Supports in a icensed residentia setting, the rate is service funding ony and does not account for housing costs (room & board, etc.), as these costs are not reimbursabe as Medicaid services. 7 The Division is working cosey with the DHS Office of Housing to identify housing costs currenty being covered under Division contracts to determine treatment of such funding in the new FFS mode

8 Rates by Tier: Individua Supports Fina Tiered Rates for Individua Supports with a 5% Absentee Factor: 8 Tier A: $70.52/Day $25,739/Annua Tier B: $141.04/Day $51,480/Annua Tier C: $235.07/Day $85,801/Annua Tier D: $329.10/Day $120,122/Annua Tier E: $423.13/Day $154,442/Annua * Annua amounts shown assume utiization of 365 days *Reminder: Housing costs are not incuded

9 Rates by Tier: Individua Supports Fina Tiered Rates for Individua Supports with a 5% Absentee Factor and an Acuity Differentia: 9 Tier Aa: $149.84/Day $54,692/Annua Tier Ba: $299.68/Day $109,383/Annua Tier Ca: $499.46/Day $182,303/Annua Tier Da: $699.25/Day $255,226/Annua Tier Ea: $899.04/Day $328,150/Annua * Annua amounts shown assume utiization of 365 days *Reminder: Housing costs are not incuded

10 Rates by Tier: Day Habiitation 10 Day Habiitation: services that provide education and training to acquire the skis and experience needed to participate in the community, consistent with the participant s Service Pan buiding probem-soving skis, sef-hep, socia skis, adaptive skis, daiy iving skis, and eisure skis may be offered in a center-based or community-based setting Day Habiitation rates have been expanded to mirror the tiers used for Individua Supports Reminder: An individua wi be assigned one tier, which is used to: determine the rate the provider wi be reimbursed for Individua Supports in a icensed residentia setting (if appicabe) determine the rate the provider wi be reimbursed for Day Habiitation (if appicabe); AND set the individua s budget amounts.

11 Rates by Tier: Day Habiitation 11 Day Habiitation rates have been adjusted to incude transportation With transportation now incuded, Day Habiitation providers are now responsibe for transportation to and from their day program (within their catchment area) Individua Supports rates for individuas in icensed residentia settings sti incude a factor for transportation therefore, residentia providers wi be responsibe for a transportation other than transport to and from day programming This does not impact the 30 hour weeky imit on day habiitation; a provider can ony bi for day habiitation when the service is being provided, not whie they are transporting the individua

12 $9. 44/ Hour $56. 64/ Da i y $13, 594/ Annua $11. 96/ Hour$71. 76/ Da i y $17, 222/ Annua $14. 92/ Hour$89. 52/ Da i y $21, 485/ Annua $22. 40/ Hour$ / Da i y $32, 256/ Annua $29. 84/ Hour$ / Da i y $42, 970/ Annua

13 $13. 72/ Hour$82. 32/ Da i y $19, 757/ Annua $17. 40/ Hour$ / Da i y $20, 056/ Annua $21. 72/ Hour$ / Da i y $31, 277/ Annua $32. 60/ Hour$ / Da i y $46, 944/ Annua $43. 48/ Hour$ / Da i y $62, 611/ Annua

14 Tiering Exampe: Liz is a Tier C Individua Supports (icensed residentia) provider is authorized/reimbursed at: A daiy rate of $235.07/day Annua amount of $85, Day Habiitation provider is authorized/reimbursed at: An houry rate of $11.02/hour A daiy amount of $66.12 (assuming 6 hours for the day) Annua amount of $15,869 (assuming 240 days)

15 Individua Budgets Overa budget aocations wi be driven by the foowing four sub-components: 15 Individua Supports (a.k.a. residentia): Component driven by tier aocation against rates for Individua Supports Ony for individuas enroed on the CCW Not appicabe to individuas enroed on the Supports Program Empoyment/Day: Component driven by tier aocation against rates for Day Habiitation Appicabe to a individuas on both waiver programs

16 Individua Budgets Supports: Every individua on both waiver programs wi have a supports component in their budget Tier A: Tiers B & C: Tier D & E: 16 $5,000/Annuay $10,000/Annuay $15,000/Annuay Supported Empoyment: With the Division s commitment to Empoyment First, an individua s budget may be adjusted upward to accommodate an individua s desire to become gainfuy empoyed Through a defined process, empoyment/day and supports budget components wi be never be a barrier to work!

17 Budget Aocation Exampe: Tom is a Tier D Individua Supports budget component - $120,122 Ony appicabe if Tom is on the CCW 17 Appies to individuas on the CCW iving in both icensed settings (GH, SA) and unicensed/own home settings Reminder: funding for housing (room and board) wi come from aternative funding sources Empoyment/Day budget component - $21,168 Supports budget component - $15,000 Tom s Tota Budget: $156,290 (+ any room & board & other income) In addition, if Tom s tota budget for Empoyment/Day and Supports cannot address Tom s Supported Empoyment needs, an approva process wi be avaiabe to ift this cap to aow for as much Supported Empoyment as needed

18 Acuity Differentiated Rates An acuity factor has been added to the rates to account for the higher costs associated with serving individuas with very compex medica and/or behaviora needs. 18 This differentia is ony appied in cases where speciaized staff, usuay with higher credentias, is necessary based on assessment. Appication of the differentia is used to address the need for a higher eve of a particuar service, not more staffing hours. Greater staffing hours = higher tier Cinica and speciaized staff needed to support = acuity factor

19 Acuity Differentiated Rates Rate setter recommendation was to imit this differentia to ony individuas who required a high eve of nursing support or had one of five specific psychiatric diagnoses. 19 The Division soicited stakehoder input through the FFS Hep Desk as we as a targeted focus group of subject matter experts. Stakehoders fet strongy that the rate setter s suggested approach was too imited, so the Division did not adopt it.

20 Acuity Differentiated Rates Who wi receive an acuity differentia? 20 An individua wi be tiered at an acuity eve based on their assessed medica and behaviora needs as per their NJ CAT. Both an individua s overa scores as we as answers to specificay designated questions wi impact whether they wi receive an acuity differentiated tier.

21 Changes to an Individua s Tier An appea process wi be in pace for individuas to request a reassessment when their needs change, when there is new information, or if there is some reason to beieve that the origina assessment was not propery conducted. Retirement: Beginning at the age of 65 (or earier if warranted), an individua who chooses to retire wi receive a higher individua supports tier in ieu of an empoyment and day services budget. 21

22 Individua Agency Tiering Reports 22 Contracted Residentia and Day Habiitation Providers were provided with a per program break-down of tiers so that they can gauge how they woud fair once the new mode is impemented if they served the exact same individuas in the exact same services. Some newer programs wi not yet show up in the reports Reports ony incuded individuas for whom we had compete assessment information. Many individuas sti need to be assessed. Reports refect current service definitions and eve of service in current contracts

23 Next Steps 23 What are the next steps for individuas and famiies? Individuas wi be given their tiering information as they are roed into the new system. Based on famiy input, consideration is being given to how eary we can make this information accessibe to individuas for panning purposes. Continue to ensure and maintain Medicaid eigibiity Become famiiar with new services and draft service definitions: Research Support Coordination The Boggs Center Guide Seecting a Support Coordination Agency: Making Choices, Becoming Empowered: Tak to service providers What are their pans? Wi they continue to offer the same services once the fee-for-service system is impemented? Are they famiiar with the new services and service definitions?

24 Next Steps What are the next steps for providers? 24 Individua Agency Impact Anayses Missing Program Tiering Info Assist with competing any missing NJ CATs Provider appication process If a decision has been made to cease providing services, notify the Division as soon as possibe so that appropriate pans can be made to transition individuas into aternative services.

25 Next Steps What are the next steps for the Division? NJ CAT Assessments continued Quaified Providers & Other Services Providers Wi Make Tiers Avaiabe Where Practicabe Support Coordination Ramp Up Reease of Poicy Manuas Provider Enroment 25

26 DDD Transition to FFS: Timeine The Division continues to be on course to begin enroment onto the Supports Program Juy 1, Enroment wi begin with new presenters (2015 grads and others), foowed quicky by individuas currenty in the interim system FFS wi go into effect for individuas in icensed residentia settings beginning January 1, Contingent on CCW Renewa Approva

27 Resources 27 Fee-for-Service Impementation web page Fee-for-Service Impementation Timeine Fee-for-Service Rate Schedue: Quick Reference Guide Supports Program Draft Service Definitions and Quaifications Community Care Waiver Draft Service Definitions and Quaifications Support Coordination Ramp-Up Timeine E-news Buetin: Division Update Subscribe by sending an emai to: Fee-for-Service Hepdesk:

28 28 Thank You