BRENT by xiagong0815


									Services and Supports for
  Arizonans through a
Medicaid Managed Care
Approach - The strengths,
  the challenges, what
    makes us unique
     Barbara Brent, Assistant Director
  Division of Developmental Disabilities
 Arizona Department of Economic Security
 A Little Background on Arizona
• 2007 estimates indicate there are 6.5 million
  people living in Arizona with 3.9 million living in
  Maricopa County (Phoenix metro) and
  approximately 1.0 million in Pima County (which
  includes Tucson) The remaining areas are rural.

• We are very diverse and have 21 federally
  recognized Native American Tribes.

   Division of Developmental Disabilities
• The Department of Economic Security/Division of
  Developmental Disabilities serves people with cognitive
  disabilities, cerebral palsy, autism and epilepsy.
• The Division currently supports 29,605 people.
• 20,771 people are funded through the Arizona Long Term
  Care System (ALTCS).
• 8,844 people are state only eligible (funded through state
  only dollars).
• 17,847 people served are children and 11,758 served are
• More adults than children are ALTCS eligible.

            ALTCS vs. Non-ALTCS



                    AGE GROUPS

                       4%                 0-5
22 - 54

          18 - 21
            5%                   6 - 17

        We Pride Ourselves on

• The vast majority (88%) of the Division’s
  services are provided through in-home and
  community based services, rating us number
  one in the country. Approximately 3,000 people
  live in residential settings, with an average group
  home size of 3-4. There is one large state-run
  institution serving 126 individuals.

                                 I   TU
                                                           )    G

                                                C               EV
                                                 H                   H
                                                  IL                      O
    H                                                  D                   M
     O                                                         D               E
         M                                                      EV                 (2
             E                                                       H                  %
                 (8                                                   O                  )
                   8%                                                     M
                        )                                                  E
                                                                                                       Where People Live

   Support Coordination

• Support Coordination is provided
  primarily through state employees,
  but there are a few contracted case
  managers, particularly in early
  intervention. This is important in a
  managed care organization.

        Support and Services
• There are very few services provided directly
  through the state, such as case management;
  most all services are provided through a large
  network of 3,500 individual, independent
  providers and 800 agency contracted vendors.
• The procurement for vendors is open and
  continuous (if you qualify, you are in) and
  families can recruit trusted friends, neighbors
  and others to become independent providers,
  using the fiscal intermediary.
• The Division also contracts with four acute care
  health plans.

    Now, the Managed Care Part
• The Division receives capitation (a mix of federal
  & State funds) for the Arizona Long Term Care
• This is the Medicaid Title XIX program for
  persons with developmental disabilities who
  meet both the medical and financial eligibility
• This is an 1115 waiver. We do not have a 1915
  Waiver. If you qualify, you are in and receive
  services based on assessed needs.

  Ok, what does that mean?
• Arizona’s entire Medicaid program
  operates under an 1115 demonstration
• The waiver provides services to all
  eligible individuals.
• The program operates on a capitated
  basis, through a managed care model.
• Individuals that qualify receive acute,
  behavioral health and long term care
  services.                                 11
  Okay, but what does that really mean?
• The Division receives a capitated amount for all eligible
  individuals that covers all services for acute care, HCBS
  services and behavioral health support needs.
• The Division must manage within the capitation and still
  provide all services assessed as being necessary.
• Any person that qualifies is in the program; there can be
  no waiting list for the Medicaid waiver.

   Okay, but what does that really mean?
• The Division receives the same amount for
  every person enrolled.
• To remain cost effective, some individual’s
  package of services will cost less than
  others and some will cost more.
• No service package is to cost more than
  the average cost of the institution ($379
  per day) for a specific short range time
  period or Medicaid dollars cannot be used.
              No Waiting List?
• There is no waiting list to get into the program if
  the person meets the functional and financial
• We cannot refuse services based on lack of
• The only caveat about not having a waiting list is
  that there are sometimes network gaps in which
  we don’t have enough providers to fill the needs.
• Examples of this are therapies (P.T., O.T. and
  Speech for young children – we have a hard time
  enrolling enough therapists).

So you can spend your capitated amount
 on each person-everybody can spend
     $3502 per person per month?
• No, we can’t quite do that as we would exceed our
• The capitation has to cover all of our services and systems:
   –   Case management
   –   Institutional (Skilled nursing, ICFs/DD)
   –   Home and Community Based Services (long term care)
   –   Behavioral Health
   –   Acute Care (all medical care)
   –   Administration
And we still have to serve all new people that come into the
  program over the course of the year.
So you can spend your capitated amount on
 each person-everybody can spend $3502
    per person per month? (continued)

• To manage this, it is like any program,
  some people’s assessed needs are
  greater and some do not need as much
  from the system.

     Do you pass the financial risk on to the
• For acute providers, yes – they receive a capitated amount based
  on actuarial rates. There is help for them; however, for catastrophic
  events through reinsurance. This would be there in the event of a
  transplant, hemophilia or other difficult medical events.
• For long term care providers of home and community based
  services, DDD assumes the financial risk.
• It isn’t necessary to do it this way in a managed care system, but our
  rate system for almost all home and community based services is
  based on published rates, developed from the ground up with firms
  that can use actuarial models. This means that the rates are the
  same for the same service for all providers, no matter where the
  persons live. We accommodate people with more significant needs
  through increasing hours or intensity of supports offered. This
  process works well with open and continuous procurement as
  vendors know what to expect when they sign up.

 That sounds scary, what tools do you have to have in
 place to run an 1115 waiver in which all people qualify
 for all services that are assessed as necessary and in
            which the state assumes the risk?

• Data, data, data – everywhere, all the time.
  – Prior authorization,
  – Utilization management,
  – Quarterly Cost Effectiveness Studies on those individuals at or
    above the 80% of the institutional cost of services,
  – An MIS system that can run very specific encounters that can be
    used for capitation discussions and actuarial purposes,
  – People that understand Medicaid beyond the regular 1915 world.

• We also need support coordinators that
  understand assessment and can take
  responsibility for linking with health plans
  and HCBS providers.
• Support coordinators need to understand
  cost effectiveness from both a practical
  and technical standpoint.

     What else does it take?
• A great knowledge of the Balanced Budget
  Act. This has significant implications for
  Notices of Action, Grievances, Appeals
  and State Fair Hearings.
• We spend a significant amount of time in
  hearings with justifications that focus on
  medical more than social necessity.
• It also takes understanding of how medical
  and human services intersect.
   What else does it take?    (continued)

We have more health care services
involvement because of the acute
services. After all, if hospital discharge
back to the family home didn’t go well, it
was us, not the “Medicaid” provider.

     What do we like about this approach?
• We believe we have been successful in helping
  people stay at home and in their communities
  (note almost 90% of services are in the family or
  individual home).
• Linking acute and home and community based
  services provides better continuity for people,
  their families and other caregivers.
• We believe we can better look at the whole
  person because of the blending of acute, home
  and community based services and behavioral
  health services.
    What do we like about this approach?

• We can provide better control over coverage
  issues with acute care plans. As an example,
  we have the ability to require certain types of
• We can also provide for specialized services and
  equipment such as augmentative
  communication devices or wheelchairs where
  we can require health plans to provide both a
  manual and power wheelchair.

Can you stay person centered in a managed
            care environment?
• Absolutely!
• Use tools to look at the whole person- person
  centered planning.
• Give staff tools about balancing advocacy and
  other duties that are more technical.
• Involve people with disabilities and family
  members at multiple levels of the organization-
  advisory, policy, listening tours, self
  determination groups, human rights committees,
  listen, listen, listen and grow!

        What Challenges Us?
• We are challenged by some of the Balanced
  Budget Act requirements:
  – performance improvement projects on areas such as
    immunizations and areas centered on acute care,
  – balancing the medical and community models,
  – grievance and appeals,
  – applying policies meant to protect managed care
    participants in areas that seem unrelated (attendant

      Any other challenges?
• We are still challenged with supporting individuals
  with a dual diagnosis and improving coordination
  with the behavioral health system; the 1115
  waiver doesn’t necessarily make this better or
  more difficult than other systems.
• All means all. We can’t develop carve out and
  develop 1915 waivers for family support, people
  with autism, comprehensive care, self-
  determination. We have to provide services and
  supports within the 1115 in which all means all.

             Anything Else?

• The program is great; we have a
  wonderful community of individuals and
  families to work with and a good
  relationship with our Medicaid agency.
• Managed care and a bundled approach
  can be scary, but very worth it for our
  collective mission.


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