The Arizona Long Term Care System ALTCS University

The Arizona Long Term Care System (ALTCS) University of Maryland Center on Aging Medicare/Medicaid Integration Program July 8, 2004 1

AHCCCS’ Mission and Vision Mission: Reaching across Arizona to provide comprehensive, quality health care for those in need. Vision: Shaping tomorrow's managed health care from today's experience, quality, and innovation. 2

The Arizona Long Term Care System History Current System Future 3

History • July 13, 1982: The Health Care Financing Administration (HCFA), which is now the Centers for Medicare & Medicaid Services (CMS) granted Arizona an 1115 Research Waiver. • October 1, 1982: The Arizona Health Care Cost Containment System (AHCCCS) began serving people in its acute care program. • Arizona was the first state to implement a statewide, Medicaid managed care system, based on prepaid, capitated arrangements with health plans. 4

History • The following long term care services were excluded with approval of the 1115 Waiver: – Skilled Nursing Facility Services to certain categorically needy individuals – Home Health Care • Why wasn’t long term care covered in the initial Arizona 1115 Waiver? – Acute care was the main concern – Needed to stabilize acute care program first 5

History • Arizona in December 1986: – New Governor – Feds requested that AHCCCS add long term care or behavioral health services – Long term care was a responsibility of the counties – Home and community based programs existed – Opportunity to refinance 6

History • December 1988: AHCCCS began phasing -in long term care services for persons who were Developmentally Disabled (DD) • January 1989: AHCCCS began serving the Elderly and Physically Disabled (E/PD) • Home and community based services were limited to a maximum expenditure of 5% of the State’s long term care expenditures for long term care services. 7

History County Involvement: Then and Now • • In the Beginning: • Today: – Maricopa County – Maricopa Long Term Care Plan – Pima County – Pima Health System A Few Years Later: – Yavapai County Long Term Care – Yavapai County – Cochise Health Systems – Pinal County – Pinal/Gila Long Term Care – Cochise County – Evercare Select – Mercy Care Plan v 1 Plan per County, except v 3 Plans in Maricopa County 8

Current System Delivery System Payors: Payors ($2 Billion) • $2. 8 Billion (Appropriated) Single State Agency • $3. 4 Billion (Appropriated & Non-Appropriated) • HCFA AHCCCS Administration Product Lines • • • State • County • Private º Foundation º Premiums • Policy • Eligibility (Special Populations) • Contract for Care • Monitor Care and Financial Viability • Information Services • Budget and Claims Processing • Legal • Intergovernmental Relations Acute Care Kids. Care Long Term Care Healthcare Group Premium Sharing • Acute health plans • LTC program contractors • State Agencies º DHS · Behavioral Health · CRS º DES · DDD · Foster Children · Eligibility • FFS ° Indian Health Services ° Emergency Services (non-qualified immigrants) ° LTCS members enrolled with Tribes/NACH 9

Current System Who Does AHCCCS Serve? 10

Current System ALTCS Elderly and Physically Disabled (EPD) Only (3/01/2003) (Excludes Tribal Enrollment) Total: 21, 969 NF: 38. 6% Own Home: 44. 7% Alt. Res. : 14. 7% Other: 2. 0% 11

Current System • ALTCS Principles: – Prepaid, capitated approach through public/private partnerships. – Integrate all long term care services by bundling acute care, long term care, case management, and behavioral health services. – Pre-admission screening process to identify those at risk for institutionalization. – Full continuum of services to ensure members are placed in least restrictive, most cost-effective care. – Primary care physicians/case managers serve as gatekeepers to coordinate care. 12

Current System • AHCCCS Health Plan Responsibilities: – Contract for Services – Develop and Ensure Adequate Network – Active Monitoring and Oversight – Case Management – Quality and Utilization Management – Integration of Medical Care – Member and Family Support – Pay Claims and Process Encounters – Grievance and Appeals 13

Current System • What Makes ALTCS Work: – Pre-admission screening (PAS) – Integrated continuum of care / choice of community settings – Network standards – Ability for members to move between settings without interruption in services – Case management standards – HCBS financial incentives to health plans – State oversight (Contract, Network, Finance, QM, CM, Annual Reviews, Technical Assistance) – Good communication between State and health plans 14

Current System Potential ALTCS Member 2, 300 Applications/Month ALTCS Model ALTCS Health Plan DES-DDD Financial/Medical Eligibility 1. 2. 3. 4. 5. 6. 7. Citizen/Qualified Alien AZ Resident $2, 000/$3, 000 Resources $1, 692 Income Maximum 1 Transfer of Resources SSN Medical Eligibility/PAS EPD Contractors Maricopa LTC Plan Pima Health System Evercare Select Mercy Care Tribes Yavapai County LTC Pinal Gila LTC Cochise Health System PCP/ CASE MANAGER KEY EPD Elderly & Physically Disabled (Age 65+, Blind or Disabled) DES/DDD Dept. of Economic Security, Div. Of Developmental Disabilities ICF/MR - Intermediate Care Facility for Mental Retarded NF Nursing Facility PAS Pre Admission Screening 1 Covered Services Acute Care Services Nursing Facility ICF/MR Hospice Behavioral Health HCBS - Homemaker - Personal Care - Respite Care - Attendant Care - Home Health Nurse - Home Health Aide - Transportation - Adult Day Health - Home Delivered Meals - DD Day Care - Habilitation - Assisted Living Facilities Income Limit is 300% of SSI maximum and increases annually in January 15

Future • Future: – Coordination of care for dual eligibles. – Revamping of the Medicare and Medicaid programs. – A better system to help individuals understand retrieve information on choices and options. – Ability to continue expansion of HCBS. This will create a need for more monitoring by plans. – Continued growth and impact on budget. – Federal law allowing people to shelter income and create annuities. – A closer look at including LTC insurance in employer benefit plans paid for by employees. 16