Sarah AdelmanDeputy Commissioner

NJ Hospital Association & LeadingAge New JerseyAcute Care, Long Term Services & Supports and

Behavioral Health Provider MeetingMarch 14, 2019

Update from the NJ Department of Human Services

The Murphy Administration is committed to a stronger and fairer New Jersey.

In our early months on the job, the team at the Department of Human Services has taken important

steps to help realize that goal.

One important step includes improving the Medicaid benefit to address pressing health issues.

A STRONGER AND FAIRER NEW JERSEY

GOVERNOR’S FY20 PROPOSED BUDGET

Fully funds DHS programs & services Provides enhanced funding for clients with

both developmental disabilities and mental health needs

Creates Doula care benefits in Medicaid for expectant and new mothers

Continues $100 million in funding to address the Opioid crisis

IMPROVING MEDICAID

New Diabetes Benefits

New Medicaid coverage of diabetes self-management education and training, medical nutrition therapy, the

National Diabetes Prevention Program and supplies and equipment to the Medicaid program.

IMPROVING MEDICAID

Expanded Hepatitis C TreatmentNew Medicaid coverage of curative Hepatitis

C drugs for all Medicaid enrollees with a Hepatitis C diagnosis.

IMPROVING MEDICAID

New Autism Spectrum Disorder Benefits

New Jersey has only covered select services for a small population in a pilot program. It’s estimated over 10,000

youth have an Autism Spectrum Disorder diagnosis.

This change will give young people with Medicaid coverage access to appropriate screening and treatment.

IMPROVING MEDICAID

Tobacco Cessation

Medicaid made it easier to get help quitting by removing the requirement that individuals need prior approval from their health plan before obtaining tobacco cessation medications.

Group counseling for tobacco cessation will also be covered.

Family PlanningMedicaid is expanding family planning services to residents with incomes

up to 200% of the federal poverty level.

These newly eligible recipients have access to a package of family planning-related services, including post-partum coverage of long-acting

reversible contraception, allowing New Jersey to remove a restriction limiting access to one of the most effective forms of contraception.

IMPROVING MEDICAID

IMPROVING MEDICAID

Treating Opioid Use Disorder

Medicaid will offer a more complete service package to assist those who are battling opioid and other substance use disorders.

Implementation will expand Medicaid coverage of peer services and case management services for individuals with a substance use disorder and include coverage for detox, short-term and long-term residential rehabilitation services.

Governor Murphy’s budget also included a $100 million investment in combatting the opioid epidemic.

COMBATTING OPIOID EPIDEMIC

Helping with Recovery

We welcomed the Division of Mental Health and Addiction Services back to DHS.

And in addition to Governor’s $100 million investment, the Administration received three federal grants totaling $30.6 million to fight the opioid crisis.

This funding will help with initiatives aimed at preventing overdoses and expanding treatment and recovery services.

NJSAVE

Helping Older Adults Save

The Division of Aging Services launched NJSave, a new online application to help older residents with low-incomes and individuals with disabilities save money.

NJSave allows individuals to use a single online application to check their eligibility for savings and assistance programs such as Medicare Savings Programs, New Jersey’s Pharmaceutical Assistance to the Aged and Disabled and the Lifeline Utility Assistance Program.

GET COVERED NJ

Ensuring Access to Health Care

The Department provided funding and support to five community organizations that will help enroll New Jersey residents in health coverage.

The initiative is part of Governor Murphy’s effort to enroll more New Jerseyans during the Affordable Care Act’s open enrollment period from Nov. 1 to Dec. 15.

That effort includes the new www.getcovered.nj.gov web site.

THANK YOU

Meghan Davey, DirectorNJ Division of Medical Assistance and Health Services

NJ Hospital Association & LeadingAge New JerseyAcute Care, Long Term Services & Supports and Behavioral Health

Provider Meeting

March 14, 2019

NJ FamilyCare Update

Office of Medicaid Innovation

15

On February 6, DHS announced the new

Office of Medicaid InnovationGregory Woods, Chief

Mission:Improve the quality, delivery and cost of care within the

state’s Medicaid program.

Office of Medicaid Innovation

16

• Major areas of focus:– Alternative Payment Models– Value-based payment strategy– Coordination of care for dual-eligibles– Complex and high-needs populations– Quality measurement– Other innovative approaches to improve

outcomes, experience of care, and efficiency

Office of Medicaid Innovation

17

• Immediate Next Steps:– Review of existing (and past) value-based and

alternative payment initiatives within NJ FamilyCare

– Extensive stakeholder outreach– Discussion with peer states re: best practices

• Input? Contact: Greg.Woods@dhs.state.nj.us

18Advisory, Consultative, Deliberative

February 2019 Enrollment Headlines

1,702,030 Overall Enrollment

Source: Monthly eligibility statistics released by NJ DMAHS Office of Research available at http://www.nj.gov/humanservices/dmahs/news/reports/index.html;Dec. eligibility recast to reflect new public statistical report categories established in January 2014Notes: Net change since Dec. 2013; includes individuals enrolling and leaving NJ FamilyCare. Does not include retroactivity.

94.9% of All Recipients are Enrolled in Managed Care

Take Out13,572 (0.8%) Net Decrease Over January 2019

19Advisory, Consultative, Deliberative

1,702,030

19.1%

781,762

NJ Total Population: 8,908,520

Sources: Total New Jersey Population from U.S. Census Bureau 2018 population estimate at https://www.census.gov/quickfacts/nj

NJ FamilyCare enrollment from monthly eligibility statistics released by NJ DMAHS Office of Research available at http://www.nj.gov/humanservices/dmahs/news/reports/index.html

Total NJ FamilyCare Enrollees(February 2019)

% of New Jersey Population Enrolled(February 2019)

Children (Age 0-18) Enrolled (almost 40% of all NJ children)

20Advisory, Consultative, Deliberative

February 2019 Eligibility SummaryTotal Enrollment: 1,702,030

Source: Monthly eligibility statistics released by NJ DMAHS Office of Research available at http://www.nj.gov/humanservices/dmahs/news/reports/index.html; Notes: Expansion Adults consists of ‘ABP Parents’ and ‘ABP Other Adults’; Other Adults consists of ‘Medicaid Adults’; Medicaid Children consists of ‘Medicaid Children’, M-CHIP’ and ‘Childrens Services’; CHIP Children consists of all CHIP eligibility categories; ABD consists of ‘Aged’, ‘Blind’ and ‘Disabled’. Percentages may not add to 100% due to rounding.

Expansion Adults 519,581 30.5%

Other Adults 98,161 5.8%

Medicaid Children 571,324 33.6%

M-CHIP Children 92,975 5.5%

CHIP Children 117,889 6.9%

Aged/Blind/Disabled 302,100 17.7%

21

NJ FamilyCare Data Dashboards

22Advisory, Consultative, Deliberative

IAP Data Analytics ProjectDeveloped public-facing NJ FamilyCare dashboards

12-month technical assistance

— CMS IAP partners• Truven Health Analytics• HealthDataViz

Currently Online (September 2018 launch)

• Eligibility• Long Term Care/MLTSS• CAHPS

23Advisory, Consultative, Deliberative

Link to New Website

http://www.njfamilycare.org/analytics/home.html

http://www.njfamilycare.org

24Advisory, Consultative, Deliberative

Mobile Friendly & Browser Independent

25Advisory, Consultative, Deliberative

In Development

Managed Care Claims Reporting – Expected Launch Spring 2019• Total Number of Claims Processed

• Total Number of Clean Claims (MLTSS only) Processed

• Total Number of Claims Processed within/outside Timely Processing

Requirements

• Total Number of Clean Claims (MLTSS only) Processed within/outside Timely

Processing Requirements

HEDIS Performance Dashboard - In Development• Plan-by-Plan Comparison and State Weighted Average will be reported

• NJFC Performance compared to National Medicaid Benchmarks

• Data will be updated annually (HEDIS 2015 through current year)

26Advisory, Consultative, Deliberative

Managed Care Claims Reporting(In Development)

In addition to guidance received from Medicaid Managed Care Final Rule, DMAHS is

reviewing available data and known stakeholder requests related to managed care claims

(encounters). Currently collected quarterly under Article 7.16.5 of MCO Contract (all

items included in draft dashboard):

• Total Number of Claims Processed

• Total Number of Clean Claims (MLTSS only) Processed

• Total Number of Claims Processed within/outside Timely Processing

Requirements

• Total Number of Clean Claims (MLTSS only) Processed within/outside Timely

Processing Requirements

MCO Contract Meeting will be used to discuss other requests related to timeliness of

payments, denied claim counts, etc.

27Advisory, Consultative, Deliberative

Highlights from Claims Processing Dashboard

99.4%* of electronic/ manual claims processed within 30/40 days (contract requirement: 90.0%)99.9%* of electronic/ manual claims processed within 60 days (contract requirement: 99.0%)99.9%* of electronic/ manual claims processed within 90 days (contract requirement: 99.5%)*MCO All Plan-Weighted Average exceeds NJFC Contractual Requirements for all time frames

Claims (excludes select MLTSS Services) Claims Processed QE 6/2018

MLTSS Select Services OnlyClaims Processed QE 6/2018

94.9%* of electronic/ manual MLTSS clean claims processed within 15/30 days (contract requirement: 90.0%)99.8%* of electronic/ manual MLTSS claims processed within 45 days (contract requirement: 99.5%)

*MCO All Plan-Weighted Average exceeds NJFC Contractual Requirements for all time frames for MLTSS Selected Services

28Advisory, Consultative, Deliberative

Timeliness of Claims Processing - DRAFT

29Advisory, Consultative, Deliberative

MLTSS Timeliness of Claims Processing - DRAFT

30Advisory, Consultative, Deliberative

MCO Performance on Quality Measures(In Development)

HEDIS Performance Dashboard for NJFC Analytics Site - Draft

- Plan-by-Plan Comparison and All Plan-Weighted Averages will be reported

- NJFC Performance will be compared to National Medicaid Benchmarks

- Data will be updated annually (HEDIS 2015 through current year)

31Advisory, Consultative, Deliberative

Selected Performance DataMedication Monitoring

• Annual Monitoring for Patients on Persistent Medications • 3 out of 4 Measures above

National Medicaid 50th

percentile• Medication Management

for People with Asthma• 3 out of 5 Measures above

National Medicaid 50th

percentile

Screenings and Preventative Care

• Comprehensive Diabetes Care• 4 out of 7 measures above

National Medicaid 50th

Percentile

• Cancer Screenings• 1 out of 2 measures above

National Medicaid 50th

percentile

HEDIS Performance Data Highlights

2017 HEDIS Performance Data Highlights 2017 HEDIS Performance Data Highlights

32Advisory, Consultative, Deliberative

HEDIS Dashboard - DRAFT

33Advisory, Consultative, Deliberative

Selected Performance Data2017 CAHPS Survey Data Highlights

(All Plan-Weighted Average)

• 84% Adults / 81% FIDE-SNPs Satisfied with Health Care

• 84% Adults / 87% FIDE-SNPs Satisfied with Health Plan

• 87% Adults / 91% FIDE-SNPs Satisfied with Personal Doctor

• 88% Adults / 88% FIDE-SNPs Satisfied with Specialist

CAHPS Performance Data Highlights(In Development)

35

LogistiCare Transportation Broker

Overview

Steven Tunney, RN, MSNNJ Department of Human Services

Division of Medical Assistance and Health Services

36

Trips Per Month and Day(Taken Trips Only)

36

37

All Complaints (All Trips)

Complaints By Type May 2018

Complaint Type Valid/Substantiated UnsubstantiatedUnsubstantiated With Concern

(Lack of Information) Open Totals Duplicate or Inquiry No Further

Action Required

Eligibility Issue 0 0 0 0 0 1Facility Issue 10 0 9 0 19 1Incident - Rider 2 1 10 8 21 14Injury 11 1 8 7 27 4LogistiCare Employee Issue 93 40 53 0 186 12LogistiCare Issue 15 29 22 0 66 40No Vehicle Available 26 10 2 0 38 9Provider Late 2498 17 324 0 2839 555Provider No Show 1419 30 144 0 1593 139Reroute 0 0 0 0 0 1Rider Issue 38 5 69 0 112 22Rider No Show 87 11 37 0 135 15Serious Injury 0 0 0 0 0 0Subcontractor Courtesy 0 0 0 0 0 0Subcontractor Safety 0 0 0 0 0 0Suspected Rider Fraud & Abuse 34 3 10 0 47 6

Suspected TP Fraud & Abuse 2 0 1 0 3 0

Transportation Provider 95 25 444 16 580 162

Transportation Provider Early 21 2 18 0 41 3

Unknown / Other 0 0 0 0 0 5Vehicle Issue 0 0 0 0 0 0Wheelchair tie down issue 0 0 0 2 2 0Total 4351 174 1151 33 5709 989

37

38

Time spent in the vehicle

< 40 Min 41-55 Min 56-70 Min 71-180 Min > 180128,707

Number of Trips 89,973 16010 11313 10313 1098Total % 69.90% 12.40% 8.80% 8.00% 0.90%

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

Num

ber o

f Trip

s

January 2018 Trips (No SUD or Dental)Trip A Time in Vehicle

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Valid Complaints(Taken Trips Only)

39

Source: New Jersey Shared Data Warehouse:LogistiCare Universe. Accessed: January-February 2017, April-September 2017.Notes: This chart depicts valid complaints only for Taken Trips (Trips that occurred).The valid complaint rate was calculated by the raw number of all valid complaints/total taken trips each month x 100.

Valid Complaints Declining

40Source: New Jersey Shared Data Warehouse:LogistiCare Universe. Accessed: January-February 2017, April-September 2017.Notes: This chart depicts valid complaints only for Taken Trips (Trips that occurred).The valid complaint rate was calculated by the raw number of all valid complaints/total taken trips each month x 100.

Top Cancellation Reasons (Excluding weather and Duplicate calls)

Rider no longer goes to Healthcare Facility 26,818Rider cancelled with sufficient notice 12,319Appointment rescheduled 11,806Rider no-show 8,739Rider sick 4,647Late cancellation (rider) 7,689Cancelled by rider and or provider 4,137Rider hospitalized 2,451Rider transported by family or friend 2,107Rider refused transport upon arrival 1,208

81,921 (82%)

Holiday 437Other 8,074Logisticare error 2,791Provider no show (recovered) 2,341Provider no show 1,818Re-routed less than 24 hours 2,228Provider late 793

18,482 (18%)

41Advisory, Consultative, Deliberative

41

Behavioral Health

42

Benefit Changes for FIDE-SNP, MLTSS and DDD Populations effective 10/1/18

Effective October 1, 2018, in order to align behavioral health benefit coverage, all managed care plans will be providing the behavioral health services currently covered under MLTSS to the beneficiaries enrolled in MLTSS, FIDE-SNP and DDD.

These services include, but are not limited to, the following behavioral health services (see MLTSS Behavioral Health Dictionary):

• Outpatient MH services• Partial care/Partial Hospitalization/Acute Partial

Hospitalization• Adult mental health rehabilitation (Group Homes) • Inpatient MH services

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NJ FamilyCare MCO Behavioral Health Changes October 2018

To bring the Substance Use Disorder (SUD) benefit in alignment with other BH Services, NJ FamilyCare is including the SUD Benefit for FIDE-SNP, MLTSS and DDD members into the MCO coverage applying ASAM criteria:

• Hospital-based services (ASAM 4.0 and 4.0WM)• Outpatient SUD services (ASAM 1.0)• Intensive Outpatient SUD Services (IOP) (ASAM 2.1)• SUD partial care (ASAM 2.5)• Residential Detox (ASAM 3.7WM)• Short Term Residential Treatment (ASAM 3.7)• Ambulatory Withdrawal Management (AWM) (ASAM 2WM) • Medication Assisted Treatment (MAT) (ASAM OMT)

44

The following services are not included in the mental health coverage benefits for 2018:Targeted Case Management (TCM) including:

•Justice Involved Services (JIS)•Children's System of Care (CSOC) Care Management Organizations (CMOs)•Integrated Case Management (ICMS)•Projects for Assistance in Transition from Homelessness (PATH)

Behavioral Health Homes (BHH)Programs in Assertive Community Treatment (PACT)Community Support Services (CSS)

Benefit Changes for FIDE-SNP, MLTSS and DDD Populations

10/1/18

45

Benefit Changes for ALL NJ FamilyCare members effective 10/1/18

Effective October 1, 2018, ALL admissions to a general acute care hospital, including admissions to a psychiatric unit, shall be the responsibility of NJ Medicaid MCOs for their enrolled members.

The MCOs will not cover State or County psychiatric hospital admissions

Managed Long Term Services and Supports

Elizabeth BrennanAssistant Division Director

NJ Department of Human ServicesDivision of Aging Services

Long Term Care (LTC) and Managed Long Term Services & Supports (MLTSS)

Total Long Term Care Recipients 58,105

MLTSS HCBS 25,900MLTSS Assisted Living 3,121

8,907

48,082

Fee For Service* (Managed Care Exempt) NF & SCNF

Managed Long Term Support & Services (MLTSS)

Long Term Care Recipients Summary – December 2018

Source: NJ DMAHS Shared Data Warehouse Regular MMX Eligibility Summary Universe, accessed February 2019.Notes: Information shown includes any person who was considered LTC at any point in a given month and includes individuals with Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, 78499 & 88499, Special Program Codes 03, 05, 06, 17, 32, 60-67, Category of Service Code 07, or MC Plan Codes 220-223 (PACE).* A portion (~25%) of the FFS NF & SCNF count is claims-based and therefore uses a completion factor (CF) to estimate the impact of nursing facility claims not yet received. Historically, 63.56% of long term care nursing facility fee-for-service claims are received one month after the end of a given service month.

MLTSS NF/SCNF 19,061

1,116PACE

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December 2018 LTC Headlines

51.9% of the NJ FamilyCare LTC Population is inHome and Community Based Services*

Prior Month = 51.6%; Start of Program = 29.4%

82.8% of NJFC Long Term Care Population is Enrolled in MLTSS

* Methodology used to calculate completion factor for claims lag in the ‘NF FFS Other’ category (which primarily consists of medically needy and rehab recipients) has been recalculated as of December 2015 to account for changes in claims lag; this population was being under-estimated.

** Nursing Facility Population includes all MLTSS recipients and all FFS recipients (grandfathered, medically needy, etc.) physically residing in a nursing facility during the reporting month.

Number of Recipients Residing in Nursing Facilities** is Down Over 1,300 Since the July 2014 Implementation of MLTSS

50

51Advisory, Consultative, Deliberative

Long Term Care Population: FFS-MLTSS Breakdown

Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed January 2019.Notes: Information shown includes any person who was considered LTC at any point in a given month based on: Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, 78499 & 88499, Special Program Codes 03, 05, 06, 17, 32, 60-67, Category of Service Code 07, or MC Plan Codes 220-223 (PACE). All recipients with PACE plan codes (220-229) are categorized as PACE regardless of SPC, Capitation Code, or COS. MLTSS includes all recipients with the cap codes listed above. FFS includes SPC 65-67 and all other COS 07, which is derived using the prior month’s COS 07 population with a completion factor (CF) included to estimate the impact of nursing facility claims not yet received. Historically, 90.76% of long term care nursing facility claims and encounters are received one month after the end of a given service month.

52Advisory, Consultative, Deliberative

MLTSS Rebalancing

Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed January 2019.Notes: All recipients with PACE plan codes (220-229) are categorized as PACE regardless of SPC, Capitation Code, or COS. Home & Community Based Services (HCBS) Population is defined as recipients with a special program code (SPC) of 60 (HCBS) or 62 (HCBS – Assisted Living) OR Capitation Code 79399,89399 (MLTSS HCBS) with no fee-for-service nursing facility claims in the measured month. Nursing Facility (NF) Population is defined as recipients with a SPC 61,63,64,65,66,67 OR CAP Code 78199,88199,78399,88399,78499,88499 OR a SPC 60,62 with a COS code 07 OR a Cap Code 79399,89399 with a COS code 07 OR a COS 07 without a SPC 60-67 (Medically Needy &/or Rehab). COS 07 count w/out a SPC 6x or one of the specified cap codes uses a completion factor (CF) due to claims lag (majority are medically needy recipients).

53Advisory, Consultative, Deliberative

Nursing Facility Population

Source: Monthly Eligibility Universe (MMX) in Shared Data Warehouse (SDW), accessed January 2019.Notes: “MLTSS NF” population is defined as recipients with Capitation Code 78199, 88199 or with a SPC 61 . “MLTSS SCNF” population is defined as recipients with Capitation Code 78399, 88399, 78499 or 88499 or with a SPC 63,or 64 . “NF FFS” population includes all recipients with a Special Program code of 65,66 or 67 as all other recipients with COS code 07 that do not meet any of the previous criteria (this subgroup uses a completion factor to account for claims which have not yet been received but are forthcoming).

9,456

9,456

28,230

18,774

54Advisory, Consultative, Deliberative

Long Term Care Population by County, by SettingNovember 2018

Source: DMAHS Shared Data Warehouse Monthly Eligibility Universe, updated 1/2019.

Notes: Information shown includes any person who was considered LTC at any point in a given month, based on CAP Codes 79399, 89399, 78199, 88199, 78399, 88399, 78499 & 88499, Special Program Codes 60-67, Category of Service Code 07, or MC Plan Codes 220-223 (PACE).

55Advisory, Consultative, Deliberative

MLTSS Population by Setting

Source: DMAHS Shared Data Warehouse Monthly Eligibility Universe, updated 1/2019.

Notes: Includes all recipients in Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, 78499, 88499 at any point in the given month and categorizes them considering both their cap code and their SPC.

56Advisory, Consultative, Deliberative

MLTSS Population by Plan

Source: DMAHS Shared Data Warehouse Monthly Eligibility Universe, updated 1/2019.

Notes: Includes all recipients in Capitation Codes 79399, 89399, 78199, 88199, 78399, 88399, 78499, 88499 at any point in the given month and categorizes them by plan. Recipients showing up as FFS were recently assessed and met level of care eligibility requirements in the given month and were awaiting MCO assignment. Those recipients will be categorized in an MCO category n the subsequent month.

2,5426%

1,259 (4%)

643 (2%)

2,388 (15%)

1,636 (14%)

846 (5%)

665 (6%)

57Advisory, Consultative, Deliberative

A Look at the June 30, 2014 Waiver Population Today

Source: DMAHS Shared Data Warehouse Monthly Eligibility Universe, accessed 1/2019.

Notes: Includes all recipients who were in a waiver SPC (03, 05, 06, 17 or 32) on 6/30/14. Where they are now is based on capitation code or PSC. Those without a current capitation code or PSC are determined to be “No Longer Enrolled”. Of the total number no longer enrolled, 93.8% (3,102) have a date of death in the system (current through 7-11-16).

MLTSS HCBS4,38636.4%

MLTSS NF1,0478.7% Other (Non-MLTSS NJ

FamilyCare)313

2.6%

No Longer Enrolled

6,29052.3%

All Waivers(6/30/14 = 12,036)

58Advisory, Consultative, Deliberative

Pre-Admission Screening and Resident Review (PASRR) Webinars

• The Division of Aging Services (DoAS) presented three PASRR webinars in January to stakeholders which included Hospitals, Rehab, Nursing Facility, Special Care Nursing Facilities, Assisted Living, MCOs, and PACE Organizations.

• These webinars were provided in collaboration with NJHA, Leading Age, and HCANJ.

• All materials are available on the DoAS website at https://www.state.nj.us/humanservices/doas/services/pasrr/index.html

• FAQs are in the process of being updated

59Advisory, Consultative, Deliberative

PASRR Reminders• PASRR is a federal requirement regardless of payer

source• PASRR must be completed prior to admission to a NF or

SCNF• Level I screening may be completed by social workers

who are Certified, Licensed Clinical, or Masters Level• Updated forms and contact information are all

available via the DoAS website• For questions (contact info is in the Power Point):

– Level I process: DoAS– Level II processes: DDD and/or DMHAS

60Advisory, Consultative, Deliberative

Any Willing Qualified Provider (AWQP)

• The Department launched AWQP in 2017 which is a Value Based Purchasing (VBP) initiative

• Communication and data collection with 290 Medicaid certified, non-small volume facilities has been ongoing

• The Annual Designation and progressive accountability actions have not yet occurred

• Stakeholder engagement on the initiative is anticipated in the second quarter of the year (April-June)

61Advisory, Consultative, Deliberative

AWQP Timeline

• March 2019: – NFs receive QPS Reporting including Core Q survey

results• April 2019:

– Appeals and Quality Performance Plan Report submissions required by NFs

– Core Q survey cycle begins• includes Hospital Utilization Tracking certification

• May/June 2019:– Stakeholder engagement on next steps

62Advisory, Consultative, Deliberative

62

Program of All Inclusive Care for the Elderly (PACE)

63Advisory, Consultative, Deliberative

PACE Expansion

• The Department remains committed to expanding the PACE Model statewide in New Jersey– Six PACE Organizations currently serving 10 counties

• Shifting focus from individual zip codes to full county coverage

• Expansion being handled primarily through public notices of Request for Application for specific counties

• Typically a 2 year process for new center development

64Advisory, Consultative, Deliberative

PACE Expansion: Current Status

• Union County: Under development by Lutheran Senior LIFE

• Ocean County: Awarded in March 2018 to AcuteCare Health System.

• Gloucester, Salem, and Cumberland Counties: Inspira LIFE will be expanding operations to all zip codes in these counties

• Essex County and Middlesex County: Notice of Request for Application was posted in the NJ Register on 1/9/19. https://www.state.nj.us/humanservices/providers/grants/public/index.html

66

Long Term Services and Supports

Enrollment and Eligibility

Kathy MartinNJ Department of Human Services

Division of Medical Assistance and Health Services

ABD Online Application

• Applications submitted online can be tracked more efficiently than paper by the CWAs and by DMAHS

• Additional documents can be uploaded into the application portal electronically

• Each application must be registered with a unique email address and in future developments, the process may be monitored by the applicant/authorized representative

• Applications submitted online can be renewed easily online with the rollout of online redeterminations by 2020.

67

• AVS• SSN• Citizenship • Verifiable Lawful

Presence • Name & Identity

• DOB• Death• Address• Disability• SSA Income• Upload Attachments

68

ABD Online Verifications

E-Mevs and Renewals

• Eligibility information is stored in E-Mevs for all Medicaid Providers

• Bi-monthly reviews of Medicaid eligibility status’ can prevent unnecessary terminations

• When a termination is seen in the system, a provider can notify the Medicaid recipient or their Authorized Representative to take action

• If a Fair Hearing is requested within 20 days of termination, continuation of benefits, if applicable, can be requested to ensure continuous eligibility

69

Office of Eligibility Policy and Operations (OEP)

• OEP provides written and oral guidance to all CWA offices on Medicaid Eligibility and Operational Issues

• OEP meets monthly with all CWA Administrators, Supervisors and Directors

• Field Staff provide daily guidance to their designated CWA offices

• OEP provides regular On-Site and Centralized Trainings for CWA staff

• OEP monitors online applications and renewal reports and reaches out to CWAs when

70

Ensuring the Privacy of Personal Information - HIPAA

• Outside vendors/insurance agents should not be provided with personal information

– Medicaid status is private information– Financial and Medical information must be

protected– Medicaid recipient’s cost share amounts must

remain private

71

72

NJ FamilyCare ABD

Online Applications Dashboards

ABD Apps Created by Month

73

ABD Statuses by Program

74

ABD Overdue Apps by Program

75

ABD Apps in New Status

76

• AVS• SSN• Citizenship • Verifiable Lawful

Presence • Name & Identity

• DOB• Death• Address• Disability• SSA Income• Upload Attachments

77

ABD Online Verifications

79

Managed Provider Relations Overview

Geralyn D. Molinari Director, Managed Provider Relations Unit

Office of Managed Health Care

NJ Department of Human ServicesDivision of Medical Assistance and Health Services

80

• DMAHS Provider Relations Overview-• Prior Authorization Parameters• Continuity of Care• Claims Appeals /Disputes • Utilization Appeals • MCO Reporting for Provider Inquiries• Resources

Presentation Topics

Overview Managed Provider Relations

81

• Addresses provider inquiries and/or complaints as it relates to Managed Care Organization (MCO) contracting, credentialing, reimbursement, authorizations and appeals, and conducts complaint resolution tracking/reporting

• Provides education and outreach for MCO contracting, credentialing, claims submission, authorization, appeals process, eligibility verification, TPL, MLTSS transition and other Medicaid program changes

• Addresses stakeholder inquiries related to the network credentialing process, network access, and payment compliance.

Prior Authorization Parameters

Managed Care Contract specifies criteria for Non-Emergency and Emergency authorization

Providers are required to request continuation of service prior to Prior Authorization end date

Source: Health Claims Authorization Processing and Payment Act, P.L. 2005, c.352.

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Prior Authorization – Emergency Services

E. Emergency Care Prior Authorization. Prior authorization shall not be required for emergency services through stabilization. This applies to out-of-network as well as to in-network providers.

Source: Health Claims Authorization Processing and Payment Act, P.L. 2005, c.352.

83

Post Stabilization of Care - Authorization

• Post-Stabilization of Care. The Contractor shall comply with 42 C.F.R. §422.113(c). The Contractor must cover post-stabilization services without requiring authorization and regardless of whether the enrollee obtains the services within or outside the Contractor’s network if:

• a. The services were pre-approved by the Contractor or its providers; or

• b. The services were not pre-approved by the Contractor because the Contractor did not respond to the provider of post-stabilization care services’ request for pre-approval within one (1) hour after being requested to approve such care; or

• c. The Contractor could not be contacted for pre-approval.

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Continuity of Care

Definition: The plan of care for an enrollee that should assure progress without unreasonable interruption

• The Contractor shall ensure continuity of care and full access to primary, behavioral, specialty, MLTSS and ancillary care as required under this contract and access to full administrative programs and support services offered by the Contractor for all its lines of business and/or otherwise required under this Contract.

Source: Article 2.B of the July 2017 NJ FamilyCare Managed Care Contract

Continuity of Care

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New MemberNo Existing Plan of Care

Member Transitions to MCO with existing Plan of Care for LTCE

MCO must prior-authorize service MCO must honor continuity of care parameter of contract

Provider must be in Network with MCO and/or have a single case agreement to serve member

MCO and Provider must set up SCA orjoin network. Approved services as per existing plan will be reimbursed until

new plan of care established

Prior Authorization Guidelines for NJ Family Care Services

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Claim Appeals and/or Dispute

Claim Dispute: Administrative review not based on Medical Necessity

6.5 PROVIDER GRIEVANCES AND APPEALS • A. Payment Disputes. The Contractor shall establish and utilize

a procedure to resolve billing, payment, and other administrative disputes between health care providers and the Contractor for any reason including, but not limited to: lost or incomplete claim forms or electronic submissions; requests for additional explanation as to services or treatment rendered by a health care provider; inappropriate or unapproved referrals initiated by the providers; or any other reason for billing disputes.

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Claim Dispute

Adjudicate--the point in the claims/encounter processing at which a final decision is reached to pay or deny a claim, or accept or deny an encounter.

Contested Claim--a claim that is denied because the claim is an ineligible claim, the claim submission is incomplete, the coding or other required information to be submitted is incorrect, the amount claimed is in dispute, or the claim requires special treatment.

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Claim Processing Compliance with Federal and State Laws and Regulations

• 1. The Provider/Subcontractor shall submit claims within 180 calendar days from the date of service.

• 2. The Provider/Subcontractor shall submit corrected claims within 365 days from the date of service.

• 3. The Provider and Subcontractor shall submit Coordination of Benefits (COB) claims within 60 days from the date of primary insurer’s Explanation of Benefits (EOB) or 180 days from the dates of service, whichever is later.

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Utilization Appeals

UM Appeal Process: Definitions

UM Appeal: An appeal of an adverse Utilization Management determination, initiated by the Member (or a provider acting on behalf of a Member with the Member’s written consent)

Utilization Management Determination: A decision made by a Managed Care Organization (MCO) to deny, reduce, suspend or terminate a service based on medical necessity

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UM Appeal Process External (IURO) Appeal

External (IURO) AppealThe IURO appeal is an external appeal conducted by an Independent Utilization Review Organization (IURO). The IURO appeal is also referred to as the External Appeal. The associated timeframes are as follows:

• The deadline to request an External Appeal is 60 days from the notification letter advising the member of the outcome of the Internal Appeal.

• The timeframe for the IURO to resolve the External Appeal (either by overturning or upholding the original denial) is 45 days.

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UM Appeal ProcessContinuation of Benefits

Continuation of Benefits while an Appeal is Pending Benefits can be continued while an appeal is pending. However, for this to occur, all of the following conditions must be met:

a) The appellant must file the appeal request timely;b) the appeal must involve the termination, suspension, or reduction of

a previously authorized course of treatment;c) the services must have been ordered by an authorized provider; and d) the appeal request must be made on or before the final day of the

previously approved authorization, or within 10 calendar days of the date on the notification of adverse benefit determination (denial letter), whichever is later.

If all of these conditions are met, the MCO must automatically provide continuation of benefits while the appeal is pending.

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IURO(ExternalAppeal)

Time Frame

Medicaid Fair Hearing

Continuation of Benefits

NJ FamilyCare A and ABP Members

Yes* Yes Member and/or Provider on behalf of member must

request within appeal timelines

Appeal Process for NJFC B, C, and D Members

Yes Not Available Member and /or Provider on Behalf of member must

request within appeal timelines

(Select services are not eligible for IURO: Adult Family Care, Assisted Living Program, Assisted Living Services, Caregiver Participant Training, Chore Services, Community Transition Services, Home Based Supportive Care,

Home Delivered Meals, PCA, Respite, Social Day Care, Structured Day Program )

Utilization Appeals Guidelines for NJ Family Care Services

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UM Appeal ProcessAppeal Process for NJ FamilyCare A and ABP Members

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Notice of Action/Appeal Template Letters 3 and 4

Continuation of Benefits Scenario: Advanced Notification

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DMAHS Office of Managed Health Care (OMHC)Provider Relations Inquiry Process

Provider and/or Member contact DMAHS:

• Provider must submit claim detail to DMAHS: Providers must submit detail indicating that Medicaid guidelines were followed and MCO was contacted prior to outreach to OMHC– check eligibility– request prior authorization,– timely claim submission – Submission of appeal timely

Member: Submits copy of balance bill DMAHS will contact the MCO

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DMAHS Office of Managed Health Care (OMHC)Provider Relations Inquiry Process

• OMHC Managed Provider Relations Unit reviews submitted information and creates inquiry upon receipt of detail

• OMHC will contact MCO on behalf of the Provider /Member requesting review of inquiry information and copy of communication to the Provider and/or member

• MCOs requested to outreach Member and/ or Provider within 10 business days and forward an update and/or summary to OMHC

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DMAHS Office of Managed Health Care (OMHC)Provider Relations Inquiry Process

• OMHC completes inquiry upon receipt of detail indicating that MCO contract guidelines were followed

• OMHC will review and follow-up with MCO on behalf of the Provider if initial response does not meet contract guidelines. All inquiries sent to MCO are logged into a SharePoint database

Example: Claim inquiries are closed upon receipt of claim number and amount and /or letter to Provider.

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MCO Provider Relations Reporting

• MCO Contracted Quarterly Report (Table 3C) includes all inquires submitted to MCO on behalf of Provider by the Office of Managed Health Care (OMHC)

• DMAHS prepares a Quarterly Provider Inquires Report (Feb 15th, May 15th, Aug 15th and Nov 15th )

• Quarterly Report documents all reported inquiries and identify inquiries that remain open beyond a designated quarterly period

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• Based on trends across plans and /or service types

– Develop Provider Education

– Develop policy guidance

– Develop contract changes / updates

– Present MCO Notices of Deficiencies or Corrective Action Plans if necessary

DMAHS Follow-up

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• NJ FamilyCare Health Plans Currently Under Contract and Providing Medicaid Managed Care Services in New Jerseyhttps://www.state.nj.us/humanservices/dmahs/clients/medicaid/hmo/index.html

• Member Relations- Access Member Manual

• Provider Relations -Provider Quick Reference Guide

NJ Family Care MCO Resources

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Access• MLTSS Resourceshttp://www.state.nj.us/humanservices/dmahs/home/mltss_resources.html

• Behavioral Health Resourceshttps://www.state.nj.us/humanservices/dmahs/news/ebhb.html

• Form to submit inquiry is located by clicking on highlight• DMAHS Provider Relations Inquiry Information• Provider Relations Inquiry Request form – single case• Provider Relations Inquiry Request form – multiple cases

Email detail via secure email to mahs.provider-inquiries@dhs.state.nj.usSeparate emails should be sent for individual MCOs.Multiple cases must include excel summary of information.

State Resource for Managed Care Providers:Office of Managed Health Care (OMHC)

Managed Provider Relations Unit

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National Core Indicators –Aging and Disabilities

Carolyn NassonOffice of MLTSS Quality Monitoring NJ Department of Human Services

Division of Medical Assistance and Health Services

107Advisory, Consultative, Deliberative

National Core Indicators –Aging and Disabilities (NCI-AD)

The NCI-AD Adult Consumer Survey project:

• Collaboration between the National Association of States United for Aging and Disabilities (NASUAD) and Human Services Research Institute (HSRI).

•• Collects information about the impact of states’ publicly funded LTSS on the

quality of life and outcomes of older adults and adults with physical disabilities receiving services

• Gathers feedback directly from service recipients during a face-to-face interview

• Participating states use the NCI-AD Survey to measure the performance of their state LTSS systems and to improve the quality of services and supports provided to individuals

New Jersey’s 2016-2017 NCI-AD HighlightsSummary of New Jersey outcomes for which New Jersey’s state average was higher than the NCI-AD Average.

Indicators Notably Higher than the NCI-AD Average

New Jersey State Avg.

NCI-ADAvg.

% Difference

SatisfactionProportion of people who always or almost always like how they spend their time during the day 68% 61% +7%

Service CoordinationProportion of people who can reach their case manager/care coordinator when they need to (if know they have a case manager/care coordinator)

88% 80% +8%

Proportion of people whose paid support staff show up and leave when they are supposed to 92% 86% +6%

Proportion of people whose case manager/care coordinator talked to them about services thatmight help with any unmet needs and goals (if have unmet needs and goals and know they have a case manager

88% 63% +25%

Care CoordinationProportion of people who felt comfortable and supported enough to go home (or where they live) after being discharged from a hospital or rehabilitation facility in the past year

95% 89% +6%

Proportion of people who had someone follow up with them after being discharged from a hospital or rehabilitation facility in the past year

90% 83% +7%

Health CareProportion of people who can get an appointment to see their primary care doctor when they need to 92% 86% +6%

Self-Direction of CareProportion of people who can choose or change what kind of services they get 79% 70% +9%

Proportion of people who can choose or change how often and when they get their services 79% 67% +12%

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NCI-AD Survey Next Steps

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• NJ will complete the 2018-2019 NCI-AD Survey in May 2019

• The 2019-2020 NCI-AD Survey, starting in June 2019, will be NJ’s fifth year of participation

• The 2017-2018 NJ-specific draft report is under review

• Once the state reports for all participating states are made final, NCI will send a draft of the National report for review.

• All state and national final reports are available at:https://nci-ad.org/resources/reports/

Questions

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