University of Maryland Center on Aging Medicare/Medicaid Integration Program July 8, 2004

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

2. 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.

3. The Arizona Long Term Care System History CurrentSystem Future

4. 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.

5. 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

6. 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 basedprograms existed • Opportunity to refinance

7. 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.

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

9. Current System Delivery System • Payors: • $2.8 Billion (Appropriated) • $3.4 Billion (Appropriated & Non-Appropriated) Payors ($2 Billion) Single State Agency • Product Lines • Acute Care • KidsCare • Long Term Care • Healthcare Group • Premium Sharing • HCFA • State • County • Private • Foundation • Premiums AHCCCS Administration • Acute health plans • LTC program contractors • Policy • Eligibility • (Special Populations) • Contract for Care • Monitor Care and • Financial Viability • Information Services • Budget and Claims Processing • Legal • Intergovernmental • Relations • State Agencies • DHS • Behavioral Health • CRS • DES • DDD • Foster Children • Eligibility • FFS • Indian Health Services • Emergency Services • (non-qualified immigrants) • LTCS members enrolled • with Tribes/NACH

10. Current System Who Does AHCCCS Serve?

11. 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%

12. 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.

13. 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

14. 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

15. Current System ALTCS Model Potential ALTCS Member 2,300 Applications/Month ALTCS Health Plan DES-DDD EPD Contractors Maricopa LTC Plan Pima Health System Evercare Select Mercy Care Tribes Yavapai County LTC Pinal Gila LTC Cochise Health System Financial/Medical Eligibility 1. Citizen/Qualified Alien2. AZ Resident3. $2,000/$3,000 Resources4. $1,692 Income Maximum1 5. Transfer of Resources6. SSN7. Medical Eligibility/PAS Covered Services Acute Care Services Nursing Facility ICF/MR Hospice Behavioral Health HCBS - Homemaker - Transportation - Personal Care - Adult Day Health - Respite Care - Home Delivered Meals - Attendant Care - DD Day Care - Home Health Nurse - Habilitation - Home Health Aide - Assisted Living Facilities PCP/ CASE MANAGER KEY EPD - Elderly & Physically Disabled (Age 65+, Blind or Disabled)DES/DDD Dept. of Economic Security, Div. Of Developmental DisabilitiesICF/MR - Intermediate Care Facility for Mental RetardedNF - Nursing FacilityPAS - Pre Admission Screening 1 Income Limit is 300% of SSI maximum and increases annually in January

16. Future • Future: • Coordination of care for dual eligibles. • Revamping of the Medicare and Medicaid programs. • A better system to help individuals understand and 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.