Understanding Medicaid Managed Long Term Care Contracting September 11, 2013

1. Understanding Medicaid Managed Long Term Care ContractingSeptember 11, 2013 LeadingAge New York Financial Managers Annual Conference Michael H. Lewensohn Manager Health Care Medical Reimbursement Services mlewensohn@odpkf.com

2. Discussion Topics • Definitions • Contract assessment • Facility specific costs and potential data resources • Communication • Other Issues

3. Definitions • Managed Care • MLTC (Managed Long Term Care) • MCO (Managed Care Organization) • Capitation • Coordination of Care • FIDA (Fully Integrated Duals Advantage) • SNP (Special Needs Plan)

4. Definitions(continued) • PACE (Program of All-Inclusive Care for the Elderly) • Evergreen Agreement • Dual Eligible • Formulary • Included Services • Excluded Services • Capitation / Fee-For-Service

5. Contract Assessment • Rates • Multiple levels of care, based on patient needs and assessment • Identify documentation requirements by level of care • Included and Excluded Services • Pharmacy formulary • Rehabilitation • Medical services • Medical Diagnostic Testing (Labs, X-Ray, Supplies)

6. Contract Assessment (continued) • Billing Protocols • Identify billing submission period • Identify the billing appeals process • Care Requirements • Delivery of care and documentation requirements • Patient assessments to support level of care/payment • Credentialing of Facility Professionals • Medical staff, Rehabilitation, Testing & Supplies

7. Contract Assessment (continued)

8. Contract Assessment (continued)

9. Identifying Facility Specific Costs: Potential Data Resources • Medicare and Medicaid cost reports • Internal facility reports • Vendor historical data • Available “public information” about neighboring providers • Information available through trade organizations

10. Communicating MLTC Issues • Staff training and ongoing communication of contractual changes • Vendors • Apprise vendors of when bills should be sent to the Facility versus other 3rd party payers • Patients and Families • Apprise patients and or families of costs which they may be responsible to pay

11. Other Issues • Facility Admission Agreement: the Facility’s contract with patients • The MLTC agreement versus the Facility Admission Agreement • Avoid Evergreen Contracts • Request specific start and end dates of agreements • Identify when re-negotiation period begins • Consult legal counsel