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Arizona's Medicaid Quality Compliance: Pilot Round 1 Insights and Improvement Strategies

The Arizona Health Care Cost Containment System (AHCCCS) is conducting its first pilot round for quality compliance in Medicaid. This initiative focuses on determining eligibility for various programs, including SSI and long-term care. The pilot involves a sample of 200 Medicaid cases pulled weekly for quality review. Challenges encountered include inconsistent universes and the need for eligibility workarounds. Findings show discrepancies in income budgeting and application processes. Steps for future rounds include stabilizing review processes and providing additional staff training to enhance quality care.

september-middleton
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Arizona's Medicaid Quality Compliance: Pilot Round 1 Insights and Improvement Strategies

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  1. Arizona PERM PilotRound 1 Kim Sanchez Quality Compliance Administrator Phone: (602) 417-4563 Email: kim.a.sanchez@azahcccs.gov

  2. AZ Organization Background AHCCCS Arizona Medicaid Determines Eligibility for SSI MAO and Long Term Care Department Of Economic Security (DES) Determines eligibility for SNAP, TANF and Medicaid for non-disabled adults and children MMIS Reaching across Arizona to provide comprehensive quality health care for those in need

  3. Systems Reaching across Arizona to provide comprehensive quality health care for those in need

  4. PERM Pilot Round 1 • Sample 200 Medicaid, 0 CHIP • Pull at the individual level • Pull weekly samples (calendar week) • Review at the household level • Reviews pulled from December and February Reaching across Arizona to provide comprehensive quality health care for those in need

  5. Resources • Social Interest Solutions – Developed HEAplus and our sampling programming • AHCCCS Medicaid QC staff – completed the reviews Reaching across Arizona to provide comprehensive quality health care for those in need

  6. Challenges and Resolutions • Universes inconsistent • Eligibility “work arounds” developed after pilot proposal was submitted • Revisions to pilot proposal Reaching across Arizona to provide comprehensive quality health care for those in need

  7. Universes inconsistent • Universe totals did not align • Majority of samples pulled in April • Quality control check the samples • Clerical pulled system screens for reviewers • Assigned to staff in May • Had May and June to complete the reviews • Result: Limited time to complete reviews Reaching across Arizona to provide comprehensive quality health care for those in need

  8. Eligibility “work arounds” developed after pilot proposal was submitted • Eligibility workers not all in the new system • Eligibility determined in the old system • Some determinations in our universes were a preliminary denial decision • Result: Had to re-evaluate our review process, re-write our internal policy and re-train staff Reaching across Arizona to provide comprehensive quality health care for those in need

  9. Revisions to Pilot Proposal • Proposal –stratification by submission method, including transfers from the FFM. • Revision 1 – no FFM referrals • Proposal – We proposed to complete 160 positive reviews and 40 negative reviews. • Revision 2 – 167 positive reviews, 33 negative reviews Reaching across Arizona to provide comprehensive quality health care for those in need

  10. Pilot Results • Medicaid Active – 6 Income not budgeted 5 No valid signed application 4 budget unit established incorrectly 2 in receipt of Medicare 2 applied old budgeting rules 1 Relationship incorrectly coded 1 Income used was not reasonably compatible Reaching across Arizona to provide comprehensive quality health care for those in need

  11. Pilot Results • Medicaid Negative – 2 Notice not sent 3 Eligible for MAGI • Client double entered self-employment • Incorrectly denied • Denied when eligible for Emergency Services Reaching across Arizona to provide comprehensive quality health care for those in need

  12. Preparation for 2nd Round Pilot • Stabilization of universes • Complete reviews of a State samples of cases transferred from the FFM • Revise our written procedures with more detail for reviewers to take into consideration eligibility “work arounds” established • Conduct additional staff training Reaching across Arizona to provide comprehensive quality health care for those in need

  13. Questions? Reaching across Arizona to provide comprehensive quality health care for those in need

  14. Thank You. Reaching across Arizona to provide comprehensive quality health care for those in need

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