Nevada DHCFP 1115 Waiver
Managing the Medicaid Population
FEBRUARY 2012
Vision to Manage the Medicaid Population
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Project based on DHCFP Legislatively Approved Budget
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Project initially will provide management for Nevada’s high need
(chronic conditions or based on utilization patterns) fee for service
(FFS) population (with some exclusions). This will be done
through the use of:
Care Management Organization (CMO) RFP was released on
February 1st 2012 with planned program initiation in August 2012.
 Pilot Health Homes with planned RFP release in Spring of 2012
and implementation in Fall of 2012
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If found favorable, the project will extend to manage all Medicaid
recipients either through a managed care organization or a
managed FFS program.
Managed Fee for Service
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 The health home and the care management programs
integrate the medical care, behavioral health and long term
care needs of the patient into one coordinated plan of care
through a medical team all focused on the needs of the
patient.
 They monitor and manage provision of patient care through
case management and health information technology.
 They utilize national benchmarks to track outcomes (hospital
re-admit rates, ER use, well child visits)
 Payment may be:
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A per-member per-month dollar amount,
Payment for improved outcomes (usually indicating savings),
An increase in the regular service rate,
Or a combination of these.
Health Home Care Integration
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 Care integration includes:
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Obtaining a “health home” – a primary care provider responsible for
overall coordination
Medical disease management for persons with mental illness; mental
health management for persons with chronic medical conditions
Preventive healthcare screening and monitoring by mental health
providers; mental health screening and monitoring by primary care
providers
Integrated and consolidated mental health and medical services
Medication adherence both mental health (MH) and non MH
medications
Assisting in scheduling and keeping appointments
Monitoring follow through, developing health and wellness services
Verify healthcare services are occurring by utilizing data management
Providing real time healthcare information to appropriate healthcare
service providers
Comprehensive Care Management Organization
(CMO)
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 The CMO would:
 1)Complete the integrated Care Management; and/or
 2) Develop a cost-effective infrastructure (health care
information exchange, data analysis and performance
measurement, care coordination and patient outreach, patient
education and wellness services) to help small medical
practices meet the requirements of a health home, thereby
promoting the expansion of health homes in Nevada. (Nevada
currently only has a few medical practices that have the
infrastructure to be a health home.)
Issues that Developed
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 Per Discussion with CMS, it was determined Nevada
would require a Section 1115 Wavier:
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The scope of desired health homes and care management programs
were not an option under the Medicaid State Plan. The programs
would require Medicaid to waive sections from 1902 of the Social
Security Act through the use of a demonstration project waiver, a
Social Security Section 1115 waiver .
Nevada would not be able to fund health homes or a case
management organization for patients receiving case management
through existing programs (Targeted Case Management (TCM) and
medical case management provided to community long term care
clients (Home and Community Based Waiver clients)) as this would
be a duplicative medical service.
Current Plan
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 Develop Health Home and Care Management program
that integrates the medical/behavioral health and long
term care needs for persons not enrolled in Medicaid
managed care plans and who have a chronic condition or
a service utilization pattern that indicates they are at
high risk.
 Initially exclude persons who are receiving TCM, longterm care waiver services or are in the state or county
child welfare and juvenile justice systems as this would
preclude the duplicate funding for the case management
these services depend on. (Long term alternate planning
needs to be completed to determine how and when this
population would be able to be included in the health
homes program.)
An 1115 Waiver is Needed
in Phase 1 to :
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 Use innovative care delivery models including per
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person per month type provider payments, shared
savings options and pay for performance.
Tailor some programs to specific populations or age
groups (health home specific to children with cardiac
conditions or adults with severe diabetes pre end stage
renal disease).
To limit some programs to Medicaid and not the dual
Medicaid/Medicare population.
To mandatorily enroll or exclude specific groups.
To act expeditiously when opportunities present, having
to go through the CMS amendment process.
Overall Timeline and Waiver Needs of 1115
Waiver Phase 1
• PHASE 1 (listed times contingent on CMS approval time
frame)
JUL 2012
• Care Management Program Lock in. (Freedom of Choice,
1902(a)(23))
JUL 2012
• Implement Medical Home pilots for high need/chronic
condition enrollees. (Comparability 1902(a)(10)(B); Payment
Reforms 1902 (a)(13)&1902(a)(30))
AUG 2012
AUG 2012
SEP 2012
• Implement Care Management Organization (CMO) for high
need enrollees where medical home not available or as
alternative. (Comparability 1902(a)(10)(B))
• Expansion of Health Homes with CMO infrastructure
Support.
• Implementation of Comprehensive Health Homes
(integration of medical, behavioral health and long term
supports).
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An 1115 Waiver is Needed
in Phase 2 to :
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 Continue these Phase 1 needs:
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Use innovative care delivery models including capitation of service
provider payments (shared savings options and pay for
performance).
Tailor some programs to specific populations or age groups (health
home specific to children with cardiac conditions or adults with
severe diabetes pre end stage renal disease).
To mandatorily enroll or exclude specific groups.
To act expeditiously when opportunities present, having to go
through the CMS amendment process.
 To implement meaningful benefit design changes
(capped benefit unless participate in care management).
Overall Timeline and Waiver Needs of 1115
Waiver Phase 2
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• PHASE 2
SEP 2013
SEP 2013
DEC 2013
• Implementation of Integrated Care for Dual Eligible's
(coordinate with Medicare for shared savings). (possible
integration on 1915(c) waivers into the 1115 waiver)
• Expansion of Managed Care for exempt populations (SED,
SMI, foster care).
• If Data projects beneficial, Implementation of Managed
Care for Other Populations not already included.
Care Delivery System Changes
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 There will be three primary delivery systems under
the section 1115 waiver, DHCFP currently has (1) for
the TANF/CHAP/CHIP populations and would
require CMS approval of the 1115 waiver to
implement (2) and (3):
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(1) HMOs,
Managed FFS
(2) health homes, and
 (3) care management organization/administrative service
organization.
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Potential Program Population based on SFY 2011
Claims data
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Definition
Caseload
Dollars
•Total Medicaid FFS (excluding
those who have Medicare)
population who have a diagnosis
of Chronic Condition on a medical
claim
66,379
$808,752,072
•Of those persons, the number of
combined TCM, Child Welfare or
Waiver patients
12,539
$253, 738,669
•The number of those with
Chronic Conditions who are not in
TCM, Child Welfare or the Waiver
53,840
$555,013,403
Other Waiver Authority Requests
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 These other waiver requests could be beneficial to
the State through providing greater flexibility:
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Managed care rate setting rules that require the rate to be
actuarially certified (actual service cost plus) versus best
practice/trends (working with CMS to determine ability and
regulation)
Once a care management option is chosen, mandatory
program lock in until yearly open enrollment (similar to
private group insurance plans) (freedom of choice
1902(a)(23))
Elimination of prior quarter coverage for certain new Medicaid
applicants (1902(a)(34)) (may not be possible under MOE
rules)