New Mexico Human Services Department Medical Assistance Division Nancy Smith-Leslie, Deputy Director (October 2013)

1. New Mexico Human Services Department Medical Assistance Division Nancy Smith-Leslie, Deputy Director (October 2013)

2. Overview • Current System • Centennial Care • Populations • Services • Community Benefit • Care Coordination Requirements • Health Risk Assessment • Comprehensive Needs Assessment • Care Plans

3. Managed Care Organizations Molina Lovelace Presbyterian Health Plan Blue Cross & Blue Shield Optum Health AmeriGroup UnitedHealthcare

4. Centennial Care Program The New Mexico Human Services Department submitted a Section1115 demonstration waiver to the Center for Medicaid and Medicare Services (CMS) to create one integrated managed care program that offers all health care services to eligible recipients, delivered by four managed care organizations. . . to begin on January 1, 2014

5. Centennial Care Provides recipients with the right care, at the right time, in the right setting Native Americans still have the choice to receive services through Fee-for-Service or from a Managed Care Organization unless in need of long-term services Fee-for- Service

6. Centennial Care MCOs The state issued an RFP and awarded contracts to four managed care organizations (MCOs) to provide Centennial Care program: Blue Cross/Blue Shield Presbyterian Health Plan Molina Healthcare of New Mexico UnitedHealthcare of New Mexico

7. What are the key components of Centennial Care? • Integration of all benefits provided through one managed care system from birth to end of life • Comprehensive care coordination system • Focus on health literacy using community health workers, community health representatives, promotoras and other trained lay-workers • Development of Health Homes • Further development of patient-centered primary care medical homes (PCMHs)

8. Centennial Goals and Objectives • Assuring Medicaid recipients receive the right amount of care, at the right time, in the right setting. • Ensuring care is measured in terms of quality and not solely by quantity. • Slowing the growth rate of costs over time while improving members’ health outcomes.

9. Populations

10. Enrollment in Centennial Care (as of Jan 1, 2014)

11. Benefits

12. General Medicaid Services All Centennial Care MCOs are mandated to cover all of the existing services under the current Medicaid benefit package for their members. This includes all acute, ancillary, specialty, behavioral and long-term care services.

13. Community Benefit Medicaid members who meet a nursing facility level of care are eligible for the Community Benefit, which provides an alternative to institutional care and is intended to supplement natural supports and community living.

14. Community Benefit Agency-Based Self-Direction Behavior Support Consultation Behavior Support Consultation Emergency Response Emergency Response Employment Supports Employment Supports Environmental Modifications Environmental Modifications Home Health Aide Home Health Aide Private Duty Nursing for Adults Private Duty Nursing for Adults Respite Respite Skilled Maintenance Therapy Skilled Maintenance Therapy Personal Care Homemaker Assisted Living Nutritional Counseling Adult Day Health Customized Community Supports Community Transition Services Related Goods Specialized Therapies Transportation (non-medical)

15. Care Coordination Care Coordination is the HEART and SOUL of Centennial Care!

16. Care Coordination The goal of Care Coordination is to provide each member with: The right care at the right time every time

17. Care Coordination Basics • Care Coordination is the process through which appropriate physical, behavioral health, and LTC needs are determined. Services are coordinated to ensure that the member receives the right care, at the right time, in the right setting. • MCO Care Coordinators develop and implement a person-centered care plans based on the Member’s individual needs and preferences while promoting independence, privacy and choice.

18. Health Risk Assessment The MCOs must conduct HRAs for all Centennial Care members to determine initial placement in care coordination levels. The HRA may be conducted by telephone or in-person.

19. Initial Assignment to Care Coordination The HRA determines whether the member requires Level 1 Care Coordination (CC) or requires a Comprehensive Needs Assessment (CNA) to determine if member should be assigned Level 2 or 3 Care Coordination.

20. Care Coordination

21. Level 1 Care Coordination Requirements • Members assigned to Level 1 CC will not be assigned an individual care coordinator; however members will receive an HRA annually to determine if the level of care coordination is appropriate; and • They will not receive a Comprehensive Needs Assessment, however; the MCO will review claims and utilization data quarterlyto determine if a change in status has occurred.

22. Comprehensive Needs Assessment (CNA)

23. CNA – Who/Where/How • All members who are assigned to Level 2 or 3 Care Coordination • The care coordinator assigned to the member must complete the CNA • Must be done in the member’s primary place of residence • Must be done face-to-face with the member (member has the right to have others present at the time of the CNA)

24. Comprehensive Needs Assessment-- Minimum Requirements • Assess physical & behavioral health needs • Assess long term care needs • Include a risk assessment using a tool and protocol approved by HSD • Assess disease management needs • Identify possible suicidal and/or homicidal thinking and/or planning • Identify cultural information including language and translation needs • Ask member for a self-assessment regarding his/her condition(s) and services needs

25. Care Coordination Level

26. Level 2 Care Coordination Assignments Members with the following: • Co-morbid health conditions • Frequent ER use (as defined by contractor) • Mental health or substance abuse • Assistance with two (2) or more ADLs or IADLs living in the community at low risk • Mild cognitive deficits requiring prompting or cues • Poly-pharmaceutical use

27. Level 2 Care Coordination Services The MCO assigns a specific care coordinator to each Member. For Level 2, care coordinators shall: • Develop, implement and monitor a care plan to ensure plan meets members identified needs; • Assessment of need for assignment to health home; • Targeted Health Education, including disease management; • Semi-annual in person visitswith the member; • Quarterly telephone contactswith the member; and • Annual CNAto determine if the care plan is appropriate and if a higher/lower level of care coordination is needed.

28. Care Coordination Level

29. Level 3 Care Coordination Assignment Members with the following: • Members who are medically complex or fragile • Members with excessive ER use (as defined by the contractor) • Members with a mental health or substance abuse condition • Members with untreated substance dependency • Members who require assistance with two (2) or more ADLs or IADLs • Members with significant cognitive deficits; and • Members with contraindicated pharmaceutical use

30. Level 3 Care Coordination Services The MCO assigns a specific care coordinator to: • Develop, implement and monitor care plan to ensure plan is meeting members identified needs; • Assessment of need for assignment to health home; • Targeted Health Education, including disease management; • Monthly telephone contacts with the member; • Quarterly in person visits with the member; and • Semi-Annual CNA to determine if the care plan is appropriate and if a lower level of care coordination is needed.

31. Care Plan Requirements • The MCO shall develop and authorize the care plan along with the member or member representative within 14 business days of the completion of the CNA. • The MCO shall ensure care coordinators consult with all necessary experts when developing the care plan (e.g. PCP, specialists, BH Providers) • The care plan shall include all the required elements outlined in the contract (e.g. demographic information, authorized services, DM needs, back-up plan, PH & BH needs, etc.).

32. Ongoing Care Coordination The MCO must conduct ongoing care coordination to ensure members receive all necessary and appropriate care. • Regular monitoring and updating of care plan to reflect current needs of member, utilization of services, etc; • Ongoing education regarding all aspects of participation in the program; and • Regular contact and on-going communication with member to ensure holistic approach is always maintained.

34. Care Coordination Unit Contacts • Erica Martinez – 476-7257 Erica.Martinez1@state.nm.us • Cindy Keiser – 476-7263 Cynthia.Keiser@state.nm.us • Alicia Bernal – 827-3186 Alicia.Bernal@state.nm.us • Juan Medina – 827-7724 Juan.Medina@state.nm.us