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Brian SandovalGovernorRichard WhitleyDirectorState of NevadaDepartment of Health and Human ServicesMEDICAID 101Dena Schmidt, Deputy Director, DHHSMarta Jensen, Acting Administrator, DHCFPNaomi Lewis, Deputy Administrator, DWSSFebruary 13, 2017Helping People. It’s who we are and what we do.

Objectives Overview of the Medicaid eligibility process andwho is eligible Understanding of Medicaid Rates Updates Managed Care ABA ImplementationHelping People. It’s who we are and what we do.2

Maximizing MedicaidHelping People. It’s who we are and what we do.3

Medicaid has many Vital Roles in theNational Health Care System Health care coverage for: Children and adults in low-income families Elderly and persons with disabilities Low income childless adults (if the State elected to enroll the expandedpopulation) Assistance to Medicare beneficiaries: Premiums, co-pays and deductible coverage Long-Term care: Institutional and community based servicesHelping People. It’s who we are and what we do.4

How to Apply for MedicaidClick in – Come in – Call in Individuals applying for assistance are provided service options via: Access Nevada – the DWSS online application systemMail/Fax in applicationsCall Center (CCT) – includes Automated Voice Response system for routine queriesVisit one of the local area offices SNAP Outreach partners also accept applications at local food banks andcommunity sites Targeted DWSS Partnerships – Eligibility staff are located onsite in communityorganizations.Helping People. It’s who we are and what we do.5

Who is Eligible for Medicaid?Mandatory IndividualsOptional IndividualsChildrenWomen with breast or cervical cancer under200% of the FPLPregnant WomenDisabled children who require medical facilitycare, but can appropriately be cared for athome – Katie Beckett eligibility groupParent/CaretakerHealth Insurance for Work Advancement(HIWA) is for individuals 16 to 64 who aredisabled. It allows them to retain essentialMedicaid benefits while working and earningincome.SSI Recipients (Blind or Disabled)Home and Community Based WaiversCertain Qualified Medicare Beneficiaries (QMB)Childless AdultsLong Term CareHelping People. It’s who we are and what we do.6

Current akerChildless Adults 1965FP100L500Children 0-5 AllHousehold Size1234Children 6-18100% FPL 990 1,335 1,680 2,025CHIPPregnant Women138% FPL 1,366 1,842 2,318 2,795165% FPL 1,634 2,203 2,772 3,341Helping People. It’s who we are and what we do.205% FPL 2,030 2,737 3,444 4,1517

Medicaid 100,0000Moms and KidsAged, Blind, and DisabledNewly Eligible Parent-CaretakersChildless AdultsHelping People. It’s who we are and what we do.Other8

General Rules of Medicaid Comparability of Services Free Choice of Provider Statewide Coverage Utilization Control Medical Necessity Proper & efficient administration Payment for services furnished outside the State Assurance of Transportation (new NET vendor: MTM) Early Periodic Screening and Diagnostic Treatment (EPSDT) States are required to provide all medically necessary services. Thisincludes services that would otherwise be optional services but not part ofthe Nevada Medicaid State Plan.Helping People. It’s who we are and what we do.9

Nevada’s Mandatory & Optional ServicesMandatory Services: Physician ServicesLaboratory and x-ray servicesInpatient hospital servicesOutpatient hospital servicesEarly and periodic screening, diagnostic, and treatment(EPSDT) services for individuals under the age of 21Family planning and suppliesFederally-qualified health center (FQHC) servicesRural health clinic servicesNurse midwife servicesCertified nurse practitioner servicesNursing facility (NF) services for individuals 21 or overTransportationHome HealthDurable Medical Equipment (DME)Covered Optional Services: Prescription drugs Medical care or remedial care furnished by licensedpractitioners (Limited) Diagnostic, screening, and preventive services Clinic services Dental services (pregnancy related, emergency, palliativeand dentures for adults) Therapy (physical, occupational, speech, audiology) Prosthetic devices, eyeglasses Primary care case management ICF/ID services Inpatient/nursing facility services for individuals 65 andover in an institution for mental diseases (IMD) Inpatient psychiatric hospital services for individualsunder age 21 Nursing Facility services for individuals under 21 Respiratory care services for ventilator-dependentindividuals Personal care services Private duty nursing services Hospice services Targeted case management (limited) Free-standing birthing centersHelping People. It’s who we are and what we do.10

Service Delivery Model: Managed CareJuly 1, 2017 Four Plans Aetna Better Health;Amerigroup;Health Plan of Nevada;SilverSummit Person centered planning and system of careprinciples Pay for performance and quality incentives Children and adolescent access to primary care physicians Comprehensive Diabetes Care – HGB1C testing Frequency of ongoing prenatal careHelping People. It’s who we are and what we do.11

Navigant Recommendations4 STEP PHASED IN APPROACH Phase I – Build State Capacity Phase 2 – Improve Medicaid Access Phase 3 – Enhance Provider Capabilities Phase 4 – Expand Case and Care ManagementProgramsHelping People. It’s who we are and what we do.12

Medicaid Rates Provider reimbursement rates are reviewed on a five yearrolling basis, some more frequently, due to State Planlanguage, provider or legislative requests. Provider rates are also reviewed during agency budget buildand recommendations are put forward based on the analysis. Physician rates are reviewed annually and the findings arereported by February 1st of each year pursuant to NRS232.354. Rate reviews do not necessarily result in a rate increase as itmay require additional State General fund appropriationsfrom Legislature.Helping People. It’s who we are and what we do.13

Medicaid Rate Methodologies Utilize the CMS Fee ScheduleRates based on a set year CMS conversion factor and the associated value units assigned byindividual procedure code. A percentage of the full rate is paid based on the methodologieslisted in the State Plan (Examples include Physician or Nurse Practitioner). Establish a Per Diem RateRates are set based on Medicaid allowable costs as defined in Federal Regulations(Examples include Free Standing Psychiatric Facilities or Skilled Nursing Facilities). Utilize Cost SettlementSelect Provider Types such as Critical Access Hospitals (CAH) are cost settled. Providersreceive an interim rate based on the previous year's costs. Development of LTSS RatesThe 2001 Legislative Session enacted A.B. 513 that created a Provider Rates TaskForce. Rates for waiver providers were recommended by the Provider Rates Task Force andwere adopted by the DHCFP August 15, 2002. Negotiated RateNegotiated rates are sometimes necessary in special situations such as access to care ordifficult placement. Both facility specific and patient specific rates can be negotiated.Helping People. It’s who we are and what we do.14

Alternatives Expanded the use of telemedicine/telehealth Implemented Community Paramedicine Program Implemented the Applied Behavioral Analysis (ABA) Program Expanded the use of Advanced Practice Registered Nurses (APRN) Implementing the Certified Community Behavioral Health Clinics(CCBHC) program Increased Inpatient Psychiatric Rate Implemented the “In Lieu of” option for MCO Easing Administrative burdens by: Aligning Prior Authorization requirements between FFS and MCO Implementing online provider enrollment Requesting funds for: Registered dieticians to perform Medical Nutrition Therapy Adult Podiatry services. rate increases in community based services, skilled nursing facilities and pediatric surgeons.Helping People. It’s who we are and what we do.15

Applied Behavioral Analysis (ABA) Age Under 21 years of age Diagnosis Autism Spectrum Disorder Coverage Services must be medically necessary Assessments Adaptive Behavior Treatment (Individual & Group) Adaptive Behavior Family Treatment Prior Authorization With the exception of assessments all services require prior authorizationHelping People. It’s who we are and what we do.16

ABA Providers Licensed Psychologist Licensed and Board Certified Behavior Analyst (BCBA) Licensed and Board Certified Assistant Behavior Analyst (BCABA) Board Certified Registered Behavior Technician (RBT)Helping People. It’s who we are and what we do.17

ABA Provider Enrollment by Specialty160140120100GroupLic. Board Certified Behavior Analyst80PsychologistLic. Board Certified Assist Behavior AnalystRegistered Behavior Technician (Rbt)6040200QTR 1 2016QTR 2 2016QTR 3 2016QTR 4 2016QTR 1 2017 to dateHelping People. It’s who we are and what we do.18

ABA Expenditures 350,000.00 300,000.00 250,000.00 200,000.00 150,000.00 100,000.00 50,000.00 0.00Helping People. It’s who we are and what we do.19

SFY16 Total Computable Spend by TypeFiscal Agent 43,755,813OperationsOther 64,127,981 43,877,517Medical 3,271,341,786Total Computable Spend: 3,423,103,097ADMIN OTHER 64,127,981(Majority of thesefunds are passthrough of federaldollars to sister &state agencies foradministrativeservices)Medical (Medicaid and Nevada Check Up)DHCFP OperationsDHCFP Fiscal AgentPublic and Behavioral HealthDivision of Welfare and Supportive ServicesDivision of Aging and Disability Services AdminLocal Governments/Administrative ClaimingDivision of Child and Family ServicesDirectors OfficeDepartment of AdministrationTransfer to Legislative Council BureauTOTAL 3,271,341,786 43,877,517 43,755,813 1,542,423 49,956,597 10,449,053 900,259 1,026,342 204,410 28,097 20,800 3,423,103,097Helping People. It’s who we are and what we .00%0.00%100.00%20

AppendixHelping People. It’s who we are and what we do.21

AcronymsABA – Applied Behavioral AnalysisACA – The Affordable Care ActADA – The Americans with Disabilities ActAPTC – Advanced Premium Tax CreditCMS – Centers for Medicare and MedicaidEPSDT – Early Periodic Screening, Diagnostic, and TreatmentFMAP – Federal Medical Assistance PercentageFPL – Federal Poverty LevelHCBS – Home and Community-Based ServicesHHS – U.S. Department of Health and Human ServicesLTSS – Long-Term Supports and ServicesMCO – Managed Care OrganizationMLTSS – Managed LTSSNET – Non-emergency transportationHelping People. It’s who we are and what we do.22

Blended Federal Medical Assistance Percentage (FMAP)Updated September 2016Helping People. It’s who we are and what we do.23

SFY16 Medicaid Cost by Budget CategoryAverage Members per Month and Average Monthly Cost Per Eligible (CPE)Helping People. It’s who we are and what we do.24

Modified Adjusted Gross Income (MAGI) Medical GroupsIncome LimitsMedical GroupsParents & CaretakersExceptions/RulesParent/Caretaker must have adependent minor child in the home.138% of PovertyChildren 6-18: 122% FPLChildren under 6: 165% FPLChildren under 19Poverty Level ChildrenPregnant Women 165% FPLChildless AdultNon-Parents 19–64 years old 138% FPLNevada Check-UpState CHIP program for children under 19Cannot be pregnant; Cannot beMedicare eligible;Cannot be eligible in another Medicalgroup.Children under 6:166%-205%Children 6-18:139%-205% FPLHelping People. It’s who we are and what we do.Premium paymentrequired;Cannot have other insurance;Cannot be Medicaid eligible.25