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Better Solutions for Better LivesAutomated Verification Systems:Automating the Asset Test for Long-TermServices and SupportsAugust 31, 20161

Agenda Background and Context– Streamlining the LTSS Eligibility and Enrollment Process– Single Point of Entry for Multiple PopulationsAutomated Asset Verification and Financial Transaction Review– Why are states adopting these systems?– What benefits do they bring?– Products Decision Point for Program Integrity Medicaid Genius Demonstration2

Applying MAXIMUS Experience to the LTSS LifecycleInquiry /Information &Referral Single point ofentry call centerfor consumersand providers Provideeducation onprogram/process Maintain I&RproviderregistryEligibilityScreen Phone screen Scheduleassessment Reminder callpre-assessment Web-basedscreening yReassessEnrollmentPostEnrollmentServices AssessADLs/IADLs Meet clientsface-to-face Educate onprovider/service choices AutomatedResourceAllocationBased UponAssessment/Plan of Care Assess and fillgaps toeligibilityrequirements Authorizeservices (withState approval) Providerequired notices AutomatedAssetVerification forFinancialEligibility Unbiased choicecounseling Enroll withselected MCO /provider Handle clientinitiated providerdisenrollment Evaluateconsumersatisfaction Verify receipt ofservices Conduct qualityassurancereviews Provide CareCoordination ManageStaffing Hearings/Appeals Paymentreconciliation Audit/Monitoring33

Background: AVS within the Broader Context of LTSSEligibility4

Evolution of the LTSS Eligibility & Enrollment ProcessInnovative approaches Single Point of Entry for MultiplePopulations Automated Asset Verification Social media and Beneficiary SupportSystemsSelf-service options added: Public-facing website with online enrollment Computer-telephony integration (CTI) IVR systemManaged Care Enrollments Choice counseling Field-based Education and Outreach Informational Web portalNew programs/populations Focus on Coordinated Care Expansion of Managed Long Term Services & Supports (MLTSS) Financial Alignment Demonstration for Medicare-Medicaid Eligibles Needs Plans (SNPs) dedicated to persons with specific conditions No Wrong DoorTraditional Services Toll-free consumer support Multiple agency eligibility and enrollment Mail-based applications Distinct systems for different agencies5

Key Components of the Eligibility ProcessNo Wrong Door/SingleEntry PointStage 1: SystemEntry Points/InitialScreeningLevel I Screening1-800 #Walk InPotentially Eligible – Stage 2WebsiteFinancialEligibility forMedicaidLevel II FunctionalEligibility AssessmentStage 3:Eligibility &EnrollmentEligible – Enrolled in LTSS66

Streamlining LTSS Eligibility for Multiple LTSS Populations FUN CTIONAL ELIGIBILITY DETERMINATION Level I Screen(PASRR Level I/LOC for HCBS)ScheduleLevel II ScreenConduct Level IIScreen (PASRRLevel II/MDS-HC/Others)Develop Plan ofCare (POC)/Select ProvidersQA Level IIand POCINTAKE CENTERIntake/MemberCounseling/Information& ReferralMonitor POC/ServicesReceived (By phone orin-person)Receive/ProcessEligibility ApplicationSubmit Request toAVS to Verify Assets Perform FinancialAnalysis/Verify AssetsF I NA NCI A L E LI G I B I LI T Y DE T ER MI N AT I O N7Determine FinancialEligibility Status

Financial Eligibility as Part of the Single Point of Entry Eligibility ProcessReceive/ReviewFinancial ApplicationTrigger AssetVerification SystemRequest(AUTOMATED)Generate rmation/Documentation?NoReceive AssetVerificationInformation(AUTOMATED)Perform Asset iesDetermine FinancialEligibilityFinanciallyEligible?Eligible forSpend Down?NoYesTrigger FinancialEligibilityTrigger FunctionalEligibilityTrack Spend DownYesNoNoGenerate FinancialEligibility ApprovalNoticeGenerate DenialNoticeReturn to FunctionalEligibility ProcessEnd FinancialEligibility ProcessDetermineLevel/Place ofServiceGenerate IDDEligiblity NoticeDevelopPOCYesNoYesYesPerform Intakethrough SinglePoint of Entry(1-800 # or“Front Door”)PotentiallyEligible forWaiver/StatePlan Services?Refer Applicant/Perform IDDEligibility (SIS/ICAP)YesPerform PASRRLevel I ScreeningIDD Eligible?CompletedMedicaid LTSSApplication?End Single Point ofEntry Intake ProcessLEGEND Single Point ofEntry/Intake Process Financial EligibilityProcessSchedule PASRRLevel IIPerform Face toFace PASRRLevel IINFPlacementApproved?NoEnd of PASRR Process/Consider Other OptionEnd BH EligibilityProcess/GenerateDenial NoticeNoProvide Referrals toOther ServicesYesNoEnd IDD Eligibility Process/Generate Denial NoticeYesNoPerform ApplicationIntake (multipleentry)Need Level IIPASRR?Perform ConflictFree LOC FunctionalScreen andPreliminary ChoiceCounselingPopulations age 65MHIDDPDNeeds IntensityTier 1 At RiskTier 2 HCBS/NFTier 3 NFNoPerson withIDD?IdentifiedBH issues?YesReferApplicant /Perform BHEligibilityBHEligible?NoYesYesWantsNF?NF Eligible?Tier 2/3NoFinanciallyEligible?ScheduleLevel IIAssessmentYesNoNoAt RiskEligible?End of Functional EligibilityProcess/Generate DenialNoticeYesNoNoI&R ReferralProvide Standard AtRisk PackageYesTier 1Perform LevelII In-HomeHCBSAssessment· interRAI· SIS/ICAP· interRAI MH· oved?YesDetermineLevel/Place ofService(ResourceAllocation)No FunctionalEligibility Process Information &Referral Process Care PlanningProcess8DevelopPOC

Single Entry Point / Conflict Free Functional & Financial Eligibility Single Entry Point for all populations – including either nursing home or HCBSwaiver programs— Elderly— Persons with Physical Disabilities— Persons with Intellectual/Developmental Disabilities— Persons with Serious Mental Illness Experience, capabilities, and systems to support multiple populationsBalanced Budget Act prohibits Enrollment Broker from having any MCOassociations – 100% conflict freeFirst contact with consumers – can perform assessment, financial eligibilitydetermination, assist with choice counseling, and enroll in single, streamlinedprocessBetter quality data for financial eligibility determinations and ability to do 60month look backs without delaying access to servicesEase of access for the consumer – more efficient and streamlined process forthe state9

Consolidating and Automating the LTSS Workflow Intake of Calls: All populations, all waivers – recording calls in Customer Relationship Management System(CRM)Choice Counseling: Counsel on service delivery options including Nursing Facility (NF), Home andCommunity Based Services (HCBS), or referral to community services - using search criteria in automatedInformation and Referral (I&R) DirectoryFinancial Eligibility Determination:— Perform Asset Verification: Verify applicant supplied information - using Asset Verification andFinancial Transaction Review Systems— Perform Follow–up Verification: Resolve discrepancies - using document imaging and automatedoutbound calling campaignsFunctional Eligibility Determination:— Perform Initial Screening: Screen callers for potential government program eligibility - usingautomated screening tool to identify potentially eligible (PASRR Level I, LOC, Waiver Screening) andprovide I&R for non-eligibles— Schedule Level II Assessment: Schedule face-to-face assessments - using automated schedulingmodule and Geographic Positioning System (GPS)— Conduct Level II Assessments: Perform in-home assessments - using automated tool for PASRRLevel II, Supports Intensity Scale, InterRAI-HC, or other instruments, depending upon the client— Develop Plan of Care (POC): Generate POC - using algorithms triggered by answers to assessmentquestions to generate standardized POCsProgram Eligibility Determination: Complete application processing, gather all required documents,coordinate inputs, and assess potential eligibility for State eligibility determination review – using imaging,workflow, and end-to-end electronic processing to speed eligibility determinationProcess Enrollment: Perform choice counseling to select Managed Care Organization (MCOs), Fee ForService (FFS) Providers, or other service authorizations - using automated enrollment transactions sent toMCOs or Service Coordinators (SCs)Verify Receipt of Service: Outbound calling, in-home visits, and quality assurance reviews to ensureappropriate provision of services - using automated tracking system and outbound calling campaigns10

Benefits of Our Integrated Approach Greater flexibility for service delivery systemIntegrated across programs – single point of entry, uniform assessments, andstandardized data for financial eligibility regardless of disability population, allowing easierhandling of co-morbidities, complex cases, andEasier access to services – convenient access for clients who can more easily navigatethe complexities of the LTSS systemEnhanced efficiency leads to improved service and cost reductions— Increased use of automation for both financial and functional eligibility enhancesefficiency— Use of QIO-like operational entity and AVS enables enhanced federal funding— Faster screening of clients and placement in NF or waivers, results in faster dischargefrom hospital and quicker access to needed services— Automating time consuming processes and reducing administrative burden frees stateworkers for more professional tasks -- quality oversight and improved service delivery— Less arbitrary judgement in allocation of resources— Fewer appeals and fair hearings reduces time and cost to the StateIncreased standardization of processes and greater equity in resource allocation— Standardized, conflict free assessment across geographic and population boundaries— Automated Asset Verification and Financial Transaction Review allows faster, moreeffective review of applicant resources— Algorithm-based resource allocation eliminates personal judgement and enhancesfairness, resulting in fewer disputes and appeals11

Automated Verification and Financial Transaction ReviewSystems12

Why Automated Verification Systems in Medicaid? Section 1940 of the Social Security Act requires an electronic assetverification service to be applied to certain Medicaid eligibilitycategories Deficit Reduction Act of 2005 required states to review 60 months ofinformation for a Medicaid long-term care applicant to identify assettransfers Supplemental Appropriations Act, 2008 Pub.L. No. 110-252required California, New Jersey, and New York to implement AVS forABD populations by the end of fiscal year 2009 and the rest of thestates to implement systems over the period from 209-2013 GAO Report identifies multiple states missing the legislative timelineestablished, resulting in Congressional letter pushing CMS take a moreproactive role in moving states to use of AVSAVS allows states to perform financial eligibilitydeterminations for LTSS faster, better, cheaper 13

AVS – Important, But Not the Full PictureAutomated VerificationSystemFinancial TransactionAnalysis System Identify all financialinstitution accounts,including those notdisclosed on theapplication Provide monthly accountbalances Identify real propertyownership and transfers Identify other assets thatmay have a bearing oneligibility Perform detailed analysisof financial transactions Expedite review to allow60 month look back Ensure 99% accuracy offinancial documentsbeing reviewed Perform sophisticatedfinancial analyses toidentify undocumentatedpayments, transfers, andsuspicious activity14

Solutions to Emerging Eligibility ChallengesChallengeDwindling State resourcesmake it increasinglydifficult to comply withasset verification and lookback periods indetermining financialeligibility for LTSSSolutionBenefitsNew technology bringsdisparate data into onecomprehensive Memberview, expediting eligibilitydecisions and reducingadministrative burdenDecisionPoint Better data arranged inmore intuitive ways leadto more accurate eligibilitydecisions, increasingprogram integrity andreducing fiscal burdenDwindling Stateresources combined withlimited data sets impedethe accuracy and integrityof eligibility decisionsReduces Administrative Burden while Increasing Program Integrity15