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Acute RFP Public Input Meeting. 1. January 18, 2012. Welcome. Monica Coury Assistant Director Office of Intergovernmental Relations. 2. January 18, 2012. AHCCCS. Mission: Reaching across Arizona to provide comprehensive, quality health care for those in need. Vision:

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welcome

Welcome

Monica Coury

Assistant Director

Office of Intergovernmental Relations

2

January 18, 2012

slide3

AHCCCS

Mission:

  • Reaching across Arizona to provide comprehensive, quality health care for those in need.

Vision:

  • Shaping tomorrow’s managed health care…from today’s experience, quality and innovation.

Customer:

  • AHCCCS recognizes many internal and external customers, but the fundamental focus that inspires our efforts:Our primary customers are AHCCCS members.

3

slide4

AHCCCS

Federal

AHCCCS

Administration

State

Health Plans

Program Contractors for

Long Term Care

County

State Agencies

Medical Policy

  • DHS

Eligibility (Special Populations)

·

·

Behavioral Health

Eligibility/DDD/CMDP

Private

  • DES

Contract for Medical and Long Term Care Services

Monitor Quality of Care and Financial Viability

Information Services

Fee-For-Service

Budget and Claims Processing

  • Native Americans
  • Emergency Services

Legal

  • Member

Cost Sharing

Intergovernmental Relations

Arizona Health Care Cost Containment System

Funding

- Medical Care

- Long Term Care

- Healthcare Group

4

slide5

Acute Care Program Highlights

  • The AHCCCS Acute Care Program will celebrate its 30th anniversary on 10/1/12
  • The Acute Care Program provides coverage for a wide array of services including, but not limited to:
    • Hospital services (inpatient & outpatient)
    • Professional Practitioner Services
    • Pharmacy
    • Lab & x-ray
    • Transportation
  • AHCCCS seeks competitive bids every five years from interested health plans who wish to serve AHCCCS members
  • Acute Care members are offered a choice of health plans in every county in Arizona
  • Members have access to a robust network of health care providers

5

slide6

AHCCCS

Who Does AHCCCS Serve?*

6

* As Of – 12/1/2011

ahcccs population demographics as of 12 1 2011
Total Population Percentages

Child 0-17 48.7%

Adult 18-21 6.3%

Adult 22-64 39.2%

Adult 65-79 4.0%

Adult 80+ 1.7%

AHCCCS POPULATION DEMOGRAPHICS – AS OF 12/1/2011

Ethnicity Percentages

Asian /Pacific Island 1.92%

Black 6.78%

Caucasian/White 34.74%

Cuban/Haitian 0.01%

Hispanic 39.95%

Native American 10.21%

Other 0.45%

Unknown 5.94%

Gender

Male – 44.6%

Females – 55.4%

geographic service areas

AHCCCS

52,150

83,042

APACHE

COCONINO

(4)

(4)

34,479

4, 855

17,181

MOHAVE

(4)

50,646

45,724

NAVAJO

(4)

YAVAPAI

15,282

196,261

(6)

34,479

LA PAZ

668,376

(2)

GILA

3,095

MARICOPA

(8)

(12)

9,352

GREENLEE

(14)

1,340

668,376

33,846

PINAL

GRAHAM

YUMA

(8)

(14)

(2)

41,294

7,250

49,055

PIMA

COCHISE

(10)

(14)

181,329

25,256

SANTA

CRUZ

(10)

14,932

Geographic Service Areas

Acute Enrollment As of 12/1/2011

Health Plan Enrollment

GSA Number Acute

APIPA, HCA

2

PHP, HCA

4

PHP, BWY

6

PHP, UFC

8

APIPA, HCA, UFC, MCP, PHP

10

APIPA, Care 1st, HCA, MHP, MCP, PHP

12

MCP, UFC

14

Total Health Plan Enrollment = 1,118,800

9

slide10

AHCCCS

Current Acute Care Contractors & Membership as of 12/1/2011

10

contract requirements
Program

Quality Management

Clinical performance measures

Performance improvement projects

Ensure receipt of EPSDT and maternal child health services

Quality of Care tracking, trending, intervening as

necessary

Medical Management

Utilization data analysis and intervention

Utilization management tools (PA, concurrent/retrospective review, chronic illness management, case/care coordination)

Contract Requirements

11

contract requirements con t
Network

Network requirements including accessibility and consideration of geography and physician referral patterns

Monitoring for improvement and resolution of service gaps

Financial/Claims/Encounters

Financial viability requirements to ensure the ability to perform and serve AHCCCS members

Claims payment timeliness and accuracy

Electronic reporting of all claims paid via encounter submissions

Contract Requirements – con’t.

12

contract requirements con t1
Program Integrity

Verification of service requirements

Cost avoidance reporting

Fraud and abuse

Contract Requirements – con’t.

13

slide14
Operational and Financial Review (OFR)

Deliverable review

Clinical performance measures

Quality improvement projects

Medical Management/Utilization Management

Provider network monitoring

Claims payment timeliness and accuracy

Grievance System (member grievances and appeals and claim dispute monitoring)

Contractor Oversight

AHCCCS monitors Contractors’ performance to ensure Contractor is able to perform under the contract via:

14

over the next 24 months ahcccs must work on implementing the following by october 1 2013
AHCCCS Acute Care Contract – $35 billion plus - largest procurement in the history of State Government

AHCCCS CRS Contract - $500 million plus – New Integration and Alignment Structure

DHS – Maricopa Integrated RBHA - $5 billion plus

Over the next 24 months AHCCCS must work on implementing the following by October 1, 2013:

AHCCCS Contracting

15

ahcccs performance measures
AHCCCS Performance Measures

Measures Exceeding the National Mean 10/1/2009 – 9/30/2010

96.3%

96.3%

100.00%

88.4%

88.4%

80.00%

64.1%

60.2%

60.00%

40.00%

20.00%

0.00%

Well Child Visits First 15

Oral Health Care

Appropriate Medication Use

Months of Life

for Asthma

AHCCCS Medicaid Rate

HEDIS Medicaid Mean

ahcccs performance measures1
AHCCCS Performance Measures

Measures Exceeding the National Mean 10/1/2009 – 9/30/2010

100.0%

89.0%

88.8%

88.1%

88.3%

80.0%

76.4%

60.0%

48.1%

45.7%

52.9%

40.0%

20.0%

0.0%

Adolescent Well Care

Oral Health Care

Children's Access

To PCP -

Children's Access

To PCP -

Visits

25 Mos - 6 Yrs

12 – 19 Yrs

AHCCCS KidsCare Rate

HEDIS Medicaid Mean

health care reform
Medicaid Expansion – up to 133% FPL

New requirements regarding eligibility - MAGI

Goal is to have streamlined processes

Health Care Exchange

Medicaid systems must be interoperable with Exchange so Exchange customers first are screened for Medicaid and then screened for Exchanged Subsidy (133% - 400% FPL)

How will Medicaid health plans work with Qualified Health Plans in the Exchange to manage coordination of care for individuals who move back and forth.

AHCCCS

Health Care Reform

18

acute rfp contact information
Web Address

http://www.azahcccs.gov/commercial/Purchasing/RPFInfo/YH14-0001/YH14PublicMeeting.aspx

E-mail Address

AcuteRFP@azahcccs.gov

Acute RFP Contact Information