Rate Update
Provider Rates update effective July 1, 2017, include mandated pass-throughs for MCOs, rate increases for NFs and HCBS, impacting services across Arizona. Actuaries assessing impacts for potential capitation amendments. Further changes expected in annual fee schedule updates from October 1, 2017.
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Presentation Transcript
Rate Update Shelli Silver July 12, 2017
Provider Rates 7/1/17 Prop 206/414 Rate Changes: o Mandated Pass-Through for all MCOs o NF 0.3% Urban/Rural Rate Increase 1.0% Flagstaff Rate Increase o MCOs must also increase NF rates not set by AHCCCS o MCOs must continue to apply 10/1/16 1% VBP Differential Adjusted Rates to these new rates Reaching across Arizona to provide comprehensive quality health care for those in need 2
Provider Rates, cont. 7/1/17 Prop 206/414 Rate Changes: o Mandated Pass-Through for all MCOs o HCBS Select Codes 1.9% Statewide Rate Increase (excluding Flagstaff) 3.3% Flagstaff Rate Increase o MCOs must also increase HCBS rates not set by AHCCCS list of 5 specific codes o HCBS update also impacts some BH services: S5150/S5151/T1019 shared codes Reaching across Arizona to provide comprehensive quality health care for those in need 3
Provider Rates, cont. Flagstaff Impacts o 2 NFs these are provider-specific rates o HCBS 3 zip codes 86001, 86004, 86005 o System logic for this still under development likely based on provider site address Prop206/414 rates loaded in PMMIS as of 7/1 MCOs have them (except HCBS Flagstaff due to system changes) Reaching across Arizona to provide comprehensive quality health care for those in need 4
Provider Rates, cont. Actuaries are assessing impacts of 7/1/17 provider rates to determine if capitation amendments are warranted pre-10/1/17 Prop 206/414 funding will be included in cap rates effective 10/1/17 prospectively Prop 206/414 will result in additional provider rate increases effective 1/1/18 Reaching across Arizona to provide comprehensive quality health care for those in need 5
Provider Rates, cont. Annual Fee Schedule Updates 10/1/17, expect changes for: o Physician Drug Schedule o Emergency Ground Ambulance o FQHC/RHC o Hospice o APR-DRG Outlier CCRs Reaching across Arizona to provide comprehensive quality health care for those in need 6
Provider Rates, cont. Budget Neutral Updates 10/1/17, expect changes for: o ASCs o BH Outpatient (other than Prop206/414) o Clinical Lab o DMEPOS o OPFS/Freestanding ED (tied to OPFS) o LTAC/Rehab hospitals o Physician Fee Schedule Reaching across Arizona to provide comprehensive quality health care for those in need 7
Capitation Rates CYE 18 10/1/17 rates will be submitted to CMS 8/15/17 Will include (not intended to be a complete list): o Historical encounter data through 9/30/16 o More current data for various analyses o FFS rate impacts o New reinsurance biologic drugs 5 added Reaching across Arizona to provide comprehensive quality health care for those in need 8
Capitation Rates CYE 18, cont. o Budget items: Occupational Therapy benefit $1,000 Adult Emergency Dental o VBP Differential Payments (requires additional CMS approval under 438.6(c)) - submitted o Access to Professional Services Initiative (APSI) (requires additional CMS approval under 438.6(c)) - submitted Reaching across Arizona to provide comprehensive quality health care for those in need 9
Capitation Rates CYE 18, cont. 10/1/17 won t include: o DRG rebase impacts o Prop 206 (1/1/18 increase) o VBP Differential Payments (Per Diem Facilities) o Updated CYE 18 risk adjustment factors AHCCCS will amend capitation rates effective 1/1/18 Reaching across Arizona to provide comprehensive quality health care for those in need 10
VBP Differential Adjusted Rates - Reminder Effective 10/1/17- 9/30/18: Hospitals (PT 02) inpatient and outpatient claims 0.5% Nursing Facilities (PT 22) all claims 1% or 2% Integrated Clinics (PT IC) select physical health claims 10% Reaching across Arizona to provide comprehensive quality health care for those in need 11
VBP Differential Adjusted Rates Reminder, cont. Physicians, Physician Assistants, and Registered Nurse Practitioners (Provider Types 08, 31, 18, 19) all 1500 claims 1% Effective 1/1/18 - 9/30/18: Other Hospitals & Inpatient Facilities (PT 71; PT B5; PT C4) inpatient and outpatient claims 0.5% Reaching across Arizona to provide comprehensive quality health care for those in need 12
DRG Rebase Highlights Effective with discharges on & after 1/1/18 3M Version 34 of APR/DRG grouper Adding projected $35 million in new spend o New Burn DRG policy adjuster of 2.700 ~$5M o New Other Adult policy adjuster of 1.025 to maintain current ~$13m o High-acuity pediatrics policy adjuster for SOI levels 3/4 increased to 2.300 ~$17M Reaching across Arizona to provide comprehensive quality health care for those in need 13
DRG Rebase Highlights, cont. Did not add rural hospital provider adjustor to replace pass-through those continue Still working to solve for claims failing outlier due to member enrollment changes expect new billing/processing rule to address Reaching across Arizona to provide comprehensive quality health care for those in need 14
DRG Readmissions - Reminder No sooner than 10/1/18, may implement new readmissions policy o No changes to existing readmissions policy prior to implementation of new policy o Considering a performance-based measurement consistent with Value-Based Purchasing differential adjusted payments More discussion with MCOs later Reaching across Arizona to provide comprehensive quality health care for those in need 15
Cap Rate Risk Adjustment CYE 17 risk adjustment to use updated encounters and enrollment o Anticipate using December 2015 November 2016 most complete, clean data set o Intend to extract after first August encounter cycle o Will take approximately 4 months to complete CYE 18 risk adjustment TBD Reaching across Arizona to provide comprehensive quality health care for those in need 16
IMD Update For members aged 21-64 exceeding 15 days in an IMD in one month o 100% of the month s capitation payment will be recouped From both the RBHA and the MCO For all members including Duals and those with TPL o Encounters will not be included in future cap development Excluded from recons Reaching across Arizona to provide comprehensive quality health care for those in need 17
IMD Update, cont. o Member still enrolled and eligible for all medically necessary services RBHAs/MCOs will self-report LOS greater than 15 days using AHCCCS-defined process AHCCCS will audit to ensure reporting compliance AHCCCS to seek IMD/SUD Waiver Reaching across Arizona to provide comprehensive quality health care for those in need 18
Questions? Reaching across Arizona to provide comprehensive quality health care for those in need 19
Thank You. Reaching across Arizona to provide comprehensive quality health care for those in need 20
