Managed Medicaid

N.M. Begins Medicaid Coordinated Long-Term Care Coverage Aug. 1

Reprinted from the July 24, 2008, issue of MEDICARE ADVANTAGE NEWS, biweekly news and analysis on the Medicare (and Medicaid) managed care programs.

New Mexico will begin covering Medicaid recipients in six counties Aug. 1 under a new mandatory managed long-term care program, state officials say. Using AMERIGROUP Corp. and UnitedHealth Group's Evercare division, the program is expected to serve 38,000 people with extensive health needs statewide by the end of the first year, state officials say.

The initiative, called the Coordinated Long Term Services (CLTS) program, is designed to address what New Mexico describes as a "fragmented mix of institutional, state plan, and home- and community-based services." It also is expected to improve what the state calls the "limited coordination and integration that currently exists across long-term services programs" in Medicaid.

"We see it as a $700 million program annually once it's fully rolled out," Larry Heyeck, deputy director of the New Mexico Dept. of Human Services' medical assistance division, tells MAN. He says the program's contractors must coordinate primary, acute and long-term care, and also must coordinate with the state's single contractor already providing behavioral health services.

While enrollment in the six counties began July 1, Heyeck conceded July 18 that the state continues to work with CMS on a Sec. 1915 (b) and (c) federal waiver to cover individuals needing home and community-based services. "We anticipate being set to go" Aug. 1, he said.

New Mexico's CLTS program will include low-income people over age 65 who are dually eligible for Medicare and Medicaid, Medicaid recipients who are nursing-home eligible or residents in nursing facilities, individuals who are getting "personal care option" services, certain individuals with brain injuries, and about 100 high-needs children, he says, but the majority of enrollees will be "healthy duals."

"We've been told by CMS, 'This is one of the most comprehensive waivers we've ever seen,'" Heyeck says. "We have 22 pueblos and nations here in New Mexico….We've worked extensively with Native Americans to make sure they're aware of it."

According to Heyeck, state officials in New Mexico finalized negotiations with AMERIGROUP and Evercare over payment rates for the new initiative July 1. New Mexico started designing the project in 2005, and in its request for proposal (RFP) asked contractors for help in developing the program. He says the state announced its intent to contract with AMERIGROUP and Evercare in January 2007, and both companies helped the state in meeting with stakeholders to identify infrastructure needs. The state awarded formal contracts in early spring 2008.

Heyeck estimates that about half, or 19,000, of the program's enrollees reside in the six counties where coverage will begin Aug. 1. Subsequently, he says, New Mexico wants Evercare and AMERIGROUP to branch out to rural areas of the state, anticipating that membership will be evenly split between the two organizations; both now are engaged in marketing to duals.

AMERIGROUP spokesman Kent Jenkins, Jr. says his company has not quantified the potential financial impact of its participation in New Mexico's CLTS program. AMERIGROUP has a second-quarter earnings investor conference call July 24, and remains in a "quiet period" until then, he says.

Similarities to Texas' STAR+Plus Program

Jenkins notes that AMERIGROUP and Evercare are covering the Supplemental Security Income (SSI) and Aged, Blind and Disabled (ABD) populations in Texas's decade-old STAR+Plus Medicaid managed care program, which includes long-term care and integrated care management components.

"I think the New Mexico program has similarities to STAR+Plus and builds on it," Jenkins says. "With this program, if you live in New Mexico, are low income, have extensive health needs and are in a nursing home or nursing-home certifiable, this program gives you one-stop shopping for your health needs." Of AMERIGROUP's 1.7 million members, about 200,000 are SSI/ABD, he says.

Citing the challenges inherent in serving New Mexico's diverse population, Jenkins notes that AMERIGROUP is preparing CLTS program materials in several Native American languages as well as in English and Spanish.

According to Heyeck, New Mexico has cost efficiencies built into the CLTS program. "We anticipate by year three [that] the projected savings will be between 10% and 15% [greater] than if we were to provide the same services under fee-for-service," he says, explaining that such savings are expected to arise from better coordination of services, and not fewer services.

Heyeck notes that a component in the contract requires plans to identify people in nursing homes who can return to the community, and then to provide support services to help accomplish this.

Moreover, he says, the state has mandated in the contract that Evercare and AMERIGROUP offer Medicare Advantage (MA) Special Needs Plans (SNPs) in counties where this is feasible, or offer regular MA prescription drug plans (MA-PDs) in New Mexico. "We're very proactive in integration," he says. "Right now a recipient gets Medicaid services and gets a card, gets Medicare services and gets a card, gets Part D [Medicare prescription drug] services and gets a card. The state's aim is one card and payer source, so we've asked contractors to do what they can and go after SNPs." Both AMERIGROUP and Evercare already have SNPs for people dually eligible for Medicare and Medicaid in the state's largest county, Bernalillo, he notes.

Heyeck concedes that the MA program is about freedom of choice, "but we want [the two plans'] best efforts in offering an integrated product." New Mexico expects about 10% of the CLTS program's 38,000 recipients in the first year to enroll in SNPs, he says. This is "very aggressive. Some states only have 2% to 3%, but [the CLTS program is] mandatory for Medicaid," he says.

Information on the program is found at http://www.nmaging.state.nm.us/CLTS_overview.html.

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