May 2019 ~

New Jersey’s reimbursement parameters for its Medicaid Managed Long Term Services and Supports (MLTSS) program are intended to be transitioned to a new, quality-based Any Willing Qualified Provider (AWQP) reimbursement model.

According to the New Jersey Department of Human Services (DHS) SFY 2020 budget discussion points, when first implemented, the MLTSS program established a “default rate” for nursing facilities (NF) that had not otherwise negotiated a reimbursement rate with a resident’s managed care organization (MCO). These reimbursement parameters, while still in effect, are intended to be transitioned to a new, quality-based AWQP reimbursement model.

As seen in the discussion points, AWQP establishes a new framework for NFs serving MLTSS enrollees and MCOs to negotiate payment rates based on performance standards to improve the quality of care by linking provider reimbursement to performance and enabling consumers to select high-quality providers. DHS with the Division of Medical Assistance and Health Services (DMAHS) are implementing the AWQP initiative over a few years.

According to DHS, after a one-year data collecting period and developing baselines, the agency intends to award AWQP designation status to NFs in the spring of 2019 and will review it annually.

To be awarded the designation, a facility must meet or exceed the State benchmark for at least four of the seven established measures:

• Rate of administered influenza vaccination
• Rate of administered antipsychotic medication
• Rate of pressure ulcers experienced by patients
• Rate of patients physically restrained
• Rate of falls with major injury
• Family experience
• Utilization of tools to measure 30-day hospitalizations and hospital utilization.

The agencies intend to align compensation with quality metrics as the program matures. According to the discussion points, in the event that a NF is unable to attain or retain AWQP designation, DHS and DMAHS may take progressive accountability actions ranging from issuing notices informing MLTSS members that they may relocate to another facility, to stopping new MLTSS long-term custodial care admissions, to terminating the NF as an MCO network provider.

Under the AWQP redesign, each eligible NF may receive up to an additional $3.00 per day, per patient for meeting quality metrics.

DHS and DMAHS state network adequacy continues to be a consideration for future planning and they will continue to establish the baseline structure of this MLTSS VBP initiative as one component of NF reimbursement, and will evaluate the continued use of a default reimbursement rate.

 

 

Source(s): HMA Weekly Update May 8, 2019; NJ.gov; FY2020 State of New Jersey Budget in Brief;