Slide 1

Report
Bureau of TennCare
2009
TennCare is Tennessee’s Managed-Care Medicaid Program serving approximately 1.2
million culturally and racially diversified low-income children, pregnant women and
disabled Tennesseans, with an annual budget of $7.6 billion.
Topics:
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TennCare Enrollment
Health Care Cultural Competency
MCC Change Schedule
Fraud & Abuse
Long Term Care Community CHOICES
Act of 2008
Provider Reminders
TennCare Enrollment
(As of 09/01/09)
• Total Enrollment - 1,143,376
– 392,999 – East Tennessee
• 8,668 – Nursing Facility
• 2,020 – HCBS
– 358,368 – Middle Tennessee
• 7,426 – Nursing Facility
• 1,427 – HCBS
– 331,415 – West Tennessee
• 6,240 – Nursing Facility
• 1,200 - HCBS
– 60,594 – TennCare Select
• 166 – Nursing Facility
MCO Enrollment Numbers
• East Tennessee
– AmeriChoice
– BlueCare
• Middle Tennessee
– AmeriChoice
– AmeriGroup
• West Tennessee
– AmeriChoice
– BlueCare
• TennCare Select
• Total Enrollment
(As of 09/01/09)
161,255
231,744
179,320
179,048
150,786
180,629
60,594
1,143,376
Cultural Competency in TennCare
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59.1% White
30.7% Black
4.6% Hispanic
5.6% Other
Considerations
– Cultural perspectives
– Gender
– Religious or moral preferences
– Limited English Proficiency
MCC Change Schedule
Starting next year (2010), members will
be allowed to change their health plan
during one month of the year.
March 2010 West TN Grand Region
May 2010
Middle TN Grand Region
July 2010
East TN Grand Region
REPORTING FRAUD & ABUSE
Office of Inspector General
1-800-433-3982
FAX: 615-256-3852
http://www.tn.gov/tnoig/
Tips can be anonymous
Cash for Tips Policy
http://www.tn.gov/tnoig/Documents/IncentiveProgram_OIG.pdf
•Tip cannot be anonymous
•Can claim cash reward if your tip leads to prosecution
•Details of how program works available at the link above
•Posters available at TennCare help desk
Office of Inspector General Statistics
ARREST BY COUNTIES
WEST
62
MIDDLE
647
EAST
223
FALCON
III
32
FALCON
IV
16
TOTAL
980
Office of Inspector General Statistics
Types of Arrests
RESOURCES
Access To Ins
55
Hotline
114
Drug Div/Sale
346
Website
12
Drug Div/Forgery
331
Law-Email
10
Doctor Shopping
76
Law-Ltr
18
Inel Per Using
17
Law-CID
360
Asset Diversion
7
Law-Hotline
130
Income
45
Law-Fax
23
Theft of Svcs
11
State Agency
62
Out of State
13
ID - Theft
28
Mail
14
Aiding & Abetting
3
Wage Ltr
23
Falcon III
32
Internal Data Mining
14
Falcon IV
16
Total Arrests
980
Total Resources
980
***
PROVIDER
***
200
Long-Term Care Services
“Carved Out” of Managed Care
• Long-Term Care (LTC) Services have
traditionally been carved out of managed
care
– Nursing Facilities (NFs)
– Intermediate Care Facilities for persons with
Mental Retardation (ICFs-MR)
– Home and Community-Based Services
(HCBS) waivers
The Long-Term Care Community
Choices Act of 2008
• Passed unanimously by the
Tennessee General Assembly
• Fundamentally restructures the Medicaid
long-term care system for the elderly and
adults with physical disabilities in
Tennessee
Why restructure the
long-term care system?
Fragmentation
• Access to LTC services scattered across different
points of entry with no coordination
– Nursing Facility Services
– Home and Community Based Waiver Services
– Home Health and Private Duty Nursing
• Difficult for individuals and families to navigate
• Fragmented quality strategy, with regulatory focus
for Nursing Facility services
Limited Options
• Heavy reliance on Nursing Facilities (NF);
home and community options extremely limited
• Only one community-based residential alternative
to NF care – Assisted Living Facility
• Few choices or decision-making opportunity
• Few services aimed at preventing or delaying
need for more costly care
Inefficient Use of
Limited Resources
• 98% of LTC spending for Nursing Facility services
• Heavily dependent on most costly services
(NF/HH/PDN) even when lower-cost alternatives
would better meet needs/desires of individuals
and families
• Supplants, rather than supports, existing natural
support networks of family and other caregivers
• Payment systems do not reward efficiency/not
based on level of need of persons receiving care
• New recurring dollars extremely limited
How will CHOICES change
the current LTC system?
Reorganize the LTC system
• Simplified access (Single Entry Point)
• Streamlined (expedited) enrollment
• Comprehensive care coordination across
acute/LTC services
• Integration of LTC services within existing
TennCare managed care delivery system
• Continuous quality improvement strategy across
acute/LTC continuum
Refocus LTC services
• Increased use of HCBS
• Self-directed care—ability to hire non-traditional
providers such as family and friends to provide
in-home care
• More community-based residential
alternatives to Nursing Facility care
Rebalance LTC funding
• Single LTC funding stream (global budget)
• Money follows the person into the appropriate,
cost-effective setting of their choice
• Serve more people with existing LTC funds
• More equitable balance of Nursing Facility/HCBS
expenditures over time
How will CHOICES impact
persons who need LTC?
Single Point of Entry
• One access point for new Medicaid applicants
seeking access to LTC services – HCBS and
Nursing Facility
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Public Education and Outreach
Information and Referral
Screening and Assessment
Facilitate eligibility and enrollment
• Area Agencies on Aging and Disability (AAADs)
TENNESSEE AREA AGENCIES ON AGING & DISABILITY
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Area
Name
Address
City
State
Zip
Phone
Fax
1
First TN Dev. District
207 North Boone Street
Suite 800
Johnson City
TN
37604
423-928-0224
423-928-5209
2
East TN Human Resource Agency
9111 Cross Park Drive,
Suite D100
Knoxville
TN
37923
865-691-2551
ext. 216
865-531-7216
3
Southeast TN Dev. District
1000 Riverfront Parkway
Chattanooga
TN
37402
423-266-5781
423-424-4225
4
Upper Cumberland Dev. District
1225 South Willow Ave.
Cookeville
TN
38506
931-432-4111
931-432-6010
5
Greater Nashville Regional Council
501 Union Street, 6th Floor
Nashville
TN
37219
615-862-8828
615-862-8840
6
South Central TN Dev. District
815 South Main Street
Columbia
TN
38402
931-381-2040
931-381-2053
7
Northwest Dev. District
124 Weldon Drive
Martin
TN
38237
731-587-4213
731-588-5833
8
Southwest TN Dev. District
27 Conrad Drive, Suite 150
Jackson
TN
38305
731-668-7112
731-668-6438
9
Aging Commission of the Mid-South
2670 Union Avenue Extended,
Suite 1000
Memphis
TN
38112
901-324-6333
901-327-7755
Member Choice
• Members eligible for LTC choose
between NF and HCBS
(even if HCBS would be more cost-effective)
– Members in HCBS must be able to have needs safely
met in the community at a cost that does not exceed
NF care
• Members will be able to choose their Nursing
Facility provider
– Contracted with the MCO
– Able to admit the member
– Able to provide the needed services
Current LTC Services
Covered under CHOICES
• Nursing Facility Care
• Same HCBS Services Available
– Adult Day Care
- Assisted Care
Living Facility
– Assistive Technology
- Attendant Care
– Home Delivered Meals
- Homemaker
Services
– Personal Care
- PERS
– Pest Control
- Minor Home
Modifications
– Respite Care (In-Home, In-Patient)
Current LTC Services
Covered under CHOICES
• Individual Service Limits (HCBS)
• Individual Cost Neutrality Cap Combined cost of all services in home
or community setting cannot exceed
average cost of NF care
– Includes all HCBS
– Includes HH/PDN
Additional Benefits
Covered Under CHOICES
• New Community Based Residential Alternatives
– Critical Adult Care Homes
• 24-hour residential care in a homelike environment to
no more than 5 elderly or disabled adults
– Level II – Specialized and/or Skilled Services for Ventilator
Care and Traumatic Brain Injury
• Continuum Model – Allows members to age in place
• Rules expected to be promulgated by January 2010
– Companion Care
• Live-in caregiver hired and supervised by the member
(consumer direction)
Consumer Directed Options
Under CHOICES
• Consumer Direction
– Allows consumers to select, direct, and employ their own
caregivers
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Personal Care
Attendant Care
Homemaker
In-Home Respite
Companion Care
• Self Direction of Health Care Tasks
– Allows members to direct and supervise a paid personal aide in
the performance of health care tasks
• Initially limited to administration of oral, topical, and inhaled
medications
• Limited to consumer directed workers
Care Coordination in CHOICES
• Comprehensive, continuous, holistic, and person-centered approach
to care coordination
– Help the member maintain or improve physical or behavioral health
status or functional abilities
– Maximize member independence
– Ensure the member’s health, safety and welfare
– Delay or prevent the need for institutional placement
• Integrated model of coordination of care –medical as well as social
• Addresses physical, behavioral, functional (ADL) and psychosocial
needs
• Coordinates ALL Medicaid services for the elderly and disabled –
physical, behavioral and long term care
Care Coordination for
Nursing Facility Residents
• Leverage existing NF Plan of Care
• May supplement NF plan of care with additional targeted
strategies related to improving health, functional, or
quality of life outcomes or to increase and/or maintain
functional abilities
• Focus on better management of chronic conditions and
coordination of services outside the scope of the NF
benefit
• Assess member potential and interest for transition to
community (based on member choice)
• Care Coordination Contact Requirements
– Quarterly grand rounds
– Semi-annual member face-to-face contact
Electronic Visit Verification (EVV)
• EVV System Required for CHOICES
– Track the provision of services
– Facilitate timely payment
– Increased ability to detect and resolve
problems
• Service gaps
• Delays in service delivery
• Log-in/Log-out by phone
What happens when CHOICES is
implemented?
– Members receiving NF care will continue to qualify for
and receive NF care
– Members will be able to stay in the NF where they
currently reside, so long as the NF meets CMS
conditions of participation
– Members are transitioned into CHOICES
• LTC Services are provided via CHOICES
• LTC Services are NO LONGER provided via the current feefor-service system
• Payment will come from the MCOs
What if Nursing Facilities don’t want
to contract with an MCO?
• Nursing Facilities are NOT obligated to contract with each MCO
BUT……………
• Existing Medicaid fee-for-service system will no longer exist once
CHOICES is implemented
• Non-contracted facilities will be reimbursed by MCO for services
provided to existing Medicaid/LTC members – but at a lower
payment rate than if contracted with the MCO
– 80% of the lowest rate paid by the MCO to participating network
providers for the same service (as set forth in TennCare Rule)
• MCOs will seek to admit all new residents to contracted facilities
Authorization of NF Services
• Immediate authorization of Nursing Facility
services for CHOICES members
– In accordance with level of nursing facility services
approved by TennCare, i.e., TennCare level of care
(reimbursement) decision drives prior authorization of
NF services
– MCO cannot authorize a lesser level or duration of
services than approved by TennCare
– MCOs will conduct concurrent review of Level II
services and may initiate a request to TennCare to
reduce when appropriate
NF Role in Level of Care Eligibility
• NFs may continue to complete and submit
PAEs to TennCare (also hospitals, SPOEs,
MCOs)
– Level I
• Nursing Facility Care
– Level II
• Skilled Nursing Facility (SNF) Care
• TennCare will continue to determine level
of care (reimbursement)
When will CHOICES
be implemented?
CHOICES Approval Timeline
• May 30, 2008 – LTC CCA passed by General Assembly
• July 11, 2008 – CHOICES Concept Paper submitted to
CMS
• October 2, 2008 – 1115 Waiver Amendment submitted to
CMS
• June 26, 2009 – Finalized MCO CRA amendment
• July 22, 2009 – CMS Terms and Conditions for Approval
of 1115 Waiver Amendment
• August 2009 – Formal execution of CMS approval for
CHOICES
CHOICES Implementation
• Phased Implementation
– Middle Region – March 1, 2010
– East and West Regions to follow –
likely first of FY 2011 (July 1, 2010)
Medical Necessity
State law establishes five components (prongs) of
medically necessity and the service must satisfy all
five components before TennCare will pay for the
service. The five components are:
1. It must be recommended by a health care
provider
2. It must be required to diagnose or treat the
medical condition
3. It must be safe and effective
4. It must not be experimental or investigational
5. It must be the least costly alternative course of
diagnosis or treatment that is adequate for the
enrollee’s medical condition
Provider Inquiries
1. Contact “Provider Services” at the MCC
2. Contact your assigned MCC Provider
Representative
3. Escalate the complaint to a MCC Manager
in the Provider Relations Department
Provider Inquiries
4. TennCare Provider Service Department by
phoning 1-800-852-2683, and telling them
you need to file a MCC provider complaint
-Goal of MCC provider complaint system
-Considered “On Request Report”
Provider Inquiries
5. Official Provider Complaint Process or
Independent Review Process through
Tennessee Department of Commerce &
Insurance at
http://tn.gov/commerce/tenncare/PCIR.shtml
Former MCC Partners Claims
• The Bureau of TennCare will NOT accept nor act
on requests from providers for reimbursement of
claims that would have otherwise been the
responsibility of the former MCC Partners
• Independent Review Process outlined in T.C.A.
56-32-126 is no longer available
• All Independent Review Requests sent to the TN
Dept. of Commerce & Insurance (TDCI) will be
processed as an official Provider Complaint as
long as the company has an active license on
file with TDCI
TennCare Eligibility Verification
• There are 2 ways to verify eligibility
directly with the Bureau of TennCare:
– Call TennCare Provider Services at 800-8522683
– Use the Tennessee Anytime online internet
website portal
Tennessee Anytime
Step-By-Step Online TennCare Eligibility Verification
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Type in www.tn.gov/tenncare
Click “For Providers” at left of page
Click “Verify Eligibility” under Provider Links
Click “Online Eligibility Verification” in center of page
Click “OK” in message box that pops up telling you that you are being taken
to a different webpage:
TennCare Online Services
https://www.tennesseeanytime.org/tcmis/tennessee/Security/logon.asp
Type in User Name and Password in the Log In section at bottom left of page
and click “Log In”
Click “Eligibility Verification”
Enter either the “Recipient ID” or “Recipient SSN and Recipient Date of
Birth”
How to subscribe for Online TennCare Eligibility Verification
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2.
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4.
5.
Type in www.tn.gov/tenncare
Click “For Providers” at left of page
Click “Verify Eligibility” under Provider Links
Click “Online Eligibility Verification” in center of page
Click “OK” in message box that pops up telling you that you are being taken
to a different webpage:
TennCare Online Services
https://www.tennesseeanytime.org/tcmis/tennessee/Security/logon.asp
6. Click “Learn how to subscribe” in center of page
7. Under Sign Up in Three Easy Steps- click “Create a TN.gov account”
8. Under Subscription Services – check mark “TennCare Eligibility Information
Search”
9. Complete Business/Account Information – click “Continue”
10. Complete Technical Contact Information – click “Continue
11. Setup Username, Password and Security Questions – click “Continue”
12. Complete Billing Information – click “Continue”
13. Print the Service Agreement, Sign and Mail to address indicated within 7
business days or account will be disabled
Retro Eligibility
• How is someone retro eligible for
TennCare?
– Most common scenario is someone who gets
approved for SSI
– In TN, when approved for SSI Disability you
are automatically approved for TennCare
Mental Health Only Coverage
• Formerly known as “State Only” or “Judicial”
Members
• Effective 1/1/2009 are handled directly by
TDMHDD (Tennessee Department of Mental
Health & Developmental Disabilities)
• Do not have TennCare benefits
• Member may be viewable on Tennessee
Anytime’s website due to past coverage but will
state Not Eligible for TennCare & No MCO on
record and No BHO on record
Mental Health Only Coverage
(continued)
• Eligibility verification and claims are
handled by TDMHDD
• For additional information:
https://mhddapps.state.tn.us/Uninsured/(S(mpzslwnjmlcj
zy45tsupjczm))/Default.aspx
TPL Policy
January 1, 2010, an updated TPL policy
will become effective.
Provider Communications
E-Mail subscription:
Sign up at:
http://tn.gov/tenncare/pro-emailsubcrip.html
RSS Feed:
Sign up at:
http://tn.gov/tenncare/providers.html
State/Government Email Address
Domain Change
• The state email domain address has
changed from:
@state.tn.us
to
@tn.gov
TENNCARE PROVIDER
SERVICES
1-800-852-2683

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