RHODY HEALTH OPTIONS - Neighborhood Health Plan of Rhode

Report
RHODY HEALTH OPTIONS (RHO)
IMPLEMENTATION
September 5, 2013
Agenda
1.
2.
3.
4.
5.
6.
Neighborhood –Who we are
Rhody Health Options Overview
State update information
Payment for Services
Case Management
Wrap up and Next Steps
2
Neighborhood- Who we are
• Founded by RI’s Community Health Centers to expand access to
care and improve health for at-risk populations
• Incorporated as an HMO in December 1993; began serving
members in Spring 1994
• EOHHS partner for proactive Medicaid managed care
• Support Medicaid programs only
• 92,000 members currently
• Serve 67 percent of all RI Medicaid managed care participants
• Non-profit; offices in Providence
3
Our Network
• Large network; nearly every doctor/provider in RI
• More than 900 Primary Care Practitioners
– 42% of Neighborhood’s members receive their primary care at one of
the 21 Community Health Centers in the state
• More than 2700 Specialists and robust ancillary and
DME networks
• More than 480 Behavioral Health Providers
• All hospitals in the state
• Nearly every pharmacy in the state
4
Accolades
• Rated “Excellent” by NCQA since 2001
• Ranked as one of Top 10 Medicaid Health Plans in America by
NCQA since rankings began in 2004 - (#5 in 2012)
• 5th Fastest Growing Private Company in RI - Providence Business News (2011)
• Sample of Community Service Awards
–
–
–
–
–
–
Healthy Moms, Healthy Babies Coalition
Latino Public Radio
Reach Out and Read Rhode Island
The African Alliance of Rhode Island
PARI Independent Living Center
Rhode Island Foster Parent Association
97%
of Neighborhood
members would
recommend us to
family or friends
(2012 CAHPS Survey)
5
Our Membership
Growth
Adults eligible for
Medicaid/Medicare
- Medicaid benefits
(Nov 2013)
Children with
special health
care needs
(2003)
Parents in
RIte Care
(1998)
Children in
RIte Care
(1994)
Children in
foster care
(2000)
Medicaid-only
eligible adults
with disabilities
(2008)
Adults in
Medicaid
Expansion
(Jan 2014)
Adults in HealthSource RI –
Both Individual (up to
250%) and Small Business
(Jan 2014)
6
Integrated Care Initiative
• EOHHS is working with CMS on an Integrated
Care Initiative
– It is designed to transform the delivery of services to elderly
and disabled Medicaid only members and Medicaid Medicare
Eligible members (duals) to maintain a high quality of life and
live independently in the community.
– The goal of the program is to integrate the two government
programs to eliminate the fragmentation and inefficiencies that
exist today and improve the quality of care for members.
– In June 2013 EOHHS selected Neighborhood to be its
managed care organization to implement this program.
7
Rhody Health Options
• Phase I
– Implementation of Medicaid Long Term Care benefits
to managed care beginning November 2013.
– These members will be known as Rhody Health
Options members.
• Phase II
– Adds the integration of the Medicare benefit
– The full integration, is currently scheduled for
implementation in early 2015.
8
Rhody Health Options
Timeline
• Awards announced August 2013
• Readiness Review July – Sept 2013
• Consumer letters Sept 1, 2013 - Feb 1, 2014 will be sent
–
–
–
–
–
EOHHS will be phasing in RHO membership in 4 waves
Approximately 6400 members per wave
Complete Enrollment Schedule available on EOHHS website
Members will be given the choice to opt out of the program
We are currently working with EOHHS to identify all members in Wave 1 to
insure smooth transition.
• Effective Enrollment Nov 1, 2013 - April 1, 2014 Dates
• Presentations & Trainings - July 2013 and ongoing Trainings by
EOHHS
9
State Update
Schedule a Presentation on the Integrated Care Initiative
• The State will begin to set up community presentations on these
two new programs: Rhody Health Options and Connect Care
Choice Community Partners. If you would like to schedule a
presentation for your agency or organization, please contact
Alison Buckser at [email protected]
• Check the state website www.eohhs.ri.gov (under “Integrated
Care”)
• Email your questions at: [email protected]
• There will be an Enrollment Help Line starting on Sept 1, 2013.
10
Teams within Medical
Management
Medical Management
Utilization/Medical Review
Nursing Home Transition Care Team
Care Management
Care Managers
Social Workers
Community Outreach Workers
Housing Specialists
11
Neighborhood Benefits
Neighborhood Case Managers can assist with:
• LTSS Waiver application assistance
• Develop and monitor individualized Plan of Care
• Collaborate to assess for safe discharge plan to the community
when appropriate
• Participate in discharge planning meetings with members and
caregivers
• Facilitate community services to ensure safe transition plan
12
Facility Requirements
• Provide access for case managers to meet member and
review medical record, including MDS
• Provide supportive clinical information for those
receiving skilled services
• Collaboration in identification of those with potential
discharge plan
• Collaboration in ensuring a safe transition to the
community when applicable
13
Payment and Billing Process for
Rhody Health Options
• Rhody Health Option members will be billed to
Neighborhood Health Plan of RI
• Connect Care Members will be billed to the state (as it is
done today).
• Claims typically process within 7-14 days
14
Payment and Billing Process for
Rhody Health Options
Neighborhood will require a claim submission for payment
• Claim submission can be completed via electronic faxes regular
mail or electronically via a clearinghouse
15
Contacts at Neighborhood
Medical Management
• Michelle Lupoli, Director of Medical Management, 459-6035
• Kathy Ullrich, Manager of Care Management, Duals 427-6526
Claims Production
• Meghan Ruane, Director of Operations, 459-6606
Provider Engagement and Contracting
• Pat Huschle, Director of Provider Engagement and
Contracting,459-6012
• Maureen Brousseau, Manager of Ancillary Network,459-6033
16
Questions?
17
NEXT STEPS AND FOLLOW UP
18

similar documents