Medicare Medicaid Alignment Initiative (MMAI) The next chapter of HFS Managed Care What is Managed Care? A health care delivery system designed to provide coordinated care that will reduce unnecessary utilization of services, control cost, increase access and maximize quality Benefits of Managed Care Better health for the member o Choices of doctors, specialists and hospitals o Additional programs and services to help them live a healthy life Better quality of life for the member o Coordination of care with a team of people working with members to help them live an independent and healthy life Reduction in the cost of the service over time Managed Care Organizations Have a network of hospitals, physicians, specialists Are responsible for covering same services as Medicaid Accept the full-risk capitated payments Key Terms to Remember Care Coordination o Determining a person’s needs and creating a care plan o Linking the person to a full range of appropriate services and monitoring the care provided over an extended period of time Medical Home o The doctor’s office or clinic where clients go to first when seeking healthcare services o The doctor’s office or clinic where a client goes to see their PCP Primary Care Provider (PCP) o The family doctor, nurse, or other healthcare provider at the clients medical home who takes care of them • Integrated Care Team o A team of health and social care staff working together to offer patients a better quality service and easier access to that service. Medicaid Managed Care Programs Voluntary Managed Care (VMC) Primary Care Case Management (PCCM) Integrated Care Program (ICP) Medicaid Long Term Supports and Services(MLTSS) Medicare Medicaid Alignment Initiative (MMAI) VMC –at a glance • A voluntary program • Provides services to All Kids, Moms and Babies, and Family Care clients • Participants choose a Primary Care Provider (PCP) in an MCO for their medical home • Operates in 28 counties throughout the state PCCM –at a glance • A mandatory program • Called Illinois Health Connect (IHC) • Provides services to most individuals covered by an HFS Medical Program (some exclusions) • Participants choose a medical home and PCP while receiving the advantages of care coordination and case management • Eligible enrollees may opt out of IHC if enrolling with MCO • Operates statewide ICP –at a glance • A mandatory program providing services to older adults and persons with disabilities •Enrollees must be eligible for Medicaid but not eligible for Medicare, and must be age 19 and older •Excluded populations: o o o o o o o Children under 19 years of age Participants eligible for Medicare Part A or enrolled in Medicare Part B American Indians and/or Natives of Alaska (may voluntarily enroll) Participants with Spenddown All Presumptive Eligibility (temporary benefits) Categories Participants in the Illinois Breast and Cervical Cancer Program Participants with high-level private health insurance (Third Party Liability or TPL) ICP –at a glance • ICP provides medical, behavioral, and home/community based services •Beneficiaries are locked into their MCO plan for one year and cannot switch health plans until their anniversary month •Operates in 29 counties in the following 5 regions of IL: Central IL Greater Chicago Quad Cities Metro East Rockford MLTSS –at a glance Begins September 1, 2014 Provides services to those who opt out of MMAI but receive LTSS (more about MMAI is coming up on our next slide) Mandatory enrollment in a health plan to receive: LTSS Behavioral Health Transportation Same health plans as MMAI MLTSS Program individuals are locked in for their LTSS services for one year and cannot switch health plans until their anniversary month MMAI – a closer look A voluntary program with passive enrollment Three-way contract between HFS, CMS, and Health Plans Robust care coordination Emphasis on quality measurement MMAI – a closer look Health plans will provide integrated benefits to full- benefit dual eligible beneficiaries ages 21 and over: o All Medicare and Medicaid services including long-term care institutional and community-based services and supports o Exclusions include individuals receiving institutional developmental disability services or Adults with Developmental Disabilities HCBS waiver services MMAI – LTSS LTSS : Long Term Supports and Services Under MMAI, the LTSS population includes nursing home residents and those receiving Home and Community Based Services(HCBS) waivers: 1. 2. 3. 4. 5. Elderly (Community Care Program participants) Traumatic Brain Injury HIV/AIDS Physically Disabled Supportive Living Facility MMAI – Geography Greater Chicago Counties: Cook, Lake, Kane, DuPage, Will, Kankakee Central Illinois Counties: Knox, Peoria, Tazewell, McLean, Logan , DeWitt, Sangamon, Macon, Christian, Piatt, Champaign, Vermilion, Ford, Menard, Stark MMAI – Number Eligible Geographic Region Number of Dual Beneficiaries Eligible for MMAI Greater Chicago 128,000 Central Illinois 20,000 MMAI – Health Plans Greater Chicago: Aetna Better Health Blue Cross Blue Shield Cigna HealthSpring Humana IlliniCare Health Plan Meridian Health Plan MMAI – Health Plans Central Illinois: Health Alliance Molina HealthCare MMAI – Timeline March 1, 2014: Voluntary Enrollment for Community population Begins June 1, 2014: Passive Enrollment for Community population Begins July 1, 2014: Voluntary Enrollment for LTSS population Begins September 1, 2014: Passive Enrollment for LTSS population Begins MMAI – Enrollment Announcement Letter o Includes general information on: • • Names of health plans participating in their area Calling the Illinois Client Enrollment Services (ICES) for help in explaining their choices • How to enroll • How to opt out Enrollment Packet o Includes detailed information on: • Health plans participating in their area • How to enroll Reminder Notices o Prior to passive enrollment date, a couple of notices will be mailed to beneficiary, these notices include: • Name of health plan and PCP • Option to change plans or opt-out at any time MMAI – Disenrollment Disenrollments are effective the first day of the month following request Individuals can disenroll thru ICES or through 1-800-Medicare Those receiving LTSS and who disenroll from MMAI will be required to enroll in the MLTSS program. How Can Clients Contact ICES? Eligible clients can contact IL Client Enrollment Services (ICES) By Phone: Call Illinois Client Enrollment Services o 1-877-912-8880 (TTY: 1-866-565-8576) How does MMAI compare to ICP? ICP • MMAI Mandatory Enrollment • • Must be 19 and over • Must be 21 and over • Must be Medicaid, but not Medicare enrolled • Must be Medicaid and Medicare enrolled (duel eligible) • Several MCOs to choose from • Several MCOs to choose from Medical, Behavioral Health, & HCBS waiver services covered (some exclusions) • Medical, Behavioral Health, & HCBS waiver services covered (some exclusions) Developmental Disabilities (DD) waiver/institutional clients included • Developmental Disabilities (DD) waiver/institutional clients excluded • Enroll through client enrollment broker • Operates in 2 regions of the state • • • • Enroll through client enrollment broker Operates in 5 regions of the state Passive Enrollment with Opt-Out option for medical services MMAI – a review MMAI is latest managed care program offered to IL Medicaid clients. The program is for those dually eligible beneficiaries who receive both Medicare and Medicaid. MMAI will affect 128,000 people in the greater Chicago region, and 20,000 people in the central IL region. The beneficiaries will be enrolled in waves rather than all at once. This “rollout” will begin with those in the community first, followed by the LTSS population, those enrollees that are in LTC facilities and on HCBS waivers. The member handbook is a valuable resource for SHIP staff including these chapters: o Chapter 2 – important contact numbers for members o Chapter 4 – covered services o Chapter 9 – grievances and appeals 10 Questions you might have about MMAI 1. Why would someone want to enroll in this program? • Care coordination – consumers will have a care coordinator to help them navigate the health care system • Receive all health care from one health plan, no longer fragmented (some from Medicaid and some from Medicare) • Some health plans offer additional services 10 Questions you might have about MMAI 2. What is the role of the client enrollment broker? The role of the client enrollment broker is to provide education in an unbiased manner and enroll individuals into a health plan. They can answer questions about each health plan and help consumers find out which MCO network their PCP, specialists or hospital has joined. 10 Questions you might have about MMAI 3 . T H E C L I E N T I S H A P P Y W I T H T H E I R C U R R E N T H E A LT H PLAN (MEDICARE FFS, MA PLAN OR D -SNP PLAN). DO T H E Y H AV E TO E N R O L L I N M M A I ? They have the choice to stay with the MA or DSNP Plan or to join an MMP health plan. The plans have similar benefits, but MMAI offers the additional benefit of care coordination and services beyond what Medicaid and Medicare offer. If they are in Long Term Supports and Services however, they are required to select a health plan for those specific services. 10 Questions you might have about MMAI 4. What is the difference between passive enrollment and voluntary enrollment? Passive enrollment means consumers will be enrolled in a health plan UNLESS they call to opt out. Voluntary enrollment means consumers can voluntarily decide if they would like to enroll in a health plan. 10 Questions you might have about MMAI 5. ARE ALL HEALTH PLANS AVAILABLE IN ALL COUNTIES? No. Please refer to the Care Coordination Map handout to see which health plans are serving which counties. 10 Questions you might have about MMAI 6. When does coverage begin? It depends what day of the month the consumer calls to enroll. If they call within the first half of the month, coverage will begin the first day of the next month. For example, if they call on March 12th to enroll, the coverage will begin April 1st. If they call in the latter part of the month, it will begin the first day of the following month. For example, if they call on March 25th to enroll, their coverage will begin May 1st. 10 Questions you might have about MMAI 7. Can consumers switch from one plan to another? Consumers can switch health plans under MMAI. It is best to stay with one health plan as that health plan’s care coordinator will get to know and understand their needs. 10 Questions you might have about MMAI 8. What services are provided under this new health plan? Consumers get all the services they currently receive plus care coordination under an integrated health care delivery system. In addition, all of the health plans offer additional services at no cost to consumer. 10 Questions you might have about MMAI 9. What if the consumer thinks they have been unfairly treated or denied a service BY THEIR MMAI PLAN? They should call their health plan. They can grieve or file an appeal with the health plan for things such as a denial of a service or for failure to provide a service in a timely manner. The health plan can help explain how to file an appeal. The information is also in the health plan’s member handbook. 10 Questions you might have about MMAI 10. If a consumer disenrolls, where do they get services? Consumers would return to services as they had prior to enrolling in MMAI - such as their Medicare Advantage (MA) Plan, Dual Eligible Special Needs Plans (D-SNPs) or Medicare Fee-For-Service.