Care Coordination Options for Dual Eligibles In Illinois

Report
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.

similar documents