medicare medicaid alignment initiative (mmai)2014/11/14 · mmai tips for assisting clients -...
TRANSCRIPT
Medicare Medicaid
Alignment Initiative (MMAI)
November 14, 2014
MMW work is supported by
grants from:
• The Chicago Community Trust
• Michael Reese Health Trust
• The Retirement Research
Foundation
Who We Are: Leadership • AgeOptions
–Area Agency on Aging (AAA) for suburban
Cook County
• Health & Disability Advocates
–Policy and advocacy group
• Progress Center for Independent Living
–Cross-disability, non-residential – suburban Cook County
What We Do
• Gather and create practical, accessible information and materials
• Educate Medicare consumers, service providers and policymakers
• Problem solving – individual and systemic
• Provide training and technical support for professionals and volunteers
• Advocate for consumer focused laws and policies
• Target underserved groups
What We Will Cover Today
• Background of Illinois Managed Care
Transitions
• Medicare Medicaid Alignment Initiative
(MMAI)
– Who does MMAI Affect?
– How Does MMAI Work?
– MMAI Enrollment
– Tips for Assisting Consumers with MMAI
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Background of
Illinois Managed
Care
Background - Illinois Managed
Care Transitions • State Initiatives
– Public Act 96-1501, January 2011: Illinois must move 50% of all Medicaid recipients into “risk-based care coordination” by 2015
– Save Medicaid Access and Resources Together Act (SMART Act), May 2012: Save $16.1 million by integrating care for most complex Medicaid beneficiaries (acute, primary, behavioral, and long-term services and supports)
“Care Coordination” vs. “Managed Care”
Care coordination: Using a primary point of contact
to establish communication and collaboration
among a patient’s health care providers to ensure
that:
• Individuals receive appropriate care and information
about his/her care
• services are not duplicated or conflicting
• patient receives appropriate follow-up to ensure
improvement of condition(s)
(http://www.wisegeek.com/what-is-carecoordination.htm)
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“Care Coordination” vs. “Managed Care”
• Managed care: a system of financing and delivering health care, involves the use of a “managed care organization” (MCO) that is responsible for implementing techniques generally designed to reduce cost of care and improve quality. Techniques may include care coordination and/or integrated delivery systems (provider networks), utilization review, emphasis on preventive care, or financial incentives to encourage members to use care efficiently
(http://en.wikipedia.org/wiki/Managed_care)
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Illinois – Multiple Entities Involved
• Managed Care Organizations (MCO’s)
• Managed Care Community Networks (MCCN’s)
• Accountable Care Entities (ACE’s)
• Care Coordination Entities (CCE’s)
– Serve specific populations – some for older adults and/or people with specific disabilities, some for children with complex medical needs
Provider
Based
Entities
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Illinois – Multiple Entities Involved
ACE’s
CCE’s
State Pays Care
Coordination rate to entity,
medical services still paid
for separately by state
(fee-for-service).
Entity takes on “full risk”
– state pays a capitated
rate to entity; entity pays
providers for services.
MCO’s
MCCN’s (MCCN’s may start
at full risk or may
progress to full risk
over time)
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Illinois – Multiple Entities Involved
• See Department of Healthcare and Family
Services (HFS) Rollout Chart and Map here:
– Fact Sheet: http://www2.illinois.gov/hfs/SiteCollectionDocuments/CCRollOutFactSheet.pd
f
– Chart: http://www2.illinois.gov/hfs/SiteCollectionDocuments/CC_rolloutchart.pdf
– Map: http://www2.illinois.gov/hfs/SiteCollectionDocuments/CCExpansionMap.pdf
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Illinois Managed Care Initiatives Affecting
Older Adults & People with Disabilities
(AABD/SPD Medicaid)
• Integrated Care Program
• Medicare/Medicaid Alignment Initiative
(MMAI)
• Innovations Project
– Care Coordination Entities (CCE’s)
– Managed Care Community Networks (MCCN’s)
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Illinois Managed Care Initiatives Affecting
Children, Families, and ACA adults
• “Mandatory Managed Care Program”
– Children, families, and the new Medicaid
category known as “ACA adults” are also being
rolled into managed care initiatives in certain
areas of the state
• Managed care organizations (MCO’s)
• Managed Care Community Networks (MCCN’s)
• Provider-based Care Coordination Projects (CCE’s,
ACE’s)
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Medicare Medicaid
Alignment Initiative
(MMAI)
Background - MMAI • Centers for Medicare and Medicaid Services (CMS)
issued demonstration project to increase care
coordination for dual eligibles (people with
Medicare and Medicaid)
• Illinois application approved February 22, 2013
• Memorandum of Understanding between CMS and
state of Illinois available here:
http://www.cms.gov/apps/media/press/factsheet.as
p?Counter=4547
Who Will MMAI Affect?
• Full benefit dual eligible beneficiaries (people with
Medicare and full Medicaid benefits – not
“spenddown”) who are:
– Over the age of 21 and in the “Seniors and Persons with
Disabilities (SPD)” Medicaid category (also known as AABD)
– Do not have high level third-party (private) insurance
– Are not receiving Developmental Disability Waiver services
– Living in Chicago area or Central Illinois:
• Chicago: Cook, Lake, Kane, DuPage, Will, and Kankakee counties
• Central IL: Knox, Peoria, Tazewell, McLean, Logan, DeWitt,
Sangamon, Macon, Christian, Piatt, Champaign, Vermilion, Ford,
Menard, and Stark counties
How Does MMAI Work?
• HFS contracts with managed care companies to
coordinate all medical, pharmaceutical, behavioral
health, and long term services and supports (like
Phase 1 and 2 of the ICP combined).
– One plan will cover all services (Medicare Parts A, B, D,
and Medicaid) - members will no longer need to find
providers who accept Medicare and Medicaid (will need
to use plan’s network instead)
How Does MMAI Work?
• Plans may not charge higher cost-sharing than
traditional fee-for-service Medicaid
• Consumers must use plan network providers
• 180 day transition period
• Must cover out of network emergency care
• Plans will have some flexibility to provide
services that are not currently covered by
Medicare and Medicaid (if they choose)
How Does MMAI Work? • Care Management Services will be offered to all
enrollees to help coordinate medical services
and long term services and supports (LTSS)
– All enrollees will be assigned a Care Coordinator and
have access to an Interdisciplinary Care Team (ICT)
within their MMAI plan.
• Care Coordinator standards/training, caseloads, and contact
requirements are based on the individual’s “risk” level
(health risk screening conducted in first 60 days of
enrollment) and specific Home and Community Based
Service (HCBS) Waiver requirements
– “High risk” enrollees must be contacted by the ICT at least every 90
days
MMAI Enrollment
• Enrollment is conducted through the Client
Enrollment Broker
• Call Client Enrollment Broker at
1-877-912-8880 to
– Enroll, opt out, or disenroll from program
– Compare provider networks
– Find plan’s drug formularies
MMAI Enrollment
• Client Enrollment Broker is an objective third
party entity – no relationship to any plan
• Before calling the Client Enrollment Broker,
client should have
– Social Security Number
– Name(s) of preferred primary care provider, hospitals and
clinics
– Medication list
– Be able to say name and language needed in English (if
needing to use teleinterpreter services)
• Can also use an authorized representative
Visit enrollhfs.illinois.gov/choose/compare-plans to
compare benefits. Client Enrollment Broker will also
assist with comparing plans and provider networks.
Scroll down
to compare
overview of
plan
benefits
Go to plan website to view more detailed benefit information and find in network
providers. Must call Client Enrollment Broker or fill out paper application to enroll.
MMAI Enrollment:
For individuals who are not receiving
Long Term Care Supports and Services
(LTSS)
MMAI and LTSS
Long Term Services and Supports (LTSS)
– Help individuals perform activities of daily living
(eating, cooking, bathing, getting dress, cleaning,
etc)
– May be provided in a long term care facility or
through home and community based services
• 5 home and community based Medicaid waiver
programs included in ICP (Aging – Community Care Program, Disability, AIDS, Traumatic Brain Injury, Supportive
Living Facility)
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Voluntary Enrollment-
Individuals not receiving LTSS
• Began March 2014
• Letters were sent to individuals about 30 days
before voluntary enrollment began explaining the
program and their options
• Clients responded to letter by:
1) Choosing to voluntarily enroll in an MCO of their
choice, OR
2) opting out of the program entirely
Passive Enrollment-
Individuals not receiving LTSS
• Began June 2014
• Individuals automatically enrolled into an MCO after
June 2014 if they did not make a choice during
Voluntary Enrollment
• Passive enrollment conducted in phases
-maximum enrollment of 5,000 beneficiaries/month in the
Chicago area, and a maximum of 3,000 beneficiaries/month in
Central Illinois
Passive Enrollment-
Individuals not receiving LTSS
• Clients received a notice about 60 days before they were
passively enrolled into a plan. Clients had the option to
1) Not respond to the letter and be automatically enrolled
in the MCO listed on the notice
2) Respond to the letters by choosing an MCO of their
choice
3) Opt out of the program entirely to continue to receive
regular Medicare and fee-for-service Medicaid
Once Enrolled-
Individuals not receiving LTSS
• Once a client is enrolled into an MCO, they can
change plans on a monthly basis throughout
year
– will not be “locked” into a plan
• Can disenroll from the program at any time of
the year to receive regular Medicare and fee-
for-service Medicaid (unless receiving LTSS)
• Can change PCP at any time (changes will
occur within 30 days)
MMAI Enrollment:
Individuals receiving LTSS
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Passive Enrollment:
Individuals receiving LTSS
• First letters mailed in September 2014
• Same options as individuals not receiving LTSS:
– Choose an MMAI plan and enroll
– Opt out of the program to continue receiving medical services
through regular Medicare and fee-for-service Medicaid
– Accept passive enrollment into MMAI plan
• Clients have about 60 days from receiving the notice to
make their coverage decision or they will be passively
enrolled into the plan listed on their letter
BUT…
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Managed LTSS Program
• Individuals who opt out of MMAI will be put into
“Managed LTSS” (MLTSS)
– Through MLTSS program, they will need to choose an
MCO to cover their LTSS services (same plans as MMAI).
Medical services will be covered by regular Medicare and
fee-for-service Medicaid. Prescriptions will be covered
under Medicare Part D.
– Will be locked in to MLTSS plan choice for one year from
date of enrollment.
• Individuals can still choose to opt back into the MMAI
program to receive ALL of their services through one plan
at any time of the year
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Options for Individuals with LTSS
MMAI • Medical and LTSS services
covered by MCO
• Can change plan or opt out at any time
MLTSS
• LTSS services covered by MCO
• Medical services through FFS Medicare/Medicaid
• Locked in for 1 year
Opt out of MMAI…
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MMAI Plans • Illinois Department of Healthcare and Family Services
has chosen 8 plans to provide MMAI services:
• Chicago area (Chicago and surrounding suburbs)*: – Aetna Better Health – IlliniCare (Centene) – Meridian Health Plan of Illinois – HealthSpring – Humana – Blue Cross/Blue Shield of Illinois
• Central Illinois: – Molina Healthcare – Health Alliance
* Note: Not all of these plans will be available in every county – visit
http://enrollhfs.illinois.gov to see which plans are available in a specific county
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MMAI Tips for Assisting Clients -
Letters
• Clients are receiving multiple letters from multiple sources about coverage transitions – can be very confusing – MMAI Enrollment Packet from Client Enrollment Broker
– Letters from Medicare Part D plans
– Letters from MMAI plans (that client will be auto-enrolled into if they do not make a voluntary choice)
• If a client gets the wrong letter (e.g., Integrated Care Program letter instead of MMAI letter), DHS system information may be incorrect!
(Contact DHS caseworker to correct immediately.)
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MMAI Tips for Assisting Clients -
Navigating Plan Network, Services
• If client’s providers are not in the plan’s network, client can communicate with them to encourage network participation – 180 day transition period
• Each client should be assigned a Care Coordinator – make sure clients have contact with that person
• Utilize MMW Desktop Guide for Navigating MMAI Insurance Plans (in Managed Care Toolkit here: http://www.ageoptions.org/services-and-
programs_MMW-MedicaidandManagedCare.html)
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MMAI Tips for Assisting Clients -
Navigating Plan Network, Services
• MMAI Ombudsman
– Unbiased advocate who can assist clients who are experiencing issues with their MMAI plan
– Contact the Illinois Department on Aging Senior Helpline at 1-800-252-8966 to be referred to a client’s local MMAI ombudsman program
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MMAI Tips for Assisting Clients -
Opting Out of MMAI and
Medicare Part D
• If an individual opts out of MMAI after being enrolled (either voluntarily or through auto-enrollment), s/he will need to re-enroll in a Medicare Part D plan (this will NOT happen automatically!)
• If the person does not re-enroll in a Part D plan, s/he can use the LINET program to get prescriptions at the pharmacy and be auto-enrolled into a Part D plan. For more information about LINET, see our MMW LINET fact sheet here: http://www.ageoptions.org/documents/LimitedIncomeNetProgram-LOCKED.docx
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For More
Information…
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Resources on Illinois Managed
Care and Care Coordination • HFS website on Care Coordination:
http://www2.illinois.gov/hfs/PublicInvolvement/cc/Pages/default.aspx
(MMAI proposal and information, information about Innovations Initiative)
• Client Enrollment Broker Materials page:
http://enrollhfs.illinois.gov/program-materials
(informational materials about each program – child/families/ACA adults program
is called “Mandatory Managed Care Program”)
• Make Medicare Work Coalition Managed Care Toolkit
http://www.ageoptions.org/services-and-programs_MMW-
MedicaidandManagedCare.html
(Includes ICP & MMAI fact sheets, recorded webinars, enrollment timelines, and
other resources)
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MMW Website
• Please visit our website at
http://www.ageoptions.org/services-and-
programs_makemedicarework.html to...
– Access our materials on Medicare, Medicaid, and
the Affordable Care Act
– Sign up for our e-mail list to receive registration
information for our webinars, trainings, and
meetings and to receive our alerts, bulletins, and
other healthcare related materials
– View our Calendar of Events
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Thank you!
If you have questions, contact:
AgeOptions
(800)699-9043
This presentation was supported in part by grants from the
Chicago Community Trust, the Retirement Research
Foundation, the Michael Reese Health Trust, and an
anonymous donor.