Managed Care OrganizationsCare Coordinators Conference

October16, 2014

The Medicaid reform law [PA 96-1501], requires that by January 1, 2015, at least 50 percent of the individuals covered under Medicaid be enrolled in a care coordination program that organized care around their medical needs.

HISTORY:

To meet this goal, the Department of Healthcare and Family Services (HFS), in collaboration with the Departments on Aging (IDoA) and Human Services (DHS), will move eligible older adults and persons with disabilities to risk-based managed care programs.

HISTORY:

Integrated Care Program (ICP)

Medicare-Medicaid Alignment Initiative (MMAI) “Duals”

Family Health Plan (FHP) (Families with Kids & ACA adults)

Coordinated Care Entities (CCEs) (Seniors and Persons with Disabilities) – Not MCOs

Care Coordination Programs:

HFS introduced the first Integrated Care Program (ICP) on May 1, 2011(for Medical services)

The Program is for older adults and persons with disabilities

Enrollees in ICP must be eligible for Medicaid, but not eligible for Medicare

What is Integrated Care Program (ICP)?

ICP brings together healthcare for participants through◦ Local primary care providers◦ Specialists◦ Hospitals◦ Nursing homes◦ Home & Community based service providers

ICP participants receive the same health services that are available through Medicaid

What is The Integrated Care Program (ICP)

Enrolled in Medicaid but NOT enrolled in Medicare.

Members have a choice of health plans and PCPs.

Receive better coordination of care, manage their own healthcare needs, and receive additional programs & services to help them live healthy independent lives.

ICP Members

ICP is made up of two Service Packages – Service Package I and II.

Service Package I includes medical & Behavioral health services

Service Package II expands services to include

long-term services & supports (LTSS), including nursing home care and Home & Community Based waiver Services (ie, CCP services including case management, INH, ADS, and EHRS)

ICP Service Packages

The first phase of ICP2 implementation started in February of 2013 in Suburban Cook.

Throughout 2013, ICP2 expanded into additional regions throughout the state.

The final phase of the ICP2 implementation included the City of Chicago in February 2014

Approximately 3,000 CCP participants have been transferred from CCP to MCO due to the ICP initiative.

Implementation of ICP2

Cook County

Dupage, Kane, Kankakee, Lake & Will

Rockford Region: Boone, McHenry, Winnebago

Central Illinois Region: Knox, Peoria, Stark, Tazewell McLean, Logan, DeWitt, Sangamon, Macon, Christian,

Menard, Piatt, Champaign, Ford, Vermilion

Quad Cities Region: Rock Island & Mercer

Metro East Region: Madison, Clinton & St. Clair

Current ICP2 areas:

Impacts those who are dually eligible for Medicaid & Medicare

Provides both medical, behavioral, long term care and home and community based services.

Starts with all services being provided at initial implementation

Medicare Medicaid Alignment Initiative (MMAI) – also known as “Duals”

Members have a choice of health plans and PCPs.

Receive better coordination of care, manage their own healthcare needs, and receive additional programs & services to help them live healthy independent lives.

MMAI Members

Operates in Greater Chicago and Central Illinois regions

Anticipated to provide services to an estimated 135,000 Seniors and Persons with Disabilities

HFS estimates that approximately 22,000 persons will be transferred from CCP to MMAI by February 2015

MMAI Members

Six managed care organizations serve MMAI clients in the Greater Chicago area.

Two managed care organizations serve clients in Central Illinois.

1st batch of letters for LTSS clients were mailed on September 22, 2014

Medicare Medicaid Alignment Initiative (MMAI) – also known as “Duals”

HFS sends out a series of 3 letters announcing enrollment in managed care programs

ICP auto enrolls clients at the end of the 3 letter process

MMAI auto enrolls clients at the beginning of the 3 letter process

The MMAI process leads to multiple changes in MCOs prior to the enrollment date.

ICP – Mandatory enrollment; MMAI – Can Opt out

How will participants be notified?

There should be no interruption in the delivery of services to the participant

The MCOs are required to keep all current service plans in effect for a minimum of 180 days (but can alter service plan with permission of participant sooner)

What will clients see?

MCOs are required to provide all waiver services to participants

MCOs have contracted with CCP providers of in-home, adult day and emergency home response services

The plans are required to utilize only IDoA certified CCP providers for CCP services

MCOs will pay, at a minimum, current hourly rates to these CCP providers

Provision of Waiver Services

MCOs are not mandated to pay for non-waiver services. (i.e. Older Americans Act Services such as home delivered meals, congregate meals or Respite or Money Management services)

MCOs do have the responsibility to make appropriate referrals to providers of non-waivered services as needed by the participant

MCOs will have discretion to pay for non-waiver and non-Medicaid services that are needed by the participant

Non-Waiver Services

The CCUs remain responsible for determining a participant’s initial and annual eligibility for services (Determination of Eligibility {DOE})

The MCO are responsible for administering the care assessment and care planning functions including all Case Management monitoring tasks

How will Managed Care impact Case Management?

MCOs are responsible for all service complaints from clients

Providers should notify the MCO case managers when changes occur with the client (ie, hospitalizations, refusal of services, etc)

The MCO serves as the case manager for all client needs.

Clients should be encouraged to contact the MCO with issues not the CCU.

How will Managed Care impact Case Management?

Initial DOE – send MCO Status form Annual DOE – send MCO Status form Notify providers when clients transfer to

MCOs – send Provider Notification Form Enter a 10/12 no bill CAT to synch

CMIS/eCCPIS Complete Prescreens Score the DON accurately Provide CM on all clients until their actual

enrollment date begins

CCU Roles & Responsibilities

DO terminate services when a client transfers to MCO & DO authorize the MCO contract

DON’T terminate the client entirely from CCP DO encourage clients to call their enrollment

broker for MCO decisions 1-877-912-8880 DON’T give the BEAM 855 # to clients DON’T decrease DON scores because a client

has MCO services in place DON’T stop HDMs and other Title III services DO continue to communicate effectively DON’T accept referrals/rede requests directly

from the MCOs

Do’s & Don’ts

CATS must be entered correctly CATs must be entered in a timely manner When a client terminates CCP services a

termination CAT terming all services must be entered

If CCUs completed the 40/061CAT to transfer a client to an MCO (old policy) but didn’t enter the 01/000 to authorize the MCO they must complete that 01/000 immediately.

Make sure you are manually changing the “next assessment dates”

Importance of Accurate DATA

Indicator codes identifying which waiver a person is enrolled are added to all open cases.

Indicator codes are removed when termination CATs are submitted.

These indicator codes are what HFS uses to notify MCOs that a client is part of the waiver and should be receiving waiver services.

Indicator Codes

The State doesn’t collect federal reimbursement for Medicaid clients.

MCOs will not know to provide case management services to the clients

MCOs will not authorize services or pay the providers for servicing CCP clients.

Clients that have not been terminated in eCCPIS will continue to look like CCP clients (budget issues/confusion to clients)

Without these Indicator Codes:

Complete assessments & establish care plans Monitor clients & provide CM for all areas Assist with completion of benefit applications Complete the MCO Participant transfer form on all

clients returning to CCP (only CCP clients) Responsible for CM until date of disenrollment –

including starting new services Make referrals to appropriate Title III and other non-

waiver services (provide all required information/assessments)

Send service authorizations to providers ASAP Communicate with providers

MCO roles & responsibilities

Make referrals to BEAM for new clients If a client transfers to a new MCO – provide all paperwork to

the new MCO & notify providers If a client requests an increase in services – you DO NOT

need to request a new DON to be completed (even if it exceeds the SCM)

Only request a reassessment if you think that the client is no longer eligible for services (improved, needs 24 NH care)

If a client’s services will be terminated the MCO must follow IDOA rules and send a letter certified mail and allow 15 days to change their mind, then notify BEAM to cancel services.

MCOs should not be contacting CCUs directly with referrals or requests for reassessments

MCO CM roles & responsibilities

MCO members can appeal any action just like CCP members.

All appeals related to services (including service levels) should be sent to the MCO

IDOA only does appeals on eligibility (29 DON)

HFS is final decision in appeal hearings

Appeals

Transferring Current CCP participants to MCOs (Revised 8/1/14)

MCO enrollee requiring waiver services New referrals for services Non-waiver services for MCO participants Demo policies

◦ IVMMP◦ SCP◦ Cash & Counseling

Transitioning MCO participants to a CCU for services Colbert Policy CCE policy

MCO Policies

MCO Status Form (IL-402-1150)

Provider Notification of MCO transfer

MCO Participant Transfer form (IL-402-1151)

New MCO Forms

MCO participants may still receive:

Illinois Volunteer Money Management Services

Senior Companion Services

CCUs must authorize IVMMP & SCP services on the CAT when they authorize the MCO service

IVMMP & SCP Demo Programs

Participants enrolled in the MCO program cannot also receive C&C or MCCP demonstration services.

If the participant receives C&C or MCCP services they will need to be transferred to traditional CCP services prior to being transferred to the MCO.

Cash & Counseling (C&C) and Managed Community Care Program (MCCP)

Disenrollment from an MCO can happen for a number of reasons. ◦ In ICP, may become eligible for Medicare (turn 65 years of age)◦ No longer eligible for Medicaid◦ Move out of MCO territory◦ In MMAI, may opt out of MCO services

Disenrollments only occur on the last day of the month

The participant will be transferred to the CCU and the CCU will then be responsible for providing case management services and authorizing CCP services as needed

What happens to participants who leave MCOs?

MCOs will be making referrals to AAAs, HDM providers, Respite providers, local service providers, etc. for services.

Providers, MCOs & CCUs will need to work

together to provide care to the clients.

MCOs are a new partner in the network and communication will be key to making this a successful implementation.

How will this affect the network?

BEAMBenefits, Eligibility, Assistance &

Monitoring

Weekly extract file from HFS Notify CCUs of transfers to MCOs, changes in

vendors, transfers back to CCP Assist CCUs, providers and MCOs obtain

required paperwork and information Investigate & resolve issues on MCO cases Monitor quality assurance during the process Coordinate with HFS on policy and

procedures for implementing additional Managed Care initiatives

BEAM MCO Activities

Eliminates the need for CATs when transferring CCP clients between CCP and MCOs.

Allows IDOA to indicate which members are in MCO or CCP

Stops CCUs from entering CATs into the wrong program types

Stops CCP providers from billing IDOA when a client is in an MCO

Notifies providers of which MCO a member is enrolled with when unauthorized billing occurs

Filter

EDD is determines if the CAT gets through Prescreens that reject as a A295 (clt in

MCO) should be regenerated as a program type 15

If you are getting rejects and you have checked MCO status with BEAM then contact Aging Advisor to have the filter verified.

Filter Helpful Hints

1-855-228-6516

Aging.Advisor@Illinois.gov

BEAM Contact Info

Questions???