Stakeholder Update March 26, 2014

GOALS FOR THIS SESSION

• To provide an overview of Healthy Connections Prime

• To provide a status update including a

discussion of proposed new implementation timeline

• To identify key operational functions and

proposed contract provisions

HISTORY

• Medicare and Medicaid programs were signed into law July 30, 1965.

• 1965 “three-layer cake”: • Medicare Part A hospital services • Medicare Part B physician and other outpatient services • Medicaid expending federal support for health care

services for poor elderly, disabled, and families with dependent children

• Medicare and Medicaid not initially designed to

integrate and coordinate services for individuals served by both programs

HISTORY

WITHOUT INTEGRATED CARE:

• Three ID cards: Medicare, Medicaid, and prescription drugs

• Three different sets of benefits

• Poor communication among providers

• Health care decisions uncoordinated and not made from a person-centered perspective

• Incomplete knowledge of patient’s condition, medical records, prescriptions, etc.

• Limited time, staff resources or financial incentives to coordinate services

• Lack of appropriate incentives to provide care at the right time and in the least restrictive setting

1. The Henry J. Kaiser Family Foundation. (2013, August 1). State demonstration proposals to integrate care and align financing for dual eligible beneficiaries. Retrieved from http://kff.org/medicaid/fact-sheet/state-demonstration-proposals-to-integrate-care-and-align-financing-for-dual-eligible-beneficiaries/

HISTORY

• May 2012 – October 2013: Participated in on-going negotiations with CMS to develop a Memorandum of Understanding (MOU)

• October 2013: MOU finalized and signed

• October 2013: CICOs announced

HISTORY

• Participating Coordinated and Integrated Care Organizations (CICOs) in Healthy Connections Prime: • Absolute Total Care, Inc.

• Advicare

• Molina Healthcare of South Carolina, Inc.

• Select Health of South Carolina

• WellCare of South Carolina

Better Care. Better Value. Better Health.

PRIME

• Healthy Connections Prime is a new option for seniors 65 older with Medicare and Medicaid, providing all the services they need, fully managed by a single entity.

• Prime offers:

• Better care through a person-centered care model • Better value by focusing on quality and not quantity • Better health for the individual

POPULATION

• Demonstration population inclusion criteria:

• Individuals ≥ 65 • Full-benefit dual eligible • Individuals receiving Home and Community Based

Services (HCBS) waivers (i.e., HIV, Vent, and Community Choices)

• Enrollment includes an opt-in period following by

passive enrollment. The Demonstration is voluntary; beneficiaries can opt-out as well as change plans at any time.

POPULATION

• Excluded populations (at time of enrollment):

• Residing in a nursing facility; • Enrolled in hospice; • Receiving End-Stage Renal Disease (ESRD) services; • Enrolled in another comprehensive health plan; • Enrolled in a Program of All-Inclusive Care for the Elderly

(PACE); or • Enrolled in Department of Disabilities and Special Needs

(DDSN) operated waiver serving adults (ID/RD, HASCI, and Community Supports).

• There are 53,600 eligible beneficiaries; however, approximately 15,041 may be enrolled in comprehensive health plan.

Status Update

TIMELINE

• Proviso introduced and accepted by House Ways and Means Committee instructing SCDHHS request a delay in implementation of Healthy Connections Prime to begin no earlier than January 1, 2015

• Discussing revised timeline with CMS

• Proposed New Timeline (draft)

• January 1, 2015 – March 30, 2015: Opt-In Enrollment Period

• April 1, 2015: Passive Enrollment Wave 1 (Upstate to Northern Midlands)

• June 1, 2015: Passive Enrollment Wave 2 (Southern Midlands to Low Country)

• August 1, 2015: HCBS Passive Enrollment Wave 3

HCBS TRANSITION

• January 1, 2015: Phase 1 • SCDHHS retains authority over all HCBS core functions. • SCDHHS retains final authority for care plan

development and service authorizations with CICO concurrence.

• If CICO objects, a process exists to resolve disputes in the best interest of the beneficiary.

HCBS TRANSITION

• May 1, 2015: Phase 2 • SCDHHS retains authority to perform all initial

assessments, initial level of care determinations and redeterminations.

• CICO assumes authority to perform reassessments. • CICO assumes contractual authority and programmatic

oversight with both provider agencies and individual case management providers.

• CICO assumes final authority for care plan development and service authorizations with SCDHHS concurrence.

HCBS TRANSITION

• January 1, 2016: Phase 3 • CICO may elect to voluntarily assume provider

monitoring and credentialing. • CICO attains authority over self-directed attendant care .

• During each phase, CICOs must pass a benchmark

review prior to moving onto the next level of authority.

• SCDHHS will monitor CICOs activities for quality assurance and compliance via Phoenix, Enrollee surveys, and direct observations.

READINESS REVIEW

• Each CICO must pass a comprehensive, joint CMS/state readiness review.

• Readiness review ensures each CICO is:

• Ready to accept enrollments • Able to provide necessary continuity of care • Can ensure access to full spectrum of Medicare,

Medicaid, and pharmacy providers • Fully able to meet the diverse needs of the target

population

READINESS REVIEW

• Process focuses on areas and processes that directly impact the beneficiary's care (e.g., assessment processes, care coordination, provider network development, and CICO staffing and staff training) | Link to Readiness Review Tool

• Readiness review process:

• Desk Review (December 2013) • Initial Network Submission (February 2014) • Site Visits (March 2014) • Network Adequacy (to be determined) • Final readiness (to be determined)

• CICOs will continue to develop provider networks in

preparation for final readiness determination.

THREE-WAY CONTRACT

• Contract agreement between CMS, SCDHHS and each CICO specifying the terms and conditions by which a CICO may participate in this Demonstration

• Key topics include: • Care delivery model; • Multidisciplinary Team; • Enrollee Rights; and • Appeals and Grievances.

WAIVER AMENDMENTS

• Community Choices, HIV/AIDS, and Ventilator Dependent Waivers

• February 11, 2014: • Public notice posted to the SCDHHS webpage

• February 18, 2014:

• Advisement presented at MCAC meeting

• February 28, 2014: • Tribal Notification issued

• March 14, 2014:

• Request for amendments to 1915 (c) waivers submitted to CMS

Core Operational Functions

OPTIONS COUNSELOR

• Options counselors provide guidance and support for beneficiaries, caregivers and Healthy Connections Prime Enrollees.

• How will options counselors discuss or provide Healthy Connections Prime enrollment assistance?

• Options counselors will help people review, complete, and

submit Healthy Connections Prime enrollment materials if they ask for assistance with or information about enrolling, opting-out, or switching plans.

PRIME ADVOCATES

• How will the options counselors discuss CICO options with people who contact them about Healthy Connections Prime?

• Those who are eligible for Healthy Connections Prime have a choice of up to five plans. Options counselors will review plan options with individuals who are considering Healthy Connections Prime.

• Who will refer individuals to the options counselors?

• A variety of sources may refer people to the options counselor for guidance related to their choices in Healthy Connections Prime.

PRIME ADVOCATES

• Ombudsman

• Supports individual advocacy and independent systematic oversight of CICOs and Healthy Connections Prime

• Focuses on compliance with principles of community integration, independent living, and person-centered care in the home and community based care context

• Coordinates relationships with stakeholders (i.e., CICOs, advocates, providers, SCDHHS, etc.)

PRIME ADVOCATES

• Answers inquiries, investigates, mediates, negotiates and otherwise resolves individual issues, concerns or complaints on behalf of Enrollees

• Provides information and referral services, including referrals to other agencies, as applicable

• Collects and analyzes data for the purpose of quality improvement

QUALITY MEASURES

• Quality measures:

• Focused on process vs. outcome, and are CICO oriented, as opposed to provider specific measures.

• Based upon measures that have been previously implemented in Illinois, Virginia, California, Massachusetts, and Ohio.

• Modeled on standards from NCQA, HEDIS, CAHPS, AMA, and CMS

• Will be refined for inclusion in three-way contract • Categories include:

• Access to Medical Care, Transitions of Care, Behavioral Health, Care Coordination, Disease Management, Customer Satisfaction, and Medication/Vaccines.

COORDINATION

• Enrollees have access to a care coordinator and a multidisciplinary team (MT) based on needs and preferences

• Primary care providers will be included in all care

coordination, including MT

• Care Coordinators serve as a single point of contact

for Enrollees and caregivers

• Enrollees/caregivers will be encouraged to participate in decision-making

COORDINATION

• Care coordination facilitates the transition of individuals to most appropriate, least restrictive setting as an Enrollee’s care needs or preferences change.

• CICOs must provide care model with elements for

person-centered coordination of care.

• The care model must include robust and meaningful mechanisms for improving care transitions, both between providers and care settings.

CICO OVERSIGHT

• Contract Management Team (CMT) performs the following functions including but not limited to:

• Monitoring three-way contract compliance; • Coordinating periodic audits and surveys of CICO; • Coordinating requests for technical assistance from CICO • Coordinating review of grievance and appeals data

• Composed of representatives from CMS, SCHHS and the Prime Advocate

COUNCIL

• Implementation Council does the following: • Assists in monitoring of implementation activities • Provides input on policies and procedures • Provides regular reporting on data and trends, quality

monitoring, and promotion of education activities • Includes of consumers/caregivers, advocates, and

providers • Meets quarterly

• Maintaining the SCDHHS’ commitment to

transparency, council will also disclose program evaluation results

PROVIDER WORKGROUS

• Solicits input from providers on matters of interest such as:

• Enhancing quality care • Containing health care costs • Improving patient experience • Identifying and developing administrative efficiencies • Monitoring CICO compliance and SCDHHS oversight

• Key provider workgroups

• Hospitals • Nursing Facilities • Home and Community Based Providers

EDUCATION

• September 2013: Internal Communications • September 2013 – February 2014

• October 2013: Provider Communications • October 2013 – December 2013

• November 2013: Legislative Affairs • November 2013 – February 2014

• December 2013: Advocacy and Nonprofit Groups Campaign

• December 2013 – February 2014

• January 2014: Media Relations • January 2014 – July 2014

• June 2014: Beneficiary and Caregiver Communications • June 2014 – January 2015

EDUCATION

• Beneficiary Outreach Proposed Timeline*: • Initial mailer/postcard (June 2014) • Host community forums statewide (July-October 2014) • Enrollment letter/materials mailed (mid-October 2014) • CICO marketing period begins (November 2014) • Enrollment begins (November 1, 2014) • Service delivery begins (January 1, 2015)

*All dates are proposed and have not been finalized

Questions?

Please send questions to:

prime@scdhhs.gov.

Thank You

CONTACT INFORMATION

Prime Website: http://www.scdhhs.gov/prime Prime E-mail Address: prime@scdhhs.gov Prime Program Manager: Teeshla Curtis SC Dept. of Health & Human Services 1801 Main Street Columbia, SC 29201 (803) 898-0070 | Office curtist@scdhhs.gov