ADAP Transition Meeting. June 18, 2013

Transcription

1 ADAP Transition Meeting June 18, 2013

2 Agenda for Call Welcome Purpose for the call Call Mechanics CountyCare Participants on the call CountyCare Overview Medical Home and PCP orientation Network participants Services Covered Compare to Ryan White Service Evaluating your Clients for CountyCare CountyCare Initial Response 2

3 Enrollment Statistics May Total apps initiated to date = 65,567 In June, each work day: Over 512 CountyCare apps started Approx. 518 CountyCare apps submitted to DHS DHS processes approximately 275 a day From submission to DHS to adjudication is, on average, 49 days 3

4 Demographic Profile Demographic profile (based on May monthly file): 55% members between ages % members between % members under 35 56% female 44% male 45% are current patients of CCHHS 23% are current patients of FQHCs 30% are new to both CCHHS and FQHCs 74% empaneled without needing auto-assignment 131 PCMH sites Majority empaneled to FQHCs

5 Covered Services Inpatient hospital services Outpatient hospital services Emergency services for life threatening events Prescriptions at Walgreens, CVS or pharmacies on the Pharmacy provider directory Mental health services (inpatient, outpatient) for behavioral health and substance abuse Primary Care and Specialty Physician Services (provided by or at the direction of the Medical Home) Lab, xrays, mammograms other tests Vouchers for public transportation to and from appointments for CountyCare member Skilled nursing facility care (after hospitalization), home care, durable medical equipment, prostheses Dental (limited to 19 and 20 year olds) Outpatient PT, ST and OT 5

6 CountyCare Network Structure Contracted hospitals Contracted services (lab, pharmacy, behavioral health) CCHHS and FQHCs Contracted specialists Contracted ambulatory Services 6

7 Provider Network CCHHS PCMH sites General Medicine Clinic-Fantus Austin Health Center Cicero Health Center John Sengstacke Health Center Near South Health Center Oak Forest Health Center Robbins Health Center CORE Center Dr. Jorge Prieto Health Center Logan Square Health Center Vista Health Center Woodlawn Health Center Englewood Health Center Cottage Grove Medical Center Woody Winston Health Center Designated sites at the following FQHCs Asian Human Services Lawndale Christian Health Center ACCESS Friend Family Health Center Beloved Community Wellness PCC Community Wellness Center Community Nurse Health Center Erie Family Health Center Salud de Esperanza PrimeCare Community Health Howard Brown Chicago Family Health Center Heartland Health Outreach Heartland International Health Center Alivio Medical Center Christian Community Health Center Aunt Martha s Near North Health Center Circle Family HealthCare Network Mercy Family Health Center 7

8 Participating Hospitals Advocate Christ Medical Center Advocate Illinois Masonic Medical Center Advocate Lutheran General Advocate South Suburban Advocate Trinity Hospital Holy Family Medical Center Long Term Acute Care Mercy Hospital & Medical Center Metro South Medical Center Mount Sinai Hospital Norwegian American Hospital Our Lady Of The Resurrection Medical Center Resurrection Medical Center RML Long Term Acute Care Hospital Roseland Community Hospital Schwab Rehabilitation Hospital South Shore Hospital St. Anthony Hospital St. Bernard Hospital St. Francis Hospital St. James Hospital and Health System St. Joseph Hospital Sts. Mary and Elizabeth Medical Center Swedish Covenant Hospital University of Chicago Medical Center Vanguard MacNeal Hospital Vanguard West Suburban Medical Center Vanguard Weiss Memorial Hospital Vanguard Westlake Hospital 8

9 Participating Other Providers (sample) Other Providers Behavioral Health: PsycHealth Durable Medical Equipment: Doctor s Choice, Premier Home Care Supplies, Orsini, Premier Home Care Supplies, Prism Healthcare Services, /Resurrection Home Medical Equipment Home Health: Doctor s Choice Home Care, Resurrection Home Health Hospice: Horizon s Hospice, Vitas Healthcare, and Rainbow Health Women s Health: Planned Parenthood 9

10 For Updates - Visit CountyCare.Com 10

11 CountyCare and HIV 11

12 CountyCare integration with HIV Care Meetings with AFC Conference call with LA County Follow-up with IDPH and CDPH Conference call with CDPH Collaboration with AFC on letter to case managers and service crosswalk HIV/AIDS Interagency Taskforce CCHHS HIV Coordinating Committee 12

13 California Waiver Experience Low Income Health Program (LIHP) Prepare for ACA implementation Improve integration of care Cover the uninsured now Bring federal dollars into LA County HRSA determined LIHP is a payer for all services Ryan White clients eligible for LIHP must be enrolled and no longer eligible for ADAP and other Ryan White funded primary care services Cost shift form State/Federal to County

14 California Waiver Experience Impact of shift to LIHP Continuity of care interrupted Other challenges: patient choice; data and privacy; measuring and monitoring transition

15 Current Cook County Residents with HIV Eligible for the 1115 Waiver Numbe er of People IL ADAP Budget CC Waiver Eligible Residents 15

16 Current Cook County Residents with HIV Eligible for the 1115 Waiver Numbe er of People IL ADAP Budget CC Waiver Eligible Residents CCHHS waiver eligible ADAP clients (est) CORE waiver elgible ADAP clients CCHHS ADAP in the gap (test) CORE ADAP in the gap 16

17 CountyCare/Ryan White Benefit Crosswalk RYAN WHITE SERVICE CATEGORY CORE MEDICAL SERIVCES Outpatient/Ambulatory Medical Care RYAN WHITE DEFINITION Covered COUNTYCARE Covered Medical Supplies, Equipment, Prostheses and Orthoses Respiratory Equipment & Supplies (Provider Handbook, Chapter 100, Section 103) EPSDT (19-21 year olds) Emergency Services (includes poststabilization services) Sub-acute alcoholism & substance use disorder services Mental Health Services (including rehabilitation & clinic option) Targeted case management (BH) 17

18 CountyCare/Ryan White Benefit Crosswalk RYAN WHITE SERVICE CATEGORY RYAN WHITE DEFINITION COUNTYCARE Pharmacy Covered Covered Oral Health Care Early Intervention Services (EI) Parts A & B Home Insurance & Cost Sharing Assistance Home Health Hospice Services Diagnostic, preventive & therapeutic services provided by a dental health care professional. Covered Covered Not Offered by Ryan White Not Offered by Ryan White Mental Health Services Covered Covered Medical Nutrition Therapy Including Nutritional Supplements Covered Dental services covered for individuals age only Not a Covered Service Not a Covered Service Home health agency visits are covered (25 visits) Hospice (and palliative) services are covered. Not a Covered Service 18

19 CountyCare/Ryan White Benefit Crosswalk RYAN WHITE SERVICE CATEGORY Medical Case Management (including treatment adherence) Substance Abuse Services (outpatient) RYAN WHITE DEFINITION Covered Covered, includes limited support or acupuncture. COUNTYCARE Care management to reconnect members to PCMH after hospitalization or ED visit Covered Support Services Covered Not a Covered Service Case Management (notmedical) Advice & assistance in obtaining medical, social, community, legal financial & other needed services. No coordination of follow-up or medical treatment. Not Covered 19

20 CountyCare/Ryan White Benefit Crosswalk RYAN WHITE SERVICE CATEGORY Pediatric Developmental Assessment & Early Intervention Services Emergency Financial Assistance Food Bank/Home Delivered Meals Health Education/Risk Reduction RYAN WHITE DEFINITION Not relevant waiver is for adults only Covered Covered Activities to educate clients with HIV about transmission & how to reduce risk of transmission. Includes activities provided under syringe exchange programs. Includes provision of medical and psychosocial support services & counseling to help clients improve health status. DOES NOT APPEAR TO BE OFFERED BY RYAN WHITE. COUNTYCARE EPSDT for year olds is covered Not a Covered Service Not a Covered Service Not a Covered Service 20

21 CountyCare/Ryan White Benefit Crosswalk RYAN WHITE SERVICE CATEGORY RYAN WHITE DEFINITION COUNTYCARE Housing Services Covered Not a Covered Service Legal Services Covered Not a Covered Service Linguistics Services Not Covered Translation services provided Medical Transportation Transportation provided directly or through a voucher to help access health care services CTA & PACE only to secure covered services will be covered. Public Transportation Outreach Services Covered Not a Covered Service Psychosocial Support Support and counseling activities, child abuse and neglect, HIV support groups, pastoral care, caregiver support, bereavement counseling, & nutrition services provided by a non-registered dietician. Rehabilitative Services Not Offered by Ryan White Not a Covered Service Inpatient and outpatient Physical, Occupational, Hearing & Speech Therapy Services are Covered 21

22 CountyCare/Ryan White Benefit Crosswalk RYAN WHITE SERVICE CATEGORY Substance Abuse Services (residential) Durable Medical Equipment RYAN WHITE DEFINITION Treatment to address substance abuse problems in a short-term residential setting. Includes acupuncture. (Covered under Part B at Bonaventure. Part A funds Loretto Hospital for this services. John is checking to get more info on the services offered to make sure its not inpatient detox.) Covered Not Offered by Ryan White COUNTYCARE Covered-uses PsycHealth Network Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies are covered. 22

23 CountyCare Eligibility Live in Cook County Be years old Have income at or below 133% of the Federal Poverty Level ($15,282 individual, $20,628 couple - annually) Not be eligible for state Plan Medicaid (parent, pregnant, blind or receiving disability income) Not be eligible for Medicare Be a legal immigrant for five years or more or a US citizen Have a Social Security number or have applied for one Note: No asset test. Note: Although most persons who have been adjudicated as disabled for SSI, SSDI purposes are ineligible, those with income above Medicaid levels ( % FPL) and those with assets above Medicaid levels can enroll in CountyCare 23

24 CountyCare Screening Do you live in Cook County? If yes Go to question #2. If no Not eligible for CountyCare. 2. Are you a US citizen or an eligible immigrant (a legal immigrant for 5 years or more)? If yes Go to question #3. If no Not eligible for CountyCare. 3. How old are you? If under 19 You may be eligible for traditional Medicaid. If 65 or older You may be eligible for traditional Medicaid. If Go to question #4. 24

25 CountyCare Screening Are you raising related children under 19? If living with and raising your own children May be eligible for traditional Medicaid. If living with and raising related children and the children s parents are not in the home May be eligible for traditional Medicaid. If living with and raising related children and the children s parent or parents are in the home? Go to question #5. If not living with related children Go to question #5. 5. Are you pregnant? If yes May be eligible for traditional Medicaid. If no - Go to question #6. 6. Are you blind or do you receive Medicare, SSI or SSDI benefits? If yes May be eligible for traditional Medicaid. If no May be eligible for CountyCare. 25

26 CountyCare How to Apply Apply with Application Assistors only by phone or in person Call or toll free M-F 8am-8pm, Sat 9am-2pm -To apply by phone -To find a CCHHS location to apply in person -To find a CountyCare FQHC site or Organization to apply in person Two steps to apply -Provide verbal answers to application questions -Submit verification documents 26

27 Documentation Requirements U.S. Citizens with a valid Social Security Number Each CountyCare application must include documents for each applicant that prove: Income A document or set of documents for each income source that, when added together, shows the dollar amount each applicant currently receives in a month from each income source. Note: Documentation is not required to verify amounts received from the Social Security Administration or from unemployment insurance benefits from the Illinois Department of Employment Security. Address A document that shows the applicant s name with a home address in Cook County. Signature - A signed signature page IMPORTANT: Documents submitted with a CountyCare application to DHS must be CLEAR, READABLE copies and information on documents must match information entered into the DHS application. Documentation Checklist at 27

28 Documentation Requirements U.S. Citizens without a valid Social Security Number Each CountyCare application must include documents for each applicant that prove: Income A document or set of documents for each income source that, when added together, shows the dollar amount each applicant currently receives in a month from each income source. Note: Documentation is not required to verify amounts received from the Social Security Administration or from unemployment insurance benefits from the Illinois Department of Employment Security. Identity A document that shows the applicant s name. Citizenship A different document from the identity document that shows the applicant is a U.S. citizen Application for SSN A document that shows the applicant recently applied to the Social Security Administration to get a Social Security Number. Address A document that shows applicant s name with a home address in Cook County. Signature - A signed signature page IMPORTANT: Documents submitted with a CountyCare application to DHS must be CLEAR, READABLE copies and information on documents must match information entered into the DHS application. Documentation Checklist at 28

29 Documentation Requirements Non-Citizens with a valid Social Security Number Each CountyCare application must include documents for each applicant that prove: Income A document or set of documents for each income source that, when added together, shows the dollar amount each applicant currently receives in a month from each income source. Note: Documentation is not required to verify amounts received from the Social Security Administration or from unemployment insurance benefits from the Illinois Department of Employment Security. Identity A document that shows the applicant s name. Legal Status A different document from the identity document that shows the applicant s legal status in the U.S. Address A document that shows the applicant s name with a home address in Cook County. Signature - A signed signature page IMPORTANT: Documents submitted with a CountyCare application to DHS must be CLEAR, READABLE copies and information on documents must match information entered into the DHS application. Documentation Checklist at 29

30 Documentation Requirements Non-Citizens without a valid Social Security Number Each CountyCare application must include documents for each applicant that prove: Income A document or set of documents for each income source that, when added together, shows the dollar amount each applicant currently receives in a month from each income source. Note: Documentation is not required to verify amounts received from the Social Security Administration or from unemployment insurance benefits from the Illinois Department of Employment Security. Identity A document that shows the applicant s name. Legal Status A different document from the identity document that shows the applicant s legal status in the U.S. Application for SSN A document that shows the applicant recently applied to the Social Security Administration to get a Social Security Number. Address A document that shows applicant s name with a home address in Cook County. Signature - A signed signature page IMPORTANT: Documents submitted with a CountyCare application to DHS must be CLEAR, READABLE copies and information on documents must match information entered into the DHS application. Documentation Checklist at 30

31 Illinois Department of Human Services Only DHS staff can determine eligibility Special DHS office on the Stroger Hospital campus with 100 staff Hiring, training new staff in process Should dramatically impact number of CountyCare pending applications Currently takes about 3 weeks to begin application and submit to DHS Currently takes DHS about xx days on average to process the application 31

32 CountyCare Initial Response Organized Call Center to dedicated agents for ADAP receipients Altered empanelment rules If care provided within CountyCare network, ok to empanel to PCP site If care provided outside CountyCare network, care to continue with historical providers until member is contacted by CountyCare coordination team member Created workgroup to address service, clinical and administrative issues that arise during transition 32

33 Questions and Answers 33