The Medicare Medicaid Alignment Initiative (MMAI): A Program for People with Medicare and Medicaid. updated July 2016

Transcription

1 The Medicare Medicaid Alignment Initiative (MMAI): A Program for People with Medicare and Medicaid updated July

2 What is the Medicare Medicaid Alignment Initiative (MMAI)? A managed care program for people who have both Medicare and Medicaid A way to receive all of your healthcare services through one private health insurance plan 2

3 What is the Medicare Medicaid Alignment Initiative? Medicare Part A Medicare Part D Medicare Part B Medicaid With MMAI, you receive all of your health services through one MMAI health plan, instead of using several different cards when you go to the doctor, hospital, or pharmacy. 3

4 What is the Purpose of MMAI? There are two main goals of MMAI: To provide better, more coordinated care to people who have Medicaid. To save money for the Medicaid program. 4

5 Services covered through MMAI Managed Care Organization (MCO) Hospital Doctors Home Health Ambulance Lab Tests Prescription Drugs Mental/ Behavioral Health Services Long Term Services & Supports (LTSS) Transportation Durable Medical Equipment Skilled Nursing Facility 5

6 What services does MMAI cover? All MMAI plans must cover everything that Medicare and Medicaid cover. Some MMAI plans cover extra services that Medicaid does not usually cover, like a gym membership, over the counter drugs, or transportation to your doctor. 6

7 What Does MMAI Cost? You will not be charged any more for your services with an MMAI plan than you would be charged with regular Medicare and Medicaid. Some MMAI plans charge less than Medicaid for certain services. (For example, some MMAI plans do not charge a copayment for prescription drugs.) 7

8 Who Can Enroll in the Program? To enroll in an MMAI plan, you must: Be enrolled in Medicare Part A and Part B OR a Medicare Advantage plan Be enrolled in full Medicaid (be on Medicaid without a spenddown) Be age 21 and over Live in one of these counties: Cook, Lake, Kane, DuPage, Will, Kankakee, Knox, Peoria, Tazewell, McLean, Logan, DeWitt, Sangamon, Macon, Christian, Piatt, Champaign, Vermilion, Ford, Menard, Stark 8

9 Who Cannot Enroll in the Program? You cannot enroll in an MMAI plan if you are: Enrolled in Medicaid Spenddown Spenddown is when you use medical bills or receipts to qualify for Medicaid because your income or resources are higher than Medicaid s limits. Getting care in the Illinois Breast and Cervical Cancer Program Getting private third party insurance (such as employer or retiree coverage) Getting services through an Illinois waiver program for people with Developmental Disabilities (in home services or living in a CILA) 9

10 What are the benefits to enrolling in an MMAI plan? You will receive all of the same services that Medicare and Medicaid cover; some plans may offer extra benefits. You will not pay more for services in an MMAI plan than you would pay with regular Medicare and Medicaid. Each plan has a large list (network) of doctors, specialists and hospitals that you can choose from to get services. (You will need to use providers who are in your plan s network.) 10

11 Care Coordination will help you manage your healthcare services and make sure that you are receiving the care you need, when you need it. After enrolling in an MMAI plan, you will be asked to complete a health risk assessment and then be assigned to a care coordinator. A Care Coordinator will help you: What are the benefits to enrolling in an MMAI plan? Understand your plan of care Provide follow up Help you access services that you need You can call your care coordinator at any time to ask about your healthcare needs. 11

12 MMAI health plans in the Chicagoland area: Aetna Better Health Premier Plan Blue Cross Community MMAI Humana Health Plan, Inc. IlliniCare Health Meridian Complete Some people are already enrolled in Cigna-HealthSpring; however, Cigna is not accepting new enrollments. 12

13 What if I want to keep my current coverage? You can choose to keep your current coverage and continue to use regular Medicare and Medicaid for your healthcare services. You must contact the Client Enrollment Services and tell them that you want to opt out of the MMAI program, or they will choose a plan and primary care provider for you. You can opt out or change your MMAI plan at any time. Remember to re-enroll in a Medicare Part D plan for your prescription drugs if you have already enrolled in an MMAI plan and then opt out. If you receive long term services and supports (LTSS), live in the Chicagoland area, and opt out of MMAI, you must enroll in a managed healthcare plan for those services (information to follow). 13

14 Managed Long Term Services and Supports (MLTSS) Program

15 What are Long Term Services and Supports (LTSS)? LTSS are services that help you accomplish activities of daily living. Such as bathing, dressing, and eating You can receive LTSS in one of two ways: While living in a long term care facility (sometimes called a nursing home) Through in-home care that you get through a Medicaid Waiver program (such as the Community Care Program or the Department of Rehabilitative Services) 15

16 What is Managed Long Term Services and Supports (MLTSS)? MLTSS is a new managed healthcare program required for people who: Have both Medicare and Medicaid, and Have opted out of MMAI, and Live in a long term care facility (sometimes called a nursing home) or receive home and community based services through a Medicaid Waiver program 16

17 Who does MLTSS affect? Effective July 1, 2016: Individuals with full Medicare (or a Medicare Advantage plan) and full Medicaid who receive long term services and supports (LTSS) must enroll in a managed healthcare plan if they have opted out of MMAI. Individuals who do not receive long term services and supports are not affected by this change. 17

18 Who does MLTSS affect? If you receive long term services and supports and are currently enrolled in an MMAI plan, you will not need to enroll in a managed long term services and supports (MLTSS) healthcare plan. You will continue to receive all of your healthcare services through your MMAI plan. If you disenroll from your MMAI plan and go back to using regular Medicare and Medicaid, you must enroll in a managed healthcare plan only for your long term services and supports. You can never have both an MMAI plan and a managed long term services and supports plan at the same time you can have only one or the other. 18

19 Mr. and Mrs. Smith Mr. Smith and Mrs. Smith are both eligible for MMAI because they have full Medicare and full Medicaid. They also have a person who comes into their home to help with cooking and cleaning through the Community Care Program. Mr. and Mrs. Smith each received a letter explaining their eligibility for MMAI and their options. They called Client Enrollment Services to let them know what they have decided to do. 19

20 Mr. and Mrs. Smith make their choices Mr. Smith decided to enroll in an MMAI plan to receive all of his healthcare services through one managed healthcare plan. Mrs. Smith decided to opt out of an MMAI plan and continue to receive her healthcare services through regular Medicare and Medicaid, because her cardiologist will not join an MMAI network. Later Mrs. Smith will receive a letter to inform her that she must enroll in a managed healthcare plan only for her long term services and supports. 20

21 Mr. Smith s services covered through his MMAI plan Managed Care Organization (MCO) Hospital Doctors Home Health Ambulance Lab Tests Prescription Drugs Mental/ Behavioral Health Services Long Term Services & Supports (LTSS) Transportation Durable Medical Equipment Skilled Nursing Facility 21

22 Mrs. Smith s services covered through her MLTSS plan Fee-for-Service Medicare (or Medicare Advantage) and Fee-for Service Medicaid Managed Care Organization Hospital Doctors Home Health Ambulance Lab Tests Prescription Drugs Mental/ Behavioral Health Services Long Term Services & Supports (LTSS) Transportation Durable Medical Equipment Skilled Nursing Facility 22

23 Mr. & Mrs. Smith use these cards for their healthcare services Mr. Smith Mrs. Smith Medicaid 23

24 Managed Care Organizations for long term services and supports (MLTSS) in the Chicagoland area: Aetna Better Health Premier Plan Blue Cross Community MMAI IlliniCare Health Meridian Complete 24

25 How do I get more information about my MMAI or MLTSS plan options? If you are eligible for MMAI, you will get a letter from Illinois Client Enrollment Services explaining the MMAI program and your new plan options. If you have opted out of MMAI, later you will get another letter from Illinois Client Enrollment Services explaining the MLTSS program and your new plan options. 25

26 How do I get more information about my MMAI or MLTSS plan options? Call Client Enrollment Services at to help you: Compare benefits of each MLTSS health plan Check which providers are in each plan s network Enroll in an MLTSS plan When you receive a letter from Client Enrollment Services, you will need to contact them to choose your health plan, or they will choose a health plan for you. 26

27 What if my healthcare providers are not in an MMAI or MLTSS plan s network? You can keep seeing your healthcare providers for 180 days from the day you join an MMAI plan, even if they are not in the plan s network This rule applies to anyone who provides you with healthcare services that are covered by Medicare or Medicaid. This rule gives time for your provider to join your plan s network or for you to find a different provider in your plan s network. Even if your provider does not join the plan s network, they may sign an agreement with your plan to keep seeing you after the 180 days. Have your doctor or other healthcare providers call your plan s Provider Relations Department for more information about the 180 day transition policy. 27

28 What information do I need when calling the Client Enrollment Services? Have the following information ready: Social Security Number Date of birth Name of your primary care doctor and other healthcare providers you wish to continue seeing (specialists, hospitals, long-term care or in-home care providers, etc.) 28

29 What if I need help in another language? Call Client Enrollment Services at (TTY: ) to request an interpreter. You will need to be able to say your name and the language that you speak in English in order to request an interpreter. If you cannot do that, you can sign an authorized representative form so that someone you trust can speak to Client Enrollment Services for you. You can also call Client Enrollment Services to request materials about MMAI in other languages or formats (such as large print). 29

30 What if I am not happy with my If you have a problem with your plan, start by calling your plan to file a complaint (called a grievance ). The state of Illinois has an Ombudsman program to help people who are having problems with their MMAI and MLTSS plans. You can reach the Ombudsman program by calling: MMAI or MLTSS plan? Remember: You can change your MMAI plan or opt out at any time and go back to using regular Medicare and Medicaid for your healthcare services. However, you must enroll in a MLTSS plan if you are getting long term services and supports. 30

31 Can I change my MLTSS plan at any time? Once you have enrolled in an MLTSS plan (or have been automatically enrolled into one), you will have a 90-day period to switch plans. After that time, you will be locked into that plan for one year. However, you can switch back to an MMAI plan. That is the only way to change managed care plans outside of your individual annual enrollment period. 31

32 Helpful Hints Watch your mail for letters about MLTSS Make sure your information with the Illinois Department of Human Services (DHS) is up to date If you have an authorized representative, make sure you have filed the proper paperwork with DHS, Client Enrollment Services and your managed care plan Get connected with your care coordinator 32

33 Thank you! If you have questions, contact: AgeOptions (800)