Michigan Health Link Integrated Care Dual Eligible Pilot. Nora Barkey MDCH Kyleen Gray SWMBH Roxanne Perry Audrey Smith DWMHA

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1 Michigan Health Link Integrated Care Dual Eligible Pilot Nora Barkey MDCH Kyleen Gray SWMBH Roxanne Perry Audrey Smith DWMHA 1

2 Today s Agenda Welcome and Introductions Nora Barkey MI Health Link Overview and Updates Nora Barkey Care Bridge Key Features Kyleen Gray & Audrey Smith Stakeholder Involvement Roxanne Perry Questions All

3 What is MI Health Link? New CMS-MDCH demonstration program that will integrate all Medicare and Medicaid benefits, rules, and payments into a single coordinated delivery system Capitated payment model using new entities called Integrated Care Organizations (ICOs) and existing Michigan Pre-paid Inpatient Health Plans (PIHPs) 3

4 What Makes this Program Different? Medicare and Medicaid services are managed and integrated A care coordinator and an integrated care team is available to all enrollees Approach is holistic with person-centered processes The delivery system will work in unison rather than in silos Data sharing capacity will be increased 4

5 Who is Eligible? People who Are age 21 and over and are eligible for both Medicare and Medicaid Reside in one of the four demonstration regions Are not enrolled in hospice People enrolled in PACE and MI Choice are eligible but will not be passively enrolled in MI Health Link 5

6 Who Will Administer the Services? Eight ICOs with experience providing Medicare and/or Medicaid services will manage acute, primary, pharmacy, dental and long term supports and services Four PIHPs in the demonstration regions are responsible for all behavioral health services for people with mental illness, intellectual/ developmental disabilities and/or substance use disorders 6

7 Where will MI Health Link be Offered? Four regions of Michigan Entire Upper Peninsula Southwest Michigan (Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph, Van Buren counties) Macomb County Wayne County 7

8 Who Will Administer the Services? Upper Peninsula: Upper Peninsula Health Plan Southwest Michigan: CoventryCares of Michigan and Meridian Health Plan Macomb and Wayne: AmeriHealth, CoventryCares of Michigan, Fidelis SecureCare, Midwest Health Plan, Molina Healthcare, and United Healthcare 8

9 What Benefits are Covered? All acute and primary health care covered by Medicare and Medicaid Pharmacy Dental Home and community based services and Nursing Facility care All behavioral health services currently covered by Medicare and Medicaid Other benefits identified by the ICOs 9

10 How Can Providers Participate? ICOs and PIHPs must meet provider network standards established in contracts with the state and the Centers for Medicare and Medicaid Services (CMS) ICOs and PIHPS will be contacting providers to join their networks in the coming months Networks must include specialists for conditions common to the population 10

Memorandum of Understanding An agreement between MDCH and CMS that provides the design of the demonstration specific to Michigan Signed by CMS and MDCH on April 3, 2014 Available on the

11 Memorandum of Understanding An agreement between MDCH and CMS that provides the design of the demonstration specific to Michigan Signed by CMS and MDCH on April 3, 2014 Available on the CMS website: Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid- Coordination-Office/FinancialAlignmentInitiative/Downloads/MIMOU.pdf 11

12 Readiness Review CMS and MDCH develop Readiness Review Tool Two components: desk review and on-site review Systems testing part of Readiness Review 12

13 When will the Mi health link program start Phase I- Upper Peninsula and Southwest Regions will begin January 1, 2015 Phase II- Detroit Wayne and Macomb Regions will begin May 1,

14 REGIONAL ENTITY EXPERIENCE Work Group Partnerships between the ICO and PIHPs 14

15 MI Health Link Workgroups There are multiple state workgroups with PIHP and ICO participation. Care Coordination which has been focused on developing the process for Level 1 and Level 2 assessments Quality- which has been focused on the 94 measures identified as part of the Demonstration project Care Bridge- which has been focused on the interface between IT systems and sharing data Behavioral Health- which has been looking at the process supporting people with behavioral health needs 15

16 Care Coordination ICOs are required to contract with PIHPs to jointly coordinate and manage care for enrollees with BH, SUD, and/or I/DD needs. Level I Assessment- ICOs will complete the Level 1 Assessment if there is evidence that a person may have behavioral health needs they will be referred to the PIHP for additional assessments. Level I Assessment - ICO will include the appropriate PIHP Supports Coordinator in conducting the assessment if the enrollee is active in the PIHP during the previous 12 months. Level II Completed for enrollees to identify additional community based needs related to LTSS, BH, SUD, I/DD services or complex medical needs. Conducted in person within 15 days of completion of Level I by PIHP supports coordinator. Level II Assessments: ASAM- for persons with SUD SIS- for persons with I/DD LOCUS for persons with SPMI 16

17 Care Coordination Integrated Care Team A team including the enrollee, enrollee s chosen allies or legal representative, Primary Care Physician, ICO Care Coordinator, LTSS Coordinator or PIHP Supports Coordinator (as applicable) and others as needed. The ICT works with the enrollee to develop, implement, and maintain the IICSP and to coordinate the delivery of services and benefits as needed for each enrollee. MOU Page 26 Integrated Care Team (ICT): Works collaboratively with enrollee and other team members to ensure the Individual Integrated Supports Care Plan (IISCP) is fulfilled according to the person-centered planning process and the enrollee s stated goals. An ICT will be offered to the enrollee. The ICT will honor the enrollee s choice about his or her level of participation. ICO Care Coordinator will convene the ICT which will also include the enrollee and the enrollee s chosen allies, primary care physician, LTSS Supports Coordinator and/or PIHP Supports Coordinator (as applicable). 17

18 Supports Coordinator PIHP Supports Coordinator will (examples): Support the person-centered planning process. Participate in the Level I Assessment when the enrollee has an identified BH, SUD, and/or I/DD need. Complete a Level II Assessment of enrollees identified as having need for community based long term BH/SUD and/or I/DD service and support. Develop, with the enrollee and the ICT, an IICSP. Coordinate resources and authorize services. Coordinate psychiatric, psychopharmacological, rehabilitative, and hab services and supports in response to needs identified in the Level I Assessment, the Level II Assessment, and IICSP. Manage transitions among psych acute and sub-acute levels of care and the community. 18

19 Quality & Withhold/Risk Core Quality Measures under the Demonstration: ICOs must collaborate with PIHPs to obtain data for the reporting of services provided through the PIHPs. A subset of these will also be used for calculating the quality withhold payment. Quality Withhold Measures for Medicaid & Medicare A/B: Medicare & Medicaid will withhold percentages of their respective capitation payments, to be repaid subject to performance by the ICO on specific quality measures, which includes the PIHP responsibilities. ICOs must include provisions that reward the PIHP when the ICO achieves the withheld amounts. 19

20 Behavioral Health Outpatient Visits (Medicaid and Medicare) for enrollees with mild, moderate, or severe behavioral health needs; Other Medicaid Behavioral Health Services (for enrollees with specialized needs related to the behavioral health and/or intellectual or developmental disability beyond covered acute care services). 20

21 Region 4: SWMBH, CoventryCares, Meridian: Currently working on a draft of the ICO/PIHP contract Reviewed and proposed a structure for the Level II assessment process to the state Reviewing IT options to support Care Bridge functionality and data sharing in addition to secure file sharing 21

22 PIHPs - Impacts Some Impacts on PIHP service delivery: Services - Medicare BH service contracts with ICOs for all mild-to-mod outpatient (Medicaid/Medicare) and psychiatric hospital. Quality - Additional quality measures, analysis and reporting to ICOs. Integrated Care & Care Coordination: PIHP Supports Coordinator: Participates on Integrated Care Team (ICT), development of Integrated Care Supports Plan (IICSP), care coordination and transitions. Claims Data Access - Care Connect 360/FRANK Medicaid claims data for BH, Physical, Pharmacy Technology Integration ICO, SWMBH, CMHSPs 22

23 Work Group Partnerships between the ICO and PIHPs Audrey E. Smith, MPH 23

24 Region # 7 Detroit/Wayne- Delivery Structure (as of 5/1/14) Detroit Wayne Mental Health Authority Regional Entity/PIHP Detroit Wayne Mental Health Authority Single CMHSP Gateway (MI/SED) CareLinlk (MI/SED) Consumer Link (I/DD) Synergy (I/DD) Community Living Services (I/DD) Managers of Comprehensive Provider Networks (MCPNS) MI/I/DD/SED PROVIDERS 24

25 CMS (Medicare) MOU State (Medicaid) CONTRACT MEDICAID, GENERAL FUND, SUD BLOCK GRANT, OTHER WAIVER SERVICES CONTRACT 3-WAY CONTRACT PIHP ICO CONTRACT (BH, SUD, I/DD) CONTRACT To Be Determined v1.aes Medicare BH benefits, Medicaid 20 visits benefit, Care Coordination activities, and other contracted services 5/27/2014 MCPN/ Providers 25 25

26 Regional/Local Efforts: DWMHA Data Sharing/Care Coordination Pilot developed framework for ICT meetings that can be a model for the Care Bridge. Midwest Health Plan Blue Cross Complete Molina Currently working collaboratively with ICOs and PIHPs to develop Level I, Level II, and Care Bridge prototypes for the State to adopt- Metro-Region Healthcare Integration Project (MI CARE Connect) v1.aes 5/27/

27 DWMHA Data Sharing/Care Coordination Pilot- Purpose of the Project: To identify consumers of DWMHA and who are also members of Medicaid Health Plans, and share utilization and cost data of these common individuals. To develop a process of sharing information on common individuals, in effort to better manage their health care utilization, and reduction of unnecessary cost. To identify systemic opportunities which facilitate an integrated approach to improve the health outcomes of consumers. 27

28 28

DWMHA Data Sharing/Care Coordination Pilot- Data Elements Physical Health Physical Health Demographics Assigned Primary Care Provider Physical Health Diagnosis Medications ER Visits Office Visits Lab

29 DWMHA Data Sharing/Care Coordination Pilot- Data Elements Physical Health Physical Health Demographics Assigned Primary Care Provider Physical Health Diagnosis Medications ER Visits Office Visits Lab Work Health/Wellness Indicators Case Management Demographics Guardianship Living Arrangement Natural Supports/Transportation Behavioral Health Diagnosis Behavioral Health Visits Medications Crisis ER Visits SUD History/Prevalence Health Case Ma 5/27/2014 v.aes 29 29

30 DWMHA Data Sharing/Care Coordination Pilot- Observations Data has value Difference in Demographics Difference in Diagnosis Understanding Residential Setting Care Team Members Bi-Directional Communication and Care Coordination has value Learning the assets of the health plan and the behavioral health system Learning the language Learning core values and principles 5/27/2014 v.aes 30 30

31 Technology to Share Data is on the Horizon 5/27/2014 v.aes 31 31

DWMHA Integrated Healthcare Initiatives In Summary DWMHA is working with regional and health plan partners to develop a best in class health information exchange to facilitate a care bridge for data

34 DWMHA Integrated Healthcare Initiatives In Summary DWMHA is working with regional and health plan partners to develop a best in class health information exchange to facilitate a care bridge for data sharing DWMHA is working with its provider network in the development of standardized access screening, and assessment tools and the overall infrastructure to advance the paradigm shift to integrated healthcare 5/27/2014 v.aes 34

35 INTEGRATED HEALTHCARE! 5/27/2014 v.aes 35 35

36 Stakeholder Involvement Roxanne Perry, Manager Integrated Programs Management Section Integrated Care Division 36

37 Stakeholder Involvement MDCH is expanding its stakeholder engagement efforts - Quarterly Regional Open Forums - MI Health Link Advisory Committee - Enrollee Participation in ICO Advisory Council 37

38 Open Forums Host an open forum every quarter Rotate the location of the forum between the 4 regions The next Forum will be in Macomb County 38

39 Advisory Committee Being formed for the MI Health Link Provides a mechanism for enrollees and stakeholders to provide input Membership represents the diverse interests of stakeholders 39

40 Roles and Responsibilities Work with MDCH to solicit input from stakeholders and other consumer groups Provide feedback on quality of services Provide input to the State on evaluation design 40

41 Roles and Responsibilities Review ICO and PIHP quality data and make recommendations for improvement Provide feedback in the development of public education and outreach campaigns Identify areas of risks and potential consequences Participate in the demonstration Open Forum sessions 41

42 Membership Selection Individuals and organization representatives will apply to serve on the Advisory Committee MDCH will evaluate all applications Membership will include representation from various populations within the demonstration regions 42

43 Membership Selection Submitted applications will be evaluated on Qualifications including interest, knowledge, skills, and experience A person who is eligible for both Medicare and Medicaid, or has experience working with this population 43

44 Advisory Committee Application A completed application form is required; a letter of reference is optional The form will be available on our website soon INTEGRATEDCARE@michigan.gov or call if you need the form mailed to you The completed form can either be sent to MDCH by , fax or regular mail 44

45 ICO Advisory Council ICOs required to have separate advisory council specific to the demonstration Membership: 1/3 enrollees, majority comprised of enrollees, family members, and advocates State requested grant funds to support enrollee participation on the advisory council 45

46 Questions and Contact Information FAX (517) MAIL Integrated Care Medical Services Administration PO Box Lansing, MI WEBSITE 46

The benefits of the Affordable Care Act for persons with Developmental Disabilities

Tuesday, 2:30 2:00, B5 The benefits of the Affordable Care Act for persons with Developmental Disabilities Objectives: Notes: Audrey E. Smith, MPH 33-402-9608 Asmith2@waynecounty.com. Identify effective