AmeriHealth Michigan Provider Overview. April, 2014

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1 AmeriHealth Michigan Provider Overview April, 2014

2 Who We Are Our Mission Dual Demonstration of Michigan AmeriHealth VIP Care Plus Agenda Our Record of Success Integrated Care Management Provider Partnerships Shared Savings Programs Questions 2 2

3 Who We Are AmeriHealth Michigan is a member of the AmeriHealth Caritas Family of Companies, one of the largest organizations of Medicaid managed care plans in the United States. For more information about AmeriHealth Caritas Family of Companies visit us online at We are: An industry leader in managing medically complex members. A company whose history includes 30 years of experience serving Medicaid beneficiaries and other low income populations in rural and urban settings. Today we operate in 15 states and touch the lives of over 5 million members. A mission driven company whose goal is to keep families and communities healthy by helping them connect to their physicians and focusing on preventive care and health maintenance. 3

4 Our Coverage Area 4

5 We help people get care, stay well and build healthy communities. Our Mission AmeriHealth Michigan can provide expertise and success in helping families to get care and stay well. By partnering with dedicated providers and working with underserved communities, we expect to achieve positive health outcomes throughout Michigan. 5 5

6 Dual Demonstration of Michigan In January 2011, Michigan was selected by the Centers for Medicare and Medicaid Services (CMS) as one of fifteen states awarded funding to design and develop a person-centered health care delivery model that coordinates primary, acute, behavioral and long-term supports and services for Medicare- Medicaid enrollees. The Michigan Department of Community Health (MDCH) released a Request For Proposal (RFP) to implement its integrated Dual Eligible Demonstration in August 2013, and the targeted implementation for the program is May 1,

7 Dual Demonstration of Michigan The Michigan dual eligible demonstration model will fully integrate primary care, acute care, behavioral health and long term supports. Eligible Enrollees are: Enrolled in Medicare and Medicaid Low-Income Seniors Younger Persons with Disabilities In 2012, nearly 200,000 Dual Eligibles became entitled to enroll in the Michigan Dual Demonstration program. Benefit package will include: All Medicaid benefits Medicare Parts A, B and D Behavioral Health Developmental Disabilities Services 1915 (c) waiver services 1915 (b)(3) services 7

8 AmeriHealth VIP CARE PLUS The demonstration project will operate statewide with implementation divided into four regions. Amerihealth Michigan has filed a CMS application to operate in two of four regions: Wayne County (Region 7) and Macomb County (Region 9). AmeriHealth Michigan will offer services to eligible enrollees under the Plan Name: 8

9 AmeriHealth Caritas Record Of Success AmeriHealth Caritas: Handles more than 6,000 member and provider calls every day in our 24-7 call center. Processes an average of 2.1 million claims each month. Receives more than 84 percent of provider claims electronically while automatically adjudicating more than 80 percent of those claims. Handles more than 8 million inquiries annually through our robust provider portal. 9

10 AmeriHealth Caritas Record Of Success As a member of the AmeriHealth Caritas Family of Companies, AmeriHealth Michigan is uniquely qualified to enable this underserved population to receive the coordinated care they deserve. AmeriHealth Caritas a leader in health care solutions for the underserved: Over 5 Million Covered Lives Employees NCQA Accredited Managed Care Plans 10

11 NCQA Accreditation The success of AmeriHealth Caritas mission driven programs is evidenced by the national recognition and awards received. Three of our Medicaid plans are ranked among the top 40 Medicaid plans nationwide: Keystone First AmeriHealth Caritas Pennsylvania Select Health of South Carolina Keystone First and AmeriHealth Caritas Pennsylvania remain among the topthree plans in Pennsylvania, Select Health remains the highest-ranked Medicaid plan in South Carolina. Rankings based upon NCQA Health Insurance Plan Rankings , issued September 19,

12 Integrated Care Management A proven integrated care management (ICM) model is used to address care gaps and foster health equity. This model incorporates a member-based decision support system that drives both communication and care-plan development through a multidisciplinary management approach. Programs are in place to assist with acute and chronic care needs, including: Diabetes Heart Disease Hypertension Asthma COPD Sickle Cell Anemia Depression 12

13 Integrated Care Management Navinet Care Gaps A pop-up alert occurs when checking member eligibility in NaviNet. These alerts indicate the member is at risk due to missing or overdue preventive services, or under-utilization or absence of disease specific controller medications. Care Management and Outreach Teams Comprised of plan medical directors, care managers (registered nurses and social workers), and skilled care connectors (for non-clinical issues), the teams collaborate with internal care managers and providers to identify and address members health needs. Members receive educational materials and if identified as high risk, are assigned to a Care Manager for one-on-one education and follow-up. 13

14 Integrated Care Management Utilization Management Inpatient, limited outpatient and out-of-network prior authorization requirements - we are sensitive to the interruption that prior authorization (PA) can cause in a provider s workflow. Our goal is to ensure that enrollees and providers alike can easily understand and identify which services require PA. We will alert providers to changes in a timely manner via the plan website or individual outreach when necessary. Services requiring prior authorization may be submitted electronically via our provider portal. Discharge planning assistance. Member education and coordination of care. 14

15 Provider Partnerships Working with dedicated medical providers, our programs offer improved health outcomes for our members Regional Provider Councils Regional Provider councils and provider committees are avenues for input on program development and processes. Emphasis is placed on patient centered medical homes to encourage coordination of care and improve the management of services. Value-Based Compensation Models Programs that recognize appropriate and efficient health care services to members. Programs developed and approved with provider committee involvement. 15

16 Administrative Ease E-Health Solutions Efficiency is emphasized to assure ease of administration for providers: electronic claims submission (EDI), electronic remittance advice (ERA), electronic funds transfer (EFT), web-based reporting, electronic prior authorizations Web Portal Functions: Member Eligibility Member Rosters Third Party Liability Information (TPL) Claims Status & Updates Prior Authorization HEDIS Performance 16

17 Provider Communications Provider Communication Strategy: Written communications; letters, provider newsletters, alerts, website updates. Provider Network Management Team: Dedicated provider network account executive staff who live and work in the local area to assist providers and meet face-to-face on a routine basis. Provider workshops and small provider group roundtable meetings held to obtain feedback and communicate important information. State-wide provider meetings to introduce the health plan and its processes. Dedicated provider support line available 24 x 7. Peer-to-peer access with locally-based Medical Directors. 17

18 Provider Credentialing Provider Credentialing: AmeriHealth Caritas works with the Council for Affordable Quality Healthcare (CAQH) to offer our providers the Universal Provider Data source that simplifies and streamlines the data collection process for credentialing and re-credentialing. AmeriHealth Caritas utilizes delegated credentialing for large provider entities when applicable. Our credentialing team is available to assist with provider enrollment and sponsoring participation with CAQH. Our turnaround times average 17 days. For credentialing and attestation information, visit: 18

19 Potential Shared Savings Program Opportunities Designed to improve patient health, reduce unnecessary cost and promote accountable care. The program contains both quality and cost & efficiency incentives as well as additional bonus opportunities for exemplary service. Key Benefits: Improved Quality and Outcomes Collaborative Transparency Monthly Financial Performance & Key Performance Indicators (KPI s) Platform for Future Risk Sharing 19

20 Potential Shared Savings Program Opportunities 3 Types of Value-Based Provider Programs Shared Savings Shared Risk Full Risk Provider Program Framework to Include: Financial Element Quality Element Access Requirement PCMH Included Minimum Membership 20

21 Serving Michigan s Vulnerable Families We are proud to have the opportunity to partner with Michigan to provide health care to its most vulnerable families. AmeriHealth Caritas 30 years of experience in Medicaid managed care makes us the best choice for families covered by the Dual Demonstration of Michigan. 21

22 Contact us at or us at