True Blue Special Needs Plan A Medicare/Medicaid Coordinated Plan

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1 True Blue Special Needs Plan A Medicare/Medicaid Coordinated Plan 06/01/ An Independent Licensee of the Blue Cross and Blue Shield Association

2 Idaho Dual Eligibles Age 21 and older Receives Full Medicaid coverage Enrolled in Medicare Part A & Part B Live within 42 eligible counties 27,200 *Current ESRD diagnosis are prohibited from enrollment 2

3 50%+ below FPL 5+ Chronic Conditions Rural Region Living Limitations Lack high school diploma Institution/Nursing Home Mental Illness More hospital stays/ readmissions More Women Dual Eligibles 1/3 African-American or Hispanic

4 Fiscally Responsible The National Commission on Fiscal Responsibility and Reform estimated that enrolling Dual Eligibles in Medicaid managed care plans would save... $12 billion through

5 Why have MMCP? Medicaid Medicare Blue Cross of Idaho Care Coordination 5

6 True Blue Special Needs Plan True Blue Special Needs Plan provides services for full-benefit, dual-eligible Medicare & Idaho Medicaid beneficiaries. The plan is available in all Idaho counties except Franklin and Lemhi. Plan enrollment is voluntary for all participants Provides coverage for A & D Waiver Services Home and Community Based Services (HCBS) Long Term Services and Supports (LTSS) Ensures necessary services; including primary and acute care, pharmacy, behavioral health, and long-term services and supports are provided, coordinated, and managed. Developmentally Disabled Waiver (D & D) 6

7 Member Benefits Hospital Medical Prescription Drugs Dental Behavioral health Aged & Disabled Waiver Personal Care Services Developmental Disability Targeted Service Coordination Nursing Home and ICF/ID Community Based Rehabilitation Services *Non-Emergent medical transportation must be arranged through Veyo and IS NOT a Waiver Benefit. This benefit is available to all MMCP enrollees. 7

8 Member s Favorite Benefits Blue Cross of Idaho Member Card Access to the True Blue Network Nurse Line Customer Service Fitness Center Benefit Vision Care Coordination 8

9 New Member Enrollment UAI or ISP/SSP requested from IDHW Authorizations are entered once received if applicable through redetermination (UAI) or plan end date (ISP). Long Term Care (LTC) Authorizations are created once Blue Cross of Idaho identifies where enrollees resides. Care Management Episode auto-created in Blue Cross of Idaho s authorization system (JIVA) on all enrollees Care Coordinator is assigned within 14 days once effective Expanded Mental Health (LMSW,LMFT,LPC, TCM and CBRS) No prospective data sent to BCI to identify these services Providers must request authorization to continue services Providers need to include a copy of the Optum Authorization and description of service when requesting authorization. 9

10 Transition Member s benefits and providers remain the same for 90 days from the effective date of enrollment. 10

11 Tips to Know Eligibility for clients who have enrolled/converted to the True Blue Special Needs Plan (MMCP) can be verified on the Blue Cross of Idaho Web Portal by conducting a Member Search within Eligibility & Claims. After the Universal Assessment Instrument (UAI) is received from Health and Welfare, it gets entered into the Blue Cross of Idaho system and the Notice of Decision (NOD) is sent to respective servicing providers. The UAI is good through the redetermination date (re-dat). Every member is assigned a Care Coordinator and offered a Face-to-Face visit within the first 90 days. Alpha prefix to assist in identifying member is XMX A Share of Cost may apply to Waiver Services (HCBS & LTSS), which is located on the Blue Cross of Idaho web portal, under eligibility and claims. 11

12 Tips to Know (cont.) $0 Premium, $0 Part D Deductible & $0 copay for medical services How do providers know if the Medicaid rate changes? Rates may change depending on the provider type. Some rates may change at the re-dat date or others may change when Medicaid changes the facility rate. (i.e., LTC) Some rates are determined by the State and usually change with the new plan year. Other rates may change if the State changes the rates during the year. 12

13 Care Plan Member s Care Plan is made available upon request to enrollee s identified interdisciplinary team on the Blue Cross of Idaho provider portal. Primary Care Physician Care Coordinator Targeted Service Coordinator (when applicable) The primary care physician is informed what services each member receives and has ongoing communication with care coordinator. 13

14 Interdisciplinary Care Team (ICT) Care Coordinator Mental Health Family Member Nursing Home Primary Care Physician Home Care 14

15 Care Plan (cont.) The ultimate purpose of the care plan is to guide all who are involved in the care of the member to provide appropriate treatment to ensure optimal outcome in their healthcare setting. Any caregiver unfamiliar with the member should be able to find all the information needed to care for them in their Care Plan. MMCP Care Plans are available on the Blue Cross of Idaho provider portal. 15

16 Elements of the Care Plan Health status Diagnosis Functional limitations Supports (natural and paid caregivers) Educational and vocational opportunities Goals Target Dates Participant requested services Participant preferences 16

17 Why Care Coordination? Patient Education Medication Monitoring & Adherence Care Setting Transition Physicians are better informed and patients are more engaged and results in better outcomes of care Gaps in care are filled, patient volume increases and the cost of delivering care can be more accurately quantified Increased preventative care leads to higher quality and more efficient coordinated care The nation benefits from reduced healthcare costs, better disease management and a generally healthier population 17

18 Agency Requests Home Community Based Services (HCBS) Agencies receive a copy of the UAI when they are chosen to provide services. If a request for the UAI, Negotiated Service Agreement (NSA)/Care Plan is made, please direct to Blue Cross of to request a copy of the care plan. Agencies must notify Blue Cross of Idaho when enrollee changes agencies, is admitted or discharged, moves, or has significant changes in care etc. Notification of Change Form Used when an member changes agencies. Blue Cross of Idaho must receive form on or before the 25th of the current month for changes to be effective by the 1st. The form is available on the Blue Cross of Idaho Web Portal under Home and Community Based Services Provider Administrative Policy HCBS303. Significant Change Form Used when an agency would like to request a change in authorized time/units due to change in member s condition. Available on bcidaho.com found under Home and Community Based Services Provider Administrative Policy HCBS302. Forms can be ed to 18

19 Long Term Care (Institutionalized) Enhanced LTC (Long Term Care/Institutionalized): Member lives in an Extended Care Nursing Facility Considered Custodial Level of Care Blue Cross of Idaho responsible for payment of claims When billing for LTC on our Direct Claim Entry tool: Place of Service = 99 CPT/HCPCS = T5999 Additional Claim Information Field = Enter admit date of 07/01/2014 or later along with rev code (rev 0100). 19

20 Expanded Mental Health Available to all members based on Medical Necessity and requires prior authorization. Includes: Community Based Rehabilitation Services (CBRS), Targeted Case Management (TCM), Treatment Plan Development, Psychotherapy (services may require prior authorization based on provider credentials; please contact Blue Cross of Idaho Medical Quality Management for additional information). Provider Administrative Policy HCBS300 on the Blue Cross of Idaho web portal provides further information on Prior Authorization for Expanded Mental Health Services. Peer Support services covered as of

21 Community Based Rehab Services (CBRS) Authorization Requirements Authorization Requirements Requester Information Enrollee Information CPT Code(s) Date span requested, units requested Reason for request Attach Optum authorization Attach care plan Fax to or to 21

22 Targeted Case Management (TCM) Authorization Requirements Authorization Requirements Requester Information Enrollee Information CPT Code(s) (Typically G9002 and G9007) You must bill a Face-to-Face Targeted Service Coordination (G9002) visit with an SC modifier. This modifier represents the targeted service coordinator s acknowledgement that the visit with the member occurred face-to-face. Date span requested, units requested Reason for request (i.e., Individual Support Plan (ISP) Fax to or to 22

23 Provider Responsibilities True Blue Special Needs Plan (MMCP) eligibility can be verified on the Blue Cross of Idaho Web Portal by conducting a Member Search within Eligibility & Claims. Required Mandatory Annual Training On Web Portal Cultural Competency, Fraud Waste and Abuse, Discrimination and Model of Care All providers must document care for their patients the same way documentation has been done for the State of Idaho Health and Welfare. 23

24 Member Enrollment is Easy Customer Service Staff at (888) Apply online at Ask Blue of Idaho or Medicaid for an application to be mailed Outreach Staff Phone or in-person Monique Johns, or

25 Contacts Member Line Dual Special Needs Plan Waiver Providers Support Line Care Coordinator Line All Requests FAX : Provider Enrollment All Medicare Advantage medical provider types (i.e., hospitals, physicians, behavioral health, facilities, clinics, etc.) Statewide Lauri Rowell ext Provider Enrollment Medicare Medicaid Coordinated Plan (MMCP): HCBS, Expanded Mental Health, ICF/Long Term Care, Certified Family Homes Statewide. Sheila Habblett ext

26 Mandatory Training Contacts Angie McCormick, CPC, CPC-P, CRC ext Contacts for Training ext Kathy Brock, CPC-P ext ext Web Site Training Leah Hulse CPC ext Counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce and Shoshone Jamie Hunihan ext Counties: Adams, Boise, Canyon, Gem, Owyhee, Payette, Valley and Washington Heidi Lowman ext Cities: Boise and Meridian Jenn Lucy CPC ext Counties: Bannock, Bear Lake, Bingham, Blaine, Bonneville, Butte, Camas, Caribou, Cassia, Clark, Custer, Franklin, Freemont, Gooding, Jefferson, Jerome, Lemhi, Lincoln, Madison, Minidoka, Oneida, Power, and Teton 26 Kylee Williams ext Cities: Eagle, Garden City, Kuna, and Star

27 Questions? 27

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