Coordinated Care Initiative Information for Advocates

Transcription

1 Coordinated Care Initiative Information for Advocates 1

2 Medicare and Medi-Cal Today What You Will Learn Your Health Care Coverage Options Cal MediConnect Medi-Cal Managed Care Plan Who Can Join Benefits Benefits Available Plans Care Coordination Keeping Your Doctors Improper (Balance) Billing Available Plans PACE Benefits Available Plans Other Resources 2

3 Medicare and Medi-Cal Today Medicare For people 65+ years & people with disabilities Medicare covers: Doctors Hospitals Prescription drugs Medi-Cal For Californians who meet income requirements Medi-Cal covers: Long-term services and supports IHSS, CBAS, MSSP, nursing facilities, non-emergency medical transit Durable medical equipment Medicare cost sharing 3

4 If beneficiaries have both Medicare and Medi-Cal, these health plans can make it simpler for them to get the services they need. Solution: New Health Plan Options Beneficiaries health plan choices include: Cal MediConnect A plan that covers both Medicare & Medi-Cal Medi-Cal managed care plan Medi-Cal plan with original Medicare separate PACE Program of All-inclusive Care for the Elderly Beneficiaries MUST choose to join one of these options (if they haven t already) to receive their Medi-Cal services. 4

5 What is Cal MediConnect Cal MediConnect is a new kind of health plan. It combines Medicare and Medi-Cal benefits into a single plan. A beneficiary-centered process of care coordination for the physical, mental, or social services they need Only one card to carry and one phone number to call Additional vision benefits (eye exams and glasses) Home- and community-based services 5

6 Beneficiaries who have both Medicare and Medi-Cal can join a CalMediConnect plan. Who Can Join This plan is available in these counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. There are no extra costs associated with joining a Cal MediConnect plan. 6

7 When to Join Beneficiaries can enroll at any time of the year. There is no specific enrollment period. New to Medi-Cal? New to a CCI county? When beneficiaries first become eligible, they will receive this booklet. It will tell them to choose a managed care health plan by a certain date. One of the options is Cal MediConnect. They can join Cal MediConnect then, or choose another option. If they do not choose, they will automatically be placed into a Medi-Cal managed care plan. They can switch their plan later, if they change their mind. 7

8 Benefits & Services in Cal MediConnect Access to doctors, hospitals, and therapy services Equipment and supplies Prescription drugs Getting care is simple. When beneficiaries have questions, they only need to call one phone number. To get services, they only need one card their Cal MediConnect card. Dental benefits Optional benefits Language services Long-Term Services and Supports (LTSS) 8

9 Working Together: Care Coordination To start, a patient receives a Health Risk Assessment. The health plan can provide a personal care coordinator. A care team works together. The care team works with the patient to create a care plan. 9

10 Care Coordination in Action Mr. Sanchez recently had a stroke and is living at home. Before Cal MediConnect, Mr. Sanchez would have to navigate Medicare, Medi-Cal, and county agencies to get the care he needs, likely relying on his doctor s office staff for help. With Cal MediConnect, Mr. Sanchez care coordinator can: Communicate with all of his doctors, pharmacists, and providers to make sure they are on the same page. Arrange for services he needs to live independently (meal delivery, in-home help, etc.). Make appointments, obtain authorizations, and check on prescriptions. 10

11 Keeping Doctors Many beneficiaries would like to keep the same health care providers. All providers must be in the Cal MediConnect plan s network. How to Help Beneficiaries Keep their Providers 1. The beneficiary needs to find out if their doctors are part of the Cal MediConnect plan. 2. If the doctors ARE part of Cal MediConnect: Make sure the doctors are a part of the same Cal MediConnect health plan the beneficiary would like to join. 3. If the doctors are NOT part of Cal MediConnect: The beneficiary may be able to keep seeing their current doctors for a limited time after they join Cal MediConnect. This is called continuity of care. The beneficiary can ask their doctor if he or she would consider joining a Cal MediConnect health plan. The beneficiary can work with their care coordinator to choose doctors in their plan s network. Continuity of Care Even if their doctor is not in the network, the beneficiary can continue to get care from their doctor for 12 months. The beneficiary can contact their health plan for more information. 11

12 Cal MediConnect plans will provide physicians with information and resources to help support care coordination. What Changes Doctors can Expect Health Risk Assessments (HRAs) Assess primary, acute, LTSS, behavioral health, and functional needs. Interdisciplinary Care Teams (ICTs) Includes the beneficiary, their family, care coordinator, providers, and caregivers. Individualized Care Plans (ICPs) Developed by the Interdisciplinary Care Teams based on the HRAs. Care Coordinators Facilitate communication between plans, providers, and patients. Help beneficiaries get social and other support they need so providers can focus on providing care. Streamlined Billing Providers can submit claims to one plan, or delegated entity, rather than navigating both Medicare and Medi-Cal billing processes. 12

13 Cal MediConnect Does Not Change IHSS or Nursing Facilities If a beneficiary receives In-Home Supportive Services (IHSS), they can keep their IHSS provider and hours when they join a Cal MediConnect plan. In-Home Supportive Services (IHSS) With Cal MediConnect, the beneficiary retains the right to hire, fire, and manage their IHSS providers. Nursing Homes If the beneficiary is in a nursing home, they can stay as long as the nursing home meets quality and safety standards. If they would like to move into their own home or a family member s home, Cal MediConnect can help the beneficiary get the services they need to live there safely. 13

14 The Facts About Improper Billing Dual-eligible beneficiaries should never receive a bill for any of their medical services. This is called improper billing (sometimes called balance billing), and is illegal under state and federal law. The beneficiary does not have to pay for copays, coinsurance, or deductibles. The only exceptions are prescription drug copays and Medi-Cal share-of-cost. If the beneficiary receives a bill, they should contact their health plan immediately. They do not have to pay it. 14

15 Cal MediConnect Health Plans Los Angeles County Plan Name Phone # TTY Care1 st Cal MediConnect CareMore Cal MediConnect Health Net Cal MediConnect L.A. Care Cal MediConnect Have a question? Call HICAP at Molina Dual Options

16 Cal MediConnect Health Plan Orange County Plan Name Phone # TTY CalOptima OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) Have a question? Call HICAP at

17 Cal MediConnect Health Plans Riverside and San Bernardino Counties Plan Name Phone # TTY Inland Empire Health Plan (IEHP) DualChoice Molina Dual Options Have a question? Call HICAP at

18 Cal MediConnect Health Plans San Diego County Plan Name Phone # TTY Care1 st Cal MediConnect Community Health Group CommuniCare Advantage Health Net Cal MediConnect Molina Dual Options Have a question? Call HICAP at

19 Cal MediConnect Health Plan San Mateo County Plan Name Phone # TTY Health Plan of San Mateo CareAdvantage Cal MediConnect or 711 Have a question? Call HICAP at

20 Cal MediConnect Health Plans Santa Clara County Plan Name Phone # TTY Anthem Blue Cross Santa Clara Family Health Plan Have a question? Call HICAP at

21 Other Health Plan Options If a beneficiary choses not to join Cal MediConnect, they still must join a Medi- Cal managed care plan to receive their Medi-Cal services. Medi-Cal Managed Care Plan Beneficiaries may choose not to join Cal MediConnect and continue to receive fee-for-service Medicare. They will still need to join a Medi-Cal managed care plan, if they are not already in one. 23

22 Medi-Cal Health Plans Los Angeles County Plan Name Phone # TTY Anthem Blue Cross Care1 st Health Net Kaiser Permanente Have a question? Call HICAP at L.A. Care Molina Healthcare

23 Medi-Cal Health Plan Orange County Plan Name Phone # TTY CalOptima Have a question? Call HICAP at

24 Medi-Cal Health Plans Riverside and San Bernardino Counties Plan Name Phone # TTY Inland Empire Health Plan (IEHP) Molina Healthcare Health Net Kaiser Permanente Have a question? Call HICAP at

25 Medi-Cal Health Plans San Diego County Plan Name Phone # TTY Care1 st Community Health Group Health Net Kaiser Permanente Have a question? Call HICAP at Molina Healthcare

26 Medi-Cal Health Plan San Mateo County Plan Name Phone # TTY Health Plan of San Mateo Have a question? Call HICAP at

27 Medi-Cal Health Plans Santa Clara County Plan Name Phone # TTY Anthem Blue Cross Kaiser Permanente Santa Clara Family Health Plan Have a question? Call HICAP at

28 Other Health Plan Options If a beneficiary qualifies for PACE, they can join PACE instead of Cal MediConnect or a Medi-Cal managed care plan. Other Option: PACE plan (Program of All-Inclusive Care for the Elderly) PACE is a program that coordinates medical care for people 55 and older with chronic illnesses or disabilities to help them live as independently as possible in their home and community. To join a PACE health plan, the beneficiary must live in a specific zip code and meet other requirements. For more information about PACE, call PACE or visit 32

29 PACE Health Plans Los Angeles County Plan Name Phone # TTY AltaMed Senior BuenaCare Brandman Centers for Senior Care Have a question? Call HICAP at

30 PACE Health Plan Orange County Plan Name Phone # TTY CalOptima PACE Have a question? Call HICAP at

31 PACE Health Plan Riverside and San Bernardino Counties Plan Name Phone # TTY InnovAge PACE Have a question? Call HICAP at

32 PACE Health Plans San Diego County Plan Name Phone # TTY St. Paul s PACE San Diego PACE Have a question? Call HICAP at

33 PACE Health Plan Santa Clara County Plan Name Phone # TTY On Lok Lifeways Use the numbers here to contact the health plan in your county. Have a question? Call HICAP at

34 Coordinated Care Initiative In Review Health Care Coverage Options for Dual-Eligible Beneficiaries Cal MediConnect Medi-Cal managed care plans PACE 40

35 Resources & Contact Information For more information and resources, visit Free health plan counseling Health Insurance Counseling & Advocacy Program: Join or leave a health plan Health Care Options: Help solving health plan problems Cal MediConnect Ombudsman: Medi-Cal Managed Care Ombudsman:

36 Spread the Word About Yearly Flu Shots #FightFlu This year, CMS launched a campaign to raise awareness about annual flu vaccinations for dually-eligible beneficiaries. Please help spread the word. Beneficiaries have likely received this post card in the mail. Visit CalDuals.org/learn-more-resources/flu-vaccine-campaign/ for more resources and materials in other languages. 42

37 Thank You! questions to 43