MI Health Link Program Nursing Facility Presentation October 27 th, Molina Healthcare of Michigan

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1 Program Nursing Facility Presentation October 27 th, 2015 Molina Healthcare of Michigan

2 Headline Goes Here MI Health Link Molina Healthcare of Michigan Molina Healthcare of Michigan is one of five health care insurers approved by the State of Michigan and the Centers for Medicare and Medicaid Services (CMS) to provide services as part of the new MI Health Link program. The goal of MI Health Link is to provide seamless access to high-quality care that reduces costs for those who are eligible. Item 1 Item 2 Item 3 MI Health Link is a new health care option for Michigan adults, ages 21 and over, who are enrolled in both Medicare and Medicaid. Many also have multiple or chronic conditions and will benefit from better care coordination, person-centered planning and management of health and long-term supports and services. Services under the program include, but are not limited to: All Medicare services All Medicaid services Long-term support services, including in-home supportive services, long-term care in nursing facilities, and Mental health and substance abuse programs A copy of the ID card is included in your packet. 2

3 Headline Goes Here Molina Healthcare of Michigan MI Health Link Demonstration Updates Item Number 1 of Molina Members in Nursing Facility's Item 2 Item 3 The MI Health Link Demonstration has been extended to 5 years. Nursing Facility must continue to submit the 2565 to the state of Michigan. Therapeutic Leave Days-facility must notify Molina when a member goes out on a Therapeutic LOA. MMP allows 18 days/365 day period. 3

4 Clinical Health Care Services 4

5 Continuity of Care PCP Assignment Members have the right to choose a PCP. If the member or his/her designated representative does not choose a PCP, one will be assigned based on historical membership or claims information and/or proximity. PCP Changes Members may change their PCP at any time. Specialist as a PCP Members may also choose a specialist as a PCP. Members may continue to receive services from any current provider for a specified time period to ensure continuity of care to avoid gaps in care. This includes any noncontracted nursing facilities. Molina will review MDCH claims files on members to contract with additional providers. 5

6 Care Coordination/Model of Care Care Coordination is the foundation of the MI Health Link Program. All Molina members that are enrolled in the MI Health Link (MMP) program will be assigned a Care Coordinator. Care Coordinators: Develop a personal care plan based on the members goals by utilizing the person-centered planning process Assists member in accessing services Provide support during transition in care Coordinate with existing providers to ensure seamless utilization of services 6

7 Care Coordination/Model of Care How Care Coordinators Work With Nursing Facility's: The Care Coordinator will work to assure all of the enrollees needs are being met and services are accessible. The Care Coordinator can also assist in the discharge planning process to assure the enrollee has appropriate care and services when returning to the community following a short or long term stay. All coordination efforts follow the person-center planning process by putting the enrollee s goals, needs, and preferences at the center of all care planning. 7

8 Care Coordination Program/Model of Care Upon Enrollment Each Member Receives: Initial screening to determine risk Comprehensive Level 1 Assessment May require reassessment for health status changes or if member request reassessment. Nursing facility residents will be considered high risk Require care plan review every 30 days 8

9 Care Coordination Program Steps The Care Coordinator Will Take Before The Assessment: Level 1 Assessment should be completed within 45 days of enrollment Care Coordinator will attempt to obtain signed consent form from the member/family/guardian before the assessment takes place Care Coordinator will contact the Nursing Facility in advance to advise them of upcoming assessments 9

10 Care Coordination Program What The Care Coordinator Will Need: Most recent MDS NFLOC Member s Face Sheet Recent Nursing Notes Next Care Plan/Care Conference Date (If Known) The Care Coordinator may need to speak with the nurse, nursing assistant, social worker etc. Please be advised that the initial assessment can take up to 2 hours When Care Coordinators Come Into The Facility: Care Coordinators will be wearing a Molina Name Badge Sign in at the front desk Ask to speak with the Clinical Manager or MDS Coordinator 10 10

11 Authorizations Authorizations 11 11

12 Molina Reduces Barriers to Care Molina does not require referrals Prior Authorization is required only on selected services: SNF Rehabilitation LTAC, Custodial/LTC requires notification Requests for services on the Molina Healthcare Prior Authorization Guide are evaluated by licensed nurses and trained staff that have authority to approve services. Molina Healthcare Follows CMS Guidelines 12 12

13 Request for Authorization Steps To Obtain A Custodial/Long Term Care Authorization: Fax your request to Molina Medicare at (888) or call (888) Include members name, DOB, original date of admission, physician progress notes, authorization type, and the Molina Healthcare will then return the form with the authorization number, date range of approved days, authorization explanation (should this be expiration) date, and date to call for a new authorization or extension of an existing authorization. Missing information may result in a delay of authorization. The initial Authorization is good for 6 months, after that you may request a continued stay authorization every six months. Therapy maximum still applies

14 Request for Authorization Steps To Obtain A Skilled Care Authorization: Fax your request form to Molina Medicare at (888) or call (888) Include members name, DOB, original date of admission, physician progress notes and, authorization type. Molina Healthcare will then return the form with the authorization number, date range of approved days, authorization explanation date, and date to call for a new authorization or extension of an existing authorization. My Patient Is Being Discharged From The Hospital What Do I Do? The Hospital is required to obtain Prior Authorization for the transfer to the nursing facility Please do not accept the member unless you have a SNF authorization or a LTC authorization. Molina Healthcare will then send the authorization to the facility in which the member will be discharged to

15 Request for Authorization When Is A New Authorization Needed Skilled Care You will need to request an extension every 7 days If the member is admitted to the hospital and stays for more then 24 hours or is admitted If the member no longer meets criteria for Skilled Care If the member no longer meets criteria for continued stay in a SNF Custodial/Long Term Care Any level of care change If the member is only in observation then you will have a continued authorization 15 15

16 Service Request Form Providers should send requests for prior authorizations to the Utilization Management Department using the Molina Healthcare Service Request available on our website, at: Skilled Care Authorization Formhttp:// pdf Long Term Authorization Form - Sheet.pdf You can also visit Service Request Forms may be faxed to the Utilization Management Department to the numbers listed below, Phone: Fax: A copy of both authorization forms are in your packet 16 16

17 Appeal Request Expedited Appeal Requests/Member appeal requests Corporate Appeals & Grievances Toll free number (for members to request expedited appeals or providers to leave clinical information) Keith Winn Denaya Andrews Lisa Bupp (Director) Fax expedited appeals to Appeals & Grievance Department Member Appeals Send hard copy charts to Appeals & Grievance, PO Box 22816, Long Beach, CA Provider Appeals to get status of an appeal contact Send appeal requests to MHM 880 W. Long Lake Rd., Troy, MI

18 Quality Management Quality Management 18 18

19 Quality Management Quality is a Molina core value and ensuring members receive the right care in the right place at right time is everyone's responsibility. Molina s Quality Management (QM) department maintains key processes and continuing initiatives to ensure measurable improvements in the care and service provided to our members. Over 100 measures of quality NCQA Standards, HEDIS, CAHPS, HOS MDHHS Measures CMS Measures Critical Incident Reporting All Critical Incidents must be reported to Molina Molina QM reports cases to MDHHS Cases are followed and updates reported until resolved There are no changes in what incidents should be reported Collaboration with nursing facilities and other LTSS providers to assure members receive required preventive care such as: Vaccines Diabetes care Cancer Screenings 19 19

20 Pharmacy Pharmacy Operations 20 20

21 Pharmacy/Drug Formulary The MI Health Link Drug Formulary is the cornerstone of a progressive program of managed care pharmacotherapy. Created to help manage quality Integral to patient s comprehensive treatment program Cost-effective, rational drug therapy The MI Health Link Drug Formulary combines the benefits of Medicare and Medicaid, the Drug Formulary contains: Traditional Medicare Part D medications such as blood pressure and cholesterol medications Medicaid drugs, such as over-the-counter (OTC) items and cough and cold products Some prescriptions for medications require prior approval: Injectable medications Medications not on the formulary Exceptions approved when medically necessary and when Formulary alternatives have demonstrated ineffectiveness Full formulary information available on Molina website: Prior Authorization Fax: (866) Medicare Phone: (855) Option 1 for English, Option 4 for Pharmacy CVS Caremark is Molina s pharmacy benefits manager. For more information on pharmacy participation, send request to chaz.washington@molinahealthcare.com

22 Claims & Appeals 22 22

23 Claims & Appeals Medicaid Claims Submission Address Molina Healthcare of Michigan P.O. Box Long Beach, CA EDI Claims Submission Medicaid & Medicare Emdeon Payor ID# Emdeon Telephone (877) Note: Online submission is also available through Web Portal Services at: Claims Notes: Providers only need to file one claim Molina will process the Medicare AND Medicaid portion. Both claims will appear on one payment advice Molina payments will include QAS as applicable No billing of members, except for patient pay amounts Filling Limit 365 Days Appeals Submission Address Molina Healthcare of Michigan Attn: Provider Inquiry Research & Resolution (PIRR) Appeals 880 West Long Lake Rd, Suite 600 Troy, MI A practitioner must submit a written appeal within 90 days of the denial notification along with an explanation of payment to show claim denial

24 Dental and Vision Claims March Vision Claims Submission Address March Vision 6701 Center Drive West Suite 790 Los Angeles, CA Phone: Avesis Dental Claims Submission Address Avesis: Third Party Administrators Attn: Dental Claims PO Box 7777 Phoeniz, AZ Phone:

25 Provider Services Provider Services 25 25

26 Quality Management Provider Services Representative Melinda Dejeu Cell Number: Office Number: Ext Please Contact your Provider Services Representative if you would like to schedule a one on one In-services or to obtain Provider Portal Training. Your Re will also be available to assist with unresolved questions or concerns. Provider Manual The Provider Manual is a reference tool that contains eligibility, benefits, contact information, and policies/procedures fro services that the Molina Dual Options Plan (MI Health Link) specifically providers and administers on behalf of Molina Healthcare. Provider Manual Link:

27 Electronic Funds Transfer and WebPortal ELECTRONIC FUNDS TRANSFER Molina Healthcare has partnered with our payment vendor, Alegeus ProviderNet, for Electronic Funds Transfer and Electronic Remittance Advice. Access to the ProviderNet portal is FREE to our participating providers and we encourage you to register after receiving your first check from Molina Healthcare. If you have questions regarding the registration process, please contact Alegeus at (877) WEB PORTAL MHM participating providers may register for access to our Web Portal for selfservice member eligibility, claims status, provider searches, to submit requests for authorization and to submit claims. The Web Portal is a secure website that allows our providers to perform many self-service functions 24/7. Web Portal Link:

28 Wrapup 28 28

29 Other Services Care Coordination Assist with long term support services Transportation Responsibility of nursing facility Included in per diem Laboratory JVHL or Quest Critical to utilize par labs for full lab values for HEDIS quality measures Infusion Active Infusion is preferred provider Dental Avesis Vision March Vision *Hearing Aids are not a covered benefit 29 29

30 Collaboration with Nursing Facilities NEXT STEPS: Continue collaborative discussions Medical Director/physician services Understanding nursing facility processes, clinical services & ancillary providers Interacting on assessments & re-assessments Frequently Asked Questions (FAQs) Frequently Asked Questions and this Presentation will be posted on the Molina website: Contracting Molina will continue to contract with new facilities Contact: Diane Carr, Provider Contract Manager , extension New provider contracting packets available today from Diane Carr 30 30

31 Headline Goes Here Questions and Comments Item 1 Item 2 Item 3 31