Commonwealth Coordinated Care Plus

Transcription

1 Commonwealth Coordinated Care Plus CCC Plus Waiver & CCC Plus Managed Care Presented by The Arc of Virginia 2147 Staples Mill Road Richmond, VA T Lucy Cantrell lcantrell@thearcofva.org

2 AGENDA Agenda: Introduction to The Arc of Virginia Virginia Medicaid Commonwealth Coordinated Care Plus Waiver - Eligibility Determination Process - Services and Supports Commonwealth Coordinated Care Plus Health Plan/Managed Care Advocacy! 2

3 About The Arc of Virginia The Arc of Virginia is a state chapter of The Arc of the United States, the nation s oldest and largest organization of and for people with intellectual and developmental disabilities (I/DD) and their families. The Arc s mission is to promote and protect the human rights of people with or at risk of developmental disabilities and actively support their full inclusion and participation in the community throughout their lifetime. The Arc of VA is a private, non-profit organization. 3

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5 About The Arc of Virginia What We Do: Public Policy Advocacy Individual and Family Support New Path for families in Early Intervention (0-3) Grow the Movement Annual State Convention Chapter Support 5

6 Virginia Medicaid Introduction Medicaid Program Oversight State Department of Medical Assistance Services (DMAS) Federal Centers for Medicare & Medicaid (CMS) 6

7 Virginia Medicaid General Assembly determines State funding $ 8 Billion in Fiscal Year 2016 (includes Federal and State funding) 50% from state funds 50% from federal funds 7

8 Medicaid Mandated Services All States EPSDT Family Planning Health Clinics Home Health Service Hospital Services Lab and X-Ray Services Medicare Premiums Nurse-Midwife Services Nurse Practitioner Nursing Facilities Physician Services Transportation 8

9 VA Medicaid Optional Services Selected by Virginia Case Management Home and Community Based Waivers Home Health Hospice ICF-DD Mental Health Services Optometry PT, OT, Speech Therapy Podiatry Prescribed Drugs Prosthetics Psychology 9

10 Home and Community Based Waivers States apply for Medicaid Waivers to the federal Medicaid agency known as the Centers for Medicare and Medicaid Services (CMS). This enables states to waive the requirements that individuals must reside in an institution in order to receive Medicaid funding for services. With a waiver, people who meet qualifications may have their services in their home rather than an institution. 10

11 Medicaid Benefits Medicaid card Once enrolled in a Medicaid Waiver All Mandatory and Optional Services (waivers) services you are eligible for Most people are enrolled in a Medicaid health care plan which has a card also. Keep both cards with you. 11

12 Early & Periodic Screening Diagnosis & Treatment EPSDT Medicaid benefits for children under the age of 21 Must be eligible for Medicaid Monitor to prevent health and disability conditions from occurring or worsening Treatment to correct or ameliorate conditions, including maintenance services EPSDT Fact Sheet: h-epsdt_fs.pdf 12

13 HIPP Health Insurance Premium Payment (HIPP) Health Insurance Premium Payment (HIPP) for Kids May pay a portion or total health insurance premium Application separate from Medicaid eligibility and filed with Dept. of Medical Assistance Services Call

14 Medicaid Works People with disabilities who work Available to people enrolled in Waivers Enroll before income goes above $804/month Complete an agreement, then work Income (gross earnings) up to $75,000 a year Resources up to $35,

15 Patient Pay $ People may have to pay for some Waiver services if they have income over $1,212 per month Some exceptions for persons who are working 15

16 Medicaid Appeal Rights Individuals have the right to challenge decisions and actions regarding Medicaid. For example denial of the waiver may be appealed to the VA Dept. of Medical Assistance Services (Medicaid). Fair Hearing Appeal must be requested within 30 days of the decision or action that you disagree with Decision should be issued by the Hearing Officer within 90 days More information about Medicaid Appeals 16

17 Home & Community Based Care Waivers Waivers give States the flexibility to develop and implement alternatives to institutionalization. 17

18 Home & Community Based Medicaid Waivers 18

19 CCC Plus Commonwealth Coordinated Care(CCC) Plus Two CCC Plus Programs: CCC Plus Waiver Effective CCC Plus Health Plan Effective

20 CCC Plus Waiver Commonwealth Coordinated Care(CCC) Plus Waiver Combined the EDCD and Tech Waiver into the CCC Plus Waiver 20

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22 Long-Term Care Medicaid Eligibility Process for Waivers Screening First Financial Eligibility Second Screening for all Waivers must be provided without any charge to the individual 22

23 Criteria for CCC Plus Waiver Functional Needs Category Combination of: Activities of daily living Behavior and orientation Mobility Joint motion Medication administration Nursing or Medical Needs Category Risk of Placement in a Nursing Facility within 30 days 23

24 Screening for CCC Plus Waiver Preadmission Screening Teams of the local Dept. of Health and/or Dept. of Social Services OR Hospitals To request a screening contact local Health Dept. or Dept. of Social Services Screening tool-uai (Uniform Assessment Instrument) Children s Screening Criteria No waiting list if found eligible Can receive services through the CCC Plus Waiver while on waiting list for DD Waiver. 24

25 Long-Term Care Medicaid Waivers Must Need Long-Term Care Assessment / screening Financial Thresholds Monthly income limit $2,250 for adults Resource limit $2,000 adults Parent income & resources do NOT count regardless of child s age Disability determination at age 18 You do not have to have Medicaid before you receive a Waiver. 25

26 Special Needs Trusts & ABLE Accounts Maintain assets for future needs Protects from disqualifying for public benefits For attorneys skilled in benefits planning: 26

27 CCC Plus Waiver Services Adult Day Health Care Personal Assistance Services Private Duty Nursing Respite care Services Facilitation Assistive Technology (AT) Environmental Modifications (EM) Personal Emergency Response System Transition Services 27

28 CCC Plus Waiver Services AT and EM Limited to $5000 per year for each service Private Duty Nursing Must meet current Tech waiver criteria Respite Limited to 480 hours/ fiscal year Increase from 360 hours for Tech waiver 28

29 CCC Plus Waiver Services Adult Day Health Care Group setting Social and recreational activities Typically used by people who are elderly and cannot be left alone 29

30 CCC Plus Waiver Services Assistive Technology Process: Prescription for AT evaluation Evaluation by a qualified Medicaid professional Quote by a Medicaid AT provider Delivery after authorization Limited to $5,000 per calendar year 30

31 CCC Plus Waiver Services Environmental Modifications Modifications to primary home Examples - Ramps and other access features Examples - Fences and other security measures Modifications to primary vehicle Examples - Lifts, ramps, hand controls Limited to $5,000 per calendar year 31

32 CCC Plus Waiver Services Nursing Private Duty Nursing Continuous care up to 16 hours/day Only if not covered by private health insurance Must meet specific criteria (previous Tech Waiver criteria) Home Health Nursing provided for periodic support and maintenance 32

33 CCC Plus Waiver Services Personal and Attendant Care Assistance with activities or daily living (ADLs) and Instrumental ADLs Can be provided in any environment Supervision for up to 8 hours/day when the primary caregiver(s) are working or going to school for all ages Consumer Directed or Agency service 33

34 CCC Plus Waiver Services Personal Emergency Response System Can include a medication management system Individual must: Not be able to use a phone in an emergency Be 14 years or older Left alone for a portion of the day Have the cognitive ability to use the device 34

35 CCC Plus Waiver Services Respite Must have a primary caregiver Caregiver does not have to live with the individual receiving services Can be provided in any environment 480 hours per year July 1-June 30 Consumer Directed or Agency service 35

36 CCC Plus Health Plan=Managed Care Commonwealth Coordinated Care(CCC) Plus Health Plan = Managed Care 36

37 Virginia Legislative Mandates General Assembly directed DMAS to transition individuals from the Fee-For-Service delivery model into the Managed Care Model to achieve high quality care and budget predictability

38 Managed Care Basics DMAS Contracts with MCO MCO MCOs contract with providers Providers Care for Enrollees Pays MCO permember-per-month Pay claims submitted by providers Bill MCOs for enrollee care 38

39 CCC Plus Populations 65 and older Adults and children living with disabilities Individuals living in Nursing Facilities (NFs) Individuals in former Tech Assisted Waiver Individuals in former EDCD Waiver Individuals in the 3 DD waivers for their acute and primary services only CCC and Medallion 3 ABD populations 39

40 Commonwealth Coordinated Care Plus Health Plan Includes many people with disabilities, but not all. If you are enrolled in the CCC Plus Health Plan managed care program, your CCC Plus Waiver services will also be administered by your CCC Plus Health Plan managed care company.

41 CCC Plus Excluded Populations Limited Coverage Groups Governor s Access Plan (GAP) Family Planning Qualified Medicare Beneficiaries only Special Low-Income Medicare Beneficiaries Qualified Disabled Working Individuals Other Programs Members of Medicaid Medallion and FAMIS managed care PACE (Program of All Inclusive Care for the Elderly) Money Follows the Person (MFP) Alzheimer s Assisted Living Waiver (AAL) Health Insurance Premium Payment (HIPP) 41

42 CCC Plus Excluded Populations Specialized Settings Intermediate Care Facilities for Individuals with Intellectual Disability Veterans Nursing Facilities VA Home Psychiatric Residential Treatment (Level C) State facilities: Piedmont, Catawba and Hancock CCC Plus Excluded Local Government- Owned Nursing Facilities Bedford County Nursing Home Birmingham Green Dogwood Village of Orange County Health and Rehabilitation Lake Taylor Transitional Care Hospital Lucy Corr Nursing Home Special Conditions Hospice and End Stage Renal Disease (CCC Plus enrolled individuals who elect hospice or have ESRD will remain CCC Plus enrolled) 42

43 Developmental Disabilities Waiver Users Commonwealth Coordinated Care Plus Health Plan Adults age 21 and over receiving supports through one of the DD Waivers Building Independence Waiver, Community Living Waiver or the Family & Individual Supports Waiver your Waiver services will not be impacted by any of the CCC Plus changes. However, your Medicaid medical services may be administered by one of the CCC Plus managed care organizations/health care plans. 43

44 6 Health Plans Contracted Statewide Aetna Better Health of Virginia Anthem HealthKeepers Plus Magellan Complete Care of Virginia Optima Health United Healthcare Virginia Premier Health Plan To learn details about the Health Plans: 44

45 CCC PLUS TTY TTY TTY or TTY TTY TTY Added benefits: Adult dental 2 exams and cleanings and 1 set of x-rays each year, plus fillings, extractions, root canal and dentures (up to $525 each year) Adult hearing Exam and 1 hearing aid each year (up to $500 each year) Adult vision Eye exam and $100 for frames, glasses or contacts each year Phone services Free cell phone with 350 minutes each month, data and free unlimited texting Wellness programs Wellness rewards card Regional wellness center Other benefits No Place Like Home grants for home modifications and rental assistance Memory alarms and devices Community health worker to help with housing, food, employment, community resources and more Diabetic shoes or inserts Added benefits: Adult dental 2 exams and cleanings and 1 set of x-rays each year Adult hearing 1 exam and up to $1,000 for hearing aids and unlimited visits for fitting 60 hearing aid batteries Adult vision $100 for glasses (lenses and frames) each year Phone services Smartphone with free minutes, data, texts and calls Mobile app to use on the go Wellness programs Online search tool to find food, jobs and more Online peer support services Other benefits More than 25,000 providers statewide to choose from 12 rides to community events, grocery stores, hair salons and more Healthy Rewards Gift Card program $50 for assistive devices and $50 for walker and wheelchair accessories HEPA-grade air purifier Added benefits: Adult dental 2 exams and cleanings and 1 set of x-rays each year (up to $1,500 each year) Adult vision $150 for glasses or contact lenses every two years Phone services Free smartphones for texts and appointment reminders Wellness programs Rewards for healthy behaviors Help to quit smoking Other benefits Fresh meals delivered to your home after discharge Environmental and home modifications Supportive employment services Online, interactive cognitive behavioral therapy support Community Connections online directory of community services and organizations Enhanced short-term services for all members, when needed Personal care attendant Meals delivered to your Respite care home after discharge, 2 meals each day for 7 days Caregiver training and support X For a list of doctors and hospitals that work with each plan, go to the plan s website or call their toll-free number listed above. Added benefits: Added benefits: Added benefits: Adult dental 1 exam, cleaning and set of x-rays each year Adult hearing Annual hearing exam 1 hearing aid for each ear every 36 months Adult vision Annual exam and refraction Discounts on eye glasses Phone services Free cell phones with 350 minutes and unlimited texting Wellness programs Help to quit smoking Weight management Wellness rewards Other benefits Individualized, fullyintegrated program with a state-wide network of providers Assistive devices Extended respite for caregivers Diabetic foot care Memory alarms and devices Pest control Meals delivered to your home after discharge from inpatient hospital or nursing facility, 2 meals each day for 7 days Adult dental 2 exams and cleanings and 1 set of x-rays each year Adult vision Eye exam each year and frames and lenses every 2 years if needed Phone services Free smartphone with 350 minutes each month, unlimited texting, and preprogrammed contacts for benefit and NurseLine support Wellness programs Alere Quit For Life program and resources to quit smoking or tobacco use Weight Watchers: 10 meeting vouchers each year, resources for healthy eating and weight loss Other benefits Baby Blocks prenatal care rewards for attending prenatal and baby s appointments Health4Me free mobile app for health tips, reminders and care team secure messaging Meals delivered to your home after discharge from inpatient hospital or nursing facility, 2 meals each day for 7 days Adult dental Exams, cleanings and x-rays each year Adult vision Eye exams plus up to $100 for lenses or frames Phone services Wellpass program with free smartphone, unlimited texting, and minute and data packages Wellness programs Exercise at YMCA, YWCA and Curves Smoking cessation services and resources Healthy Heartbeats prenatal and postpartum wellness program Other benefits Chronic disease management including self-management education classes Gift card rewards for wellness and preventive activities Online tools for accessing health plan services Meals delivered to your home after discharge from hospital or nursing facility for up to 14 days X For a list of basic benefits that all plans offer, see the brochure in this packet.

46 Enrollment Letters Enrollee Choice of Health Plan Initial Assignment Letter 1. Enrollees will receive an initial assignment into a health plan along with a comparison chart of all of the health plans available in their region. 2. Enrollees can change their health plan by contacting the CCC Plus Helpline by the call by date identified in their Initial Assignment Letter or by using the website. 3. Enrollees will be informed of the potential option of PACE. Confirmation Letter 1. A Confirmation Letter will be mailed to the enrollee confirming their Health Plan assignment. 2. Enrollees have 90 days from their effective date to change their final health plan assignment by contacting the CCC Plus Helpline. 3. In 2018, an annual open enrollment period will occur October through December, effective for January 1. 46

47 CCC Plus Helpline Call the CCC Plus Helpline or use the website to choose your health plan. Phone Number: Website: cccplusva.com To get health care from a provider they must be in network with your health plan. The Helpline can tell you which health plans have your current providers in network. 47

48 CCC Plus Enrollee Benefits Person centered, individualized support plan Same standard Medicaid services provided Choice of health plans Care coordinator for each individual Team of health care professionals working together Assistance connecting to housing, food and community resources Possible additional benefits offered by health plans 48

49 Coordination with Targeted Case Managers Targeted Case Management (TCM) Services assist individuals in gaining access to specific services TCM services include: early intervention, developmental disabilities, mental health, treatment foster care, addiction and recovery treatment services (ARTS), and high risk prenatal and infant case management services CCC Plus Care Coordinators will incorporate but not duplicate services provided by the TCM CCC Plus Care Coordinator Targeted Case Manager 49

50 Enrollee Protections During the continuity of care period of 90 days, MCOs have to pay existing providers MCO must go out of network to provide a service that they don t have in network Individuals in Nursing Facility (NF) at the time of enrollment will not be moved even if the NF does not choose to participate. NF will be paid as an out of network provider. 50

51 If you have Medicaid and Medicare Medicaid Medicare CCC Plus Health Plan Dual Special Needs Plan Covers Part A, B and prescription drug coverage under D Or Traditional Medicare or any Medicare Advantage plan 51

52 Why Should I Enroll in a D-SNP? Enrolling in the same health plan for your Medicare and Medicaid services will greatly simplify and enhance the coordination of benefits and reduce burden on both the member and provider. WITH COMPANION D-SNP INDIVIDUALS MAY HAVE: One system to coordinate care and enhanced coordination of services One health plan that will facilitate communication between providers Coordinated Medicaid and Medicare health care decisions made from the patient-centered perspective 52

53 Enrolling in a Dual Special Needs Plan Call MEDICARE ( )to choose a Dual Special Needs Plan or go to: For help call: Virginia Insurance Counseling and Assistance Program (VICAP) at

54 Changing Health Plans 90 days from effective date in CCC Plus Open enrollment in Oct/Nov/Dec Good Cause at any time (e.g. for continuity of care or due to poor quality care) Exemptions PACE 54

55 CCC Plus Enrollment CCC Plus Helpline: Maximus Enrollees change plans by calling the CCC Plus Helpline or via the website. Neutral third party Assist in determining which providers are contracted with specific health plans. Answer questions about additional benefits offered by participating health plans. Can field complaints about health plans, access to care or services and reports to DMAS Toll-free number: TTY: Hours of operation: Monday Friday, 8:30 a.m. 6:00 p.m. 55

56 Carved Out Services *Carved-out services are paid by DMAS or a DMAS Contractor for managed care enrolled individuals Services for CCC Plus enrolled individuals that are paid for through fee-for-service. Dental Services (Smiles for Children) School Health Services Preadmission Screening 56

57 Carved Out Services Community Mental Health Rehabilitation Services will be carved out until Jan 1, These services will be covered by Magellan, the behavioral health services contractor for DMAS. Services include: Mental Health Case Management Therapeutic Day Treatment (TDT) for Children Day Treatment/ Partial Hospitalization for Adults Crisis Intervention and Stabilization Intensive Community Treatment Mental Health Skill-building Services (MHSS) Intensive In-Home Psychosocial Rehab Level A and B Group Home Treatment Foster Care Case Management Behavioral Therapy Mental Health Peer Supports 57

58 If you have problems: Step 1 Health Plan Step 2 Medicaid Contact Health Plan Care Coordinator Submit a complaint or grievance Appeal any adverse action or medical decision After Health Plans appeal process can appeal to Medicaid Client Appeals through the State Fair Hearing Process 58

59 Problem Resolution Resource CCC Plus Advocates CCC Plus Advocates may assist with problem resolution at any time. During or when you are in Step 1 or Step 2 on the previous slide. To contact the CCC Plus Advocates click here or here Office of the State Long-Term Care Ombudsman Department for Aging & Rehabilitative Services TTY Toll-free

60 Role of the CCC Plus Advocate Help you understand your rights and receive person-centered assistance and problem solving. Provide independent assistance to Medicaid managed care members who reside in health care facilities, assisted living programs and those that receive home and community based care.

61 What CCC Plus Advocates Do: Help you understand your rights, responsibilities and benefits; Help resolve problems with care and services under the CCC Plus health plans or services; Empower you to resolve problems with your health care, behavioral health care, prescription drugs, and long term services and supports; Assist you with access to covered benefits, urgent needs for services and quality issues; Serve as a resource for you, your family members and advocates; Track problems reported and provide recommendations for quality improvement.

62 Examples of the Types of Issues that CCC Plus Advocates May Address Enrollment and Disenrollment Continuity of Care Access and Information Timeliness of Plan Responses to Member Questions and Needs Questions about Bills, Care Coordination, and Plan Benefits Appeals and Grievances

63 CCC Plus Advocate Program Contact Information Office of the State Long-Term Care Ombudsman Department for Aging & Rehabilitative Services TTY Toll-free

64 CCC Plus Website 64

65 More Information For More Information... Additional CCC Plus information is available at: Send CCC Plus questions, comments, and suggestions to: 65

66 Stay Current State Regulations being revised Provider Manuals being revised Green Waiver Guide being revised Join The Arc of VA, Follow us on Facebook 66

67 CCC Plus Waiver CCC Plus Medicaid Manual being developed Follow current Medicaid Manuals for EDCD and Tech until the new manual is posted 67

68 Be Informed! Sign up for The Arc of VA Updates: Visit our website: Like us on Facebook: Follow us on Twitter: 68

69 Communicate to your State and Federal Legislators! Every Voice and Face Matters! Share your story Include a picture Find your legislators 69

70 Advocate for Community Services! Stay informed about issues, policy, legislation that affects people with disabilities Join your local Arc and The Arc of VA to learn about issues and advocate with others. Know your elected representatives in the VA General Assembly and US Congress. Tell your 3 minute elevator story Write, Call, Visit your representatives. Attend Virginia s Public Budget Hearings in January 70

71 Questions? Contact The Arc of Virginia Tel: (804) More info about Waivers on our website 71