Special Needs BasicCare

Transcription

1 Minnesota Disability Health Options (MnDHO) Special Needs BasicCare (SNBC) Special Needs Purchasing Deb Maruska Program Coordinator Susan Kennedy Project Coordinator

2 Managed Care Programs for People with Disabilities People with disabilities in MN are excluded from mandatory managed care programs. Two voluntary programs exist: MnDHO: 7 county metro, people with disabilities People with DD limited to 120 enrollees in three counties under pilot. Enrollment is voluntary. Includes Medicare, Medicaid, all Medicare and Medicaid drugs, extensive case management, home and community based services and some nursing home care. Operating since No longer needs CMS waivers. DHS contracts with one SNP for services. Legislation prohibits expansion until after 7/2009. SNBC: Started 1/2008. Statewide, open to all Medicaid eligible people with disabilities Voluntary enrollment. Integrates Medicare and Medicaid primary, acute and drugs. Long term care services covered under FFS, except for some S/NF care. Medicaid co-pays covered by plan. Includes most Medicaid mental health services but not county case management.

3 Disability Managed Care Programs Enrollment Medicare Services Medicaid Basic Care Services Medicaid Long Term Care Services MnDHO (1000 enrollees) Voluntary, people with physical disabilities in 7 county metro and with DD in 3 counties with limit of 120 DD All Medicare services including Part D drugs through Medicare Advantage SNP Most Medicaid services provided through same SNP plan including remaining drugs and PCA services Medicaid CADI/TBI and DD waiver services though same SNP plan plus 180 days of Medicaid nursing home care (except for DD pilot) Special NeedsBasicCare Open to all Medicaid dually eligible and non dually eligible with disabilities potentially statewide. Starts January All Medicare services including Part D drugs through Medicare Advantage SNP Most Medicaid services provided through same SNP plan including remaining drugs except PCA and PDN which remain Fee for Service Medicaid HCBS waivers and long term care services remain Fee for Service except for the first 100 days of nursing home care

4 What Is SNBC? Special Needs Basic Care (SNBC) is a new managed care option designed especially for people with disabilities ages who are on Medical Assistance (Medicaid). Enrollment in SNBC is totally voluntary, and enrollees can decide to drop out and return to what they had before if they don t like it. SNBC does NOT include long term care services such as PCA, ICF-DD, county case management and home and community based waiver services, Those long term care services remain available under fee for service Medical Assistance to anyone who enrolls.

5 Purpose of SNBC To provide additional health care delivery options for people with disabilities by integrating Medicare and Medicaid primary and acute care services To simplify access to health care services by including all prescription drugs under one health plan To improve access to primary and preventive care for people with disabilities To improve care for enrollees with chronic conditions

6 Special Needs BasicCare (SNBC) Voluntary Managed Care Adults with Disabilities Age BASIC CARE COVERED SERVICES * Adult Mental Health Rehab Services: Crisis Services, Assertive Community Treatment (ACT), Adult Rehabilitative Services (ARMHS), Intensive Residential Treatment Services (IRTS) Advanced Practice Nurse Services Cancer Clinical Trials Care Management Services - (Acute Medical) Chemical Dependency Treatment Services Child and Teen Checkups Children s Residential Mental Health Treatment Chiropractic Services Clinic Services Dental Services Disease Management Family Planning Services Home Care Services - Specified: Home Health Aid (HHA), Skilled Nurse Visit (SNV), Home Care Therapies (PT, OT, RT, ST) Hospice Services Inpatient Hospital Services Interpreter Services Laboratory, Diagnostic and Radiological Services Medical Emergency, Post-Stabilization Care, and Urgent Care Services * This is not an all inclusive list of services covered under each category of services. Medical Supplies and Equipment Medical Transportation Services Mental Health Services including: diagnostic assessment and testing, crisis assessment and intervention, day treatment/partial hospitalization, individual and family group therapy, inpatient and outpatient treatment, neuropsycnologicai assessment and rehab, medication management Nursing Home services (100 days for people admitted from the community) OBRA Level 1 (NF) Obstetrics and Gynecological Services Outpatient Hospital Services Physician Services Podiatric Services Prescription and Over-the-Counter Drugs Not Otherwise Covered by Part B or D Prosthetic and Orthotic Devices Public Health Services Reconstructive Surgery Regional Treatment Centers (under certain circumstances) Rehabilitation and Therapeutic Services (PT, OT, RT.ST) Transplants Tuberculosis-Related Services Vaccines and Immunizations Vision Care Services

7 Special Needs BasicCare (SNBC) Adults with Disabilities Age SERVICES CONTINUED UNDER FEE-FOR-SERVICE BASIC CARE SERVICES Abortion Services, as specified by State and Federal law Child Welfare Targeted Case Management Circumcision for Newborns, as specified by State law Individual Education Plan (IEP) and Individual Family Service Plan (IFSP) Services ICF-DD Services Mental Health Targeted Case Management Long Term Nursing Home services (post 100 days) OBRA Level 2 assessments Personal Care Assistance Services (PCA) Private Duty Nursing (PDN) Vulnerable Adult - Developmental Disability (VADD) Targeted Case Management HOME AND COMMUNITY BASED SERVICES WAIVER SERVICES Community Alternative for Disabled Individuals (CADI) Community Alternative Care (CAC) Traumatic Brain injury (TBI-NF, TBI-NB) Developmental Disabilities (DD) Waiver Case Management Long Term Care Coordination (LTCC) OBRA assessments, Level 1 and 2 (waivers) Relocation Service Coordination (RSC) SERVICES COVERED ELSEWHERE Group Residential Housing (GRH) Medicare SSI SSDI IV-E Section 8 Housing Food Stamps

8 Who is Eligible to Enroll? People can enroll if they: Are 18 through 64 years of age. Are Medical Assistance eligible, with or without Medicare. Are certified disabled by SSA or SMRT or determined disabled by the county for Developmental Disability waiver services. Reside in one of the counties where SNBC is available.

9 Who is Eligible to Enroll? People can also enroll if they have: Medical Assistance Employed Persons with Disabilities. No Medicare coverage. An institutional or medical spenddown. Elected hospice coverage. Waiver programs, including CADI, CAC, TBI and DD. Members continue to receive those services FFS. PCA or PDN under Medical Assistance state plan. PCA or PDN under Consumer Support Grant.

10 Medical Spenddowns People with Medical Spenddowns will be allowed to enroll PCA/Waiver providers will collect the spenddown if they are listed as the designated provider in MMIS Cost of waivered or PCA services must exceed the spenddown amount If the enrollee has a designated provider listed in MMIS and is not meeting the spenddown. The enrollee will be disenrolled from the SNBC health plan and returned to fee-for-service

11 Medical Spenddown No Designated Provider If no designated provider is listed in MMIS, the enrollee will be billed monthly by DHS Special Recovery Unit Enrollee will be responsible for paying DHS directly each month Spenddowns are to be paid in advance Enrollees will be disenrolled from the SNBC plan if the medical spenddown is not paid in full for 3 consecutive months

12 Institutional Spenddowns Institutional spenddowns are collected by the NF provider just like all other Medicaid recipients. When the health plan has the NF liability for an SNBC enrollee, the plan pays the facility the full charges for 100 days. DHS will deduct the amount of the AIM spenddown from the provider on the remittance advice DHS pays to the provider Once the 100 day liability ends, the claims are submitted to DHS fee-for-service and the amount is reduced on the submitted claims NF provider will be listed as the designated provider in MMIS

13 What happens at age 65? Enrollee may remain in the SNBC plan when they turn 65, unless; They lose MA eligibility for a period of time and a new enrollment needs to be sent the CMS to restart the Medicare coverage. They choose to become a participant in the Elder Waiver (EW) program and receive Home and Community Based Services through EW. Things to consider: SIS-EW budget allows the recipient to retain more of their income. EW may not have all the services provided through CAC, CADI, DD or TBI waivers. The SNBC service area is not the same as the MSC+ or MSHO service area. The same health plan may not be available.

14 Enrollee Rights Enrollee of SNBC have access to the same rights to appeal as they do under fee for service. For Medicare covered services, enrollee may file an appeal with the health plan. For Medicaid covered services, enrollee may appeal directly to DHS for a State Fair Hearing.

15 Ombudsman Contacts Assistance is available: DHS Ombudsman for Managed Care Ombudsman for Mental Health and Developmental Disabilities

16 Disability and Senior Linkage Line The Disability Linkage Line (DLL) and Senior Linkage Line (SLL) are available to assist people with Medicare Part D choices They have received special training on the new SNBC option They are also available to assist people with disabilities to make an informed choice about SNBC options DLL SLL

17 2008 SNBC Health Plans Public Enrollment Blue Plus » CareBlue Special Needs Basic Care First Plan » First Plan Blue Basic Medica » AccessAbility Solution Metropolitan Health Plan » Cornerstone Solutions Prime West » PrimeWest Special Needs BasicCare South Country Health » Ability Care UCare » UCare Connect

18 SNBC Plan Provider Contacts Blue Plus or First Plan Blue Medica Metropolitan Health Plan PrimeWest Health South Country Health Alliance UCare

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20 Thank you!! Together, we will make health care work for people.