2015 CMS National Training Program Workshop Monika Vega, MSW Harbage Consulting, LLC Representing California s Department of Health Care Services

Transcription

1 California s Coordinated Care Initiative 2015 CMS National Training Program Workshop Monika Vega, MSW Harbage Consulting, LLC Representing California s Department of Health Care Services

2 Roadmap Nationally The Coordinated Care Initiative (CCI) Cal MediConnect Medi-Cal Managed Long Term Services and Supports Program of All Inclusive Care for the Elderly (PACE) Continuity of Care Authorized Representatives Additional Resources 2

3 Nationally Many states are working on financial alignment demonstrations. California, Colorado, Illinois, Massachusetts, Michigan, Minnesota, New York, Ohio, South Carolina, Idaho, Virginia, Washington Today focus on California Demonstrations intend to: Increase access to quality supports and programs Better coordinate benefits and services for Medicare- Medicaid beneficiaries. 3

4 Separate Services Doctors Hospitals Medicare Who: 65+, under 65 with certain disabilities Prescription drugs Short-term skilled nursing facility stays Medi-Cal Who: low-income Californians Long-term services and supports Durable medical equipment Medicare cost sharing Long-term skilled nursing facility stays 4

5 Need for Coordinated Care People with multiple chronic conditions: See many doctors Have many prescriptions Need many treatments Are often people with both Medicare and Medi-Cal aka Medi-Medi or dual eligible beneficiaries. Today s system does not typically support the care coordination that this population needs. Leads to increased risk of hospital/nursing home admissions and poor health outcomes. 5

6 Problems with Current System Programs in silos Who pays for what? How do I get help? What services are available to me? Fundamental lack of coordinated care and support for both providers and beneficiaries. Many physicians do an excellent job coordinating care, but many dual eligibles do not get the help/support they need. 6

7 The Coordinated Care Initiative The Coordinated Care Initiative a new program designed to provide extra support for older Californians and Californians with disabilities, including those who are dual eligible for Medicare and Medi-Cal. Goal achieve coordination between medical care, behavioral health, and home and community-based services in order to better manage chronic conditions and reduce unnecessary hospital and nursing home admissions. 7

8 Seven CCI Counties San Mateo Santa Clara Los Angeles San Bernardino Riverside Orange San Diego 8

9 The Coordinated Care Initiative: Two Parts Cal MediConnect Managed Long-Term Services and Supports (MLTSS) Voluntary Who: many full dual eligible patients Mandatory Who: Medi-Cal only patients Full dual eligibles who opt out of Cal MediConnect Other identified groups eligible for Medi-Cal 9

10 Cal MediConnect Who: Many Dual Eligible Beneficiaries in CA Benefits Original Medicare (parts A, B & D) and Medi-Cal services One plan for health care needs Vision benefit: one routine eye exam annually and $100 for eye glasses/contacts every two years Transportation benefit: thirty 1- way trips per year in addition to the existing transportation benefit Care Coordination 10

11 Cal MediConnect Care Coordination Health Risk Assessments (HRAs) Health plans evaluate beneficiaries as they enroll. Primary, acute, LTSS, behavioral health and functional needs Plan Care Coordinators Facilitates communication between plans, providers, and patients Interdisciplinary Care Teams Team of professionals Patient, plan care coordinator, and key providers Individualized Care Plans (ICPs) Care teams will develop and implement ICPs 11

12 Plan Care Coordinator The plan care coordinator helps facilitate communication among a person s continuum of providers, including: Medical LTSS Behavioral Health Communication processes is developed jointly between the plan and providers. 12

13 Care Coordination Example: Ms. Lee Ms. Lee recently had a stroke and is back living at home. Before Cal MediConnect, Ms. Lee would have to navigate Medicare, Medi-Cal and county agencies to get needed social services likely relying on her doctor s office staff for help. Under Cal MediConnect, a plan care coordinator ensures that Ms. Lee has: Transportation to appointments Coverage for prescriptions Meals on Wheels Other support for activities of daily living 13

14 Cal MediConnect Plan Options Los Angeles * Care1st, CareMore, Health Net, LA Care and Molina Health Orange CalOptima San Diego Care 1 st, Community Health Group, Health Net and Molina Health San Mateo Health Plan of San Mateo 14 Santa Clara Anthem Blue Cross and Santa Clara Family Health Plan San Bernardino Inland Empire Health Plan and Molina Health Riverside Inland Empire Health Plan and Molina Health

15 Long-Term Services and Supports In-Home Supportive Service, IHSS: a state program to provide caregivers for homebound and limited-mobility individuals who need assistance with cooking, bathing, etc. Community-Based Adult Services, CBAS: day services for older adults, or adults with disabilities, to restore or maintain their capacity for self-care and delay moving into an institutionalized setting Multipurpose Senior Service Programs, MSSP: social and health care management for seniors who qualify to live in a nursing home but wish to remain at home Nursing Facilities, NFs: long-term care for people who cannot live independently at home care that s primarily paid for by Medi-Cal 15

16 Medi-Cal Managed Long-Term Services and Supports Who: Medi-Cal only, full dual eligibles who opt out of Cal MediConnect Mandatory The same Medi-Cal services someone currently receives Hearing aids Bathrooms aids (grab bars, shower chairs) Non-emergency medical transportation (wheelchair vans and litter vans) Incontinence supplies Medi-Cal long-term services and supports (MLTSS) are now coordinated by a managed care plan MSSP: Multipurpose Senior Services Program IHSS: In-Home Supportive Services CBAS: Community-Based Adult Services Nursing facilities 16

17 MLTSS Plan Options Los Angeles Care1st, CareMore, Health Net, LA Care, Molina Health, Kaiser Orange CalOptima San Diego Care 1 st, Community Health Group, Health Net, Molina Health, Kaiser San Mateo Health Plan of San Mateo Santa Clara Anthem Blue Cross and Santa Clara Family Health Plan San Bernardino Inland Empire Health Plan, Molina Health, Kaiser, Health Net Riverside Inland Empire Health Plan, Molina Health, Kaiser, Health Net 17

18 MLTSS Rule and Exceptions Basic Qualification Rule: Beneficiaries with Medi-Cal only and those who opt out of Cal MediConnect must enroll into a MLTSS plan for their Medi-Cal services. Exceptions: Those under 21 Residents of intermediate care facility/developmentally disabled (ICF-DD) Residents of Veterans Homes / Having Veterans insurance Individuals in PACE, Kaiser, or Aids Healthcare Foundation Individuals with other health insurance 18

19 PACE Program of All-inclusive Care for the Elderly Who: Medi-Medi and Medi-Cal beneficiaries Option available to those who are determined eligible Patients may be eligible to enroll in a PACE program If they re: Are 55 or older Live in your home or community setting safely Need a high level of care for a disability or chronic condition Live in a ZIP code served by a PACE health plan 19

20 PACE Plans Different PACE programs serve different counties. Visit: for information on PACE Programs in each CCI County. 20

21 Continuity of Care People have the right to see their physicians for up to six months for Medicare services and 12 months for Medi-Cal services their physician must reach agreeable terms. Continuity of Care Medicare services up to 6 months Medi-Cal services up to 12 months 21

22 Continuity of Care, Cont d Payment terms under continuity of care will be equivalent to the Medicare and Medi-Cal fee schedule or the plan s fee schedule whichever is higher. Beneficiaries must show an existing relationship with their physician. Primary care: one visit over past 12 months Specialists: two visits over past 12 months Note: This does not apply to providers of ancillary services like durable medical equipment (DME) or transportation. 22

23 Requesting Continuity of Care Providers or beneficiaries can request Continuity of Care Continuity of Care can be requested by phone Request must be processed within 3 days if there is a risk of harm to the patient Plans must actively try to determine continuity of care needs as part of the HRA process 23

24 Retroactive Continuity of Care Providers or patients can request continuity of care after service delivery Request must come within 30 days of first service following enrollment Allows beneficiaries to see providers while plan processes request 24

25 Resources for Beneficiaries Problems should first be voiced to the plan. Plans will have internal appeals and grievance procedures. If a beneficiary cannot resolve their complaint with the plan, there are several options: Cal MediConnect Ombudsman Program (855) Medi-Cal Managed Care Ombudsman (888) Office of the Patient Advocate (866)

26 Who to Call Cal MediConnect Plans People should contact their health plan for questions or if they experience problems. Enrollment Health Care Options: Additional Support Local HICAP:

27 Additional Resources Web: Outreach: us or complete the online request form 27

28 THANK YOU! For more information contact: Monika Vega, Senior Outreach Coordinator (662) CCI Website: