Tufts Health Unify A One Care plan (Medicare-Medicaid) for people ages 21-64 March 16, 2017 3/27/2017 1
About Tufts Health Plan Founded in 1979, Tufts Health plan is a nonprofit organization nationally recognized for its commitment to innovative, high-quality health care coverage. Our plans offer an array of health management programs, which support evidence-based approaches to health and wellness. Tufts Health Public Plans, Inc. (THPP) is a licensed health maintenance organization but does business under the name Tufts Health Plan. THPP is the legal name of our division of Tufts Health Plan. Our headquarters is located in Watertown, Massachusetts. Tufts Health Public Plans was rated 4.5 out of 5 among health insurance plans in NCQA s Medicaid Health Insurance Plan Ratings in 2015-2016 and was the No. 1 Medicaid Health Plan in the U.S. for 2014-2015. We currently offer three plans in Massachusetts: - Tufts Health Together (MassHealth) - Tufts Health Direct (a focused-network plan for individuals and small groups) - Tufts Health Unify (Medicare-Medicaid Plan), a One Care plan for people ages 21-64 3/27/2017 2
Tufts Health Plan s mission and vision Our mission To improve the lives of the diverse communities we serve Our vision Every life improved through access to high-quality, affordable health care 3
About One Care Starting in 2013, MassHealth (Medicaid) and Medicare joined together with health plans in Massachusetts to offer One Care. One Care is an easier option for people with disabilities to get the full set of services provided by both MassHealth and Medicare. With One Care, a patient has one plan, one card and one person to coordinate their care, in addition to their health care providers. By bringing care together, we support patients to live healthier, more active lives in the community. For more information about One Care or provider trainings, please visit: http://www.mass.gov/eohhs/consumer/insurance/one-care/ 3/27/2017 4
Tufts Health Unify, a One Care plan Tufts Health Unify is a plan that participates in a demonstration program integrating Medicare and Medicaid benefits into the One Care program in Worcester and Suffolk counties. In April 2017, Tufts Health Unify is expanding its service area into the greater Lowell region.* Tufts Health Unify is the first Medicare-Medicaid plan in Massachusetts to expand its footprint since the launch of the duals demonstration program in October 2013. For more information about Tufts Health Unify, please visit: tuftshealthplan.com/provider/our-plans/tufts-health-unify Tufts Health Unify covers eligible Massachusetts residents, ages 21-64. Eligible enrollees may have one or more of the following health care needs: Physical and developmental disabilities Mental illness and/or substance use disorders Chronic illnesses and/or cognitive limitations *For a complete listing of expanded zip codes, see next slide. 3/27/2017 5
Tufts Health Unify expansion The following table includes the zip codes of the April 2017 service area expansion: City/town Zip codes Billerica 01821, 01822 Chelmsford 01824 Dracut 01826 Lowell 01850, 01851, 01852, 01853, 01854 North Billerica 01862 North Chelmsford 01863 Tewksbury 01876 Tyngsboro 01879 Westford 01886 3/27/2017 6
Key goals The aim of Tufts Health Unify is to provide better care at lower costs through improved care coordination for members. This is achieved through collaboration with our providers, a dedicated care team and personal care support. Recognize and address care needs holistically, keeping enrollees central in their own care plans Improve quality of care by addressing Member needs across the care continuum Promote independence in the community Improve health and functional outcomes Collaborate with care providers Footnote area 3/27/2017 7
3/27/2017 8 Tufts Health Unify Model of care
Philosophy of care management model Nothing about me without me. Our care model is member-centric and focused on the needs, values and preferences of individual members Our efforts focus on areas where we make a meaningful difference for our member Care planning is inclusive and based on the principle of shared decisions between members and their interdisciplinary team Care coordination is designed around a collaborative and inter-professional model of care management Care management strategies follow the member s personal commitment to overall health management and self-direction Gorski, David. Dr. Donald Berwick and patient-centered medicine: Letting the woo into the new health care law?. Jul 20 2010. https://sciencebasedmedicine.org/dr-donald-berwick-and-patient-centered-medicine-letting-the-woo-into-the-newhealth-care-law/ 3/27/2017 9
Key principles All members are assigned their own care manager Primary care management contributes to a personal and member-centric approach, built on trust and collaboration Member assessments and reassessments are conducted to ensure a foundation for effective and member-centric care management and ongoing attention to a member s changing needs Activities of Daily Living (ADL) and Independent Activities of Daily Living (IADL) assessments are conducted to enable access to supportive services, which have demonstrated independence and self-directed care in the community 3/27/2017 10
Care management framework An interdisciplinary care team (ICT) of medical, behavioral and social care management offers a holistic care management approach to meet the needs of members who are clinically complex and vulnerable The Primary Care Physician (PCP) is a critical component of the member s ICT, as well as other providers, such as specialists, community-based organizations and personal supports Care management, in collaboration with the PCP and other Utilization Management clinicians, focuses on cost-effective service planning that promotes wellness, reducing high-cost services whenever possible Members are stratified based on complexity, including potential for clinical exacerbation and/or unstable support and living situations 3/27/2017 11
Care plan/central enrollee record (CP/CER) Set up a Tufts Health Provider Connect* account. The member account can be set up through Tufts Health Member Connect.* Tufts Health Provider Connect is our convenient self-service tool that allows you to: View claims and enrollee-reported health information Facilitate ICT collaboration Allow members to access their own care plan Enable members to delegate records access via variable permission levels Automate data entry and medical record consistency For questions, please call Provider Services at 888.257.1985. To access Tufts Health Provider Connect go to: https://thpprovider.healthtrioconnect.com/app/index.page? To access Tufts Health Member Connect go to: https://thpmember.healthtrioconnect.com/index.cfm? 3/27/2017 12
Care management process Member signs up for Tufts Health Unify plan Care manager completes a comprehensive assessment, including LTSS needs Care manager and member create personal care plan within first 90 days Member and care manager develop the ICT listing and review care plan with ICT and obtain member s consent Care manager uploads key information into the CP/CER (Provider Connect portal) ICT ensures delivery of appropriate care ICT confers per the request of member and/or per member s level of care Care manager reassesses member and updates the ICT and care plan Continual outreach to determine member engagement and assessment of needs 3/27/2017 13
Behavioral health model of care Group Counseling Structured Outpatient Addiction Program In-home therapy Partial Hospitalization Program Primary Care Provider (PCP) Community Crisis Stabilization Services Tufts Health Plan Care Manager Emergency Services Program Interdisciplinary Care Team Member (inclusive of advocate & family) Other Member Supports Psychiatric Day Treatment Enhanced Acute Treatment Services Specialists & Other Ancillary Providers Peer Support Long-term Services and Supports (LTSS) Community Support Services Clubhouse Acute treatment Services (detox) Tufts Health Plan s model of care is designed around an interdisciplinary care team that is memberfocused. Coordination of health services, including mental health, substance use, and primary care, is necessary to achieve positive outcomes for people with complex health care needs. 3/27/2017 14
Tufts Health Unify: Member impact story (pt. 1) A female member in her 50s moved to Boston several years ago from the South and found herself homeless. In October 2016, she met with her Tufts Health Unify care manager for the first time. She reported to her care manager that her mother had died a year ago and that she had a relapse with heroin. She had been off of it for 30 years. She did, however, use cannabis, cocaine, ETOH and pills. She had also been assaulted the previous year and sustained a head injury, which she said makes her forgetful. Medically, she has COPD, PAF, hepatitis C, CHF, adrenal insufficiency and hypertension. She also has been diagnosed with anxiety, depression, bipolar disorder and ETOH dependence. Soon after her meeting, she had a PCP appointment and reported being on 20 different medications, including methadone. She was staying at a recovery home for women that managed her medications. She reported that her time ran out at the recovery home and that she needed help finding a place to live. 3/27/2017 15
Tufts Health Unify: Member impact story (pt. 2) The member s care manager worked with her to set goals so she could become healthier and more independent. A referral was placed to a community health worker through the Tufts Health Unify program to help with housing, appointments and transitioning her to the community. The member agreed to the plan of care and agreed to work with her PCP and nutritionist. Over time, the care manager assisted the member with housing, follow-up from ER visits, medical management coordination with the VNA, and Tufts Health Unify transportation logistics. As of 2017, the member is living independently in her own apartment and going to the methadone clinic daily. She has had no ER visits recently and has been working collaboratively with her care team and the help of a visiting nurse to manage medications and dietary needs. In addition, her care manager helped her find a dentist, and she is now getting dental care. She loves living independently and is looking for a part-time job. Her care manager and interdisciplinary care team discuss her progress and make adjustments with her as needed. 3/27/2017 16
Assessment drives care planning Members receive the following assessments to help determine their care plan: Tufts Health Unify comprehensive assessment Minimum Data Set-Home Care (MDS-HC), if applicable LTSS assessment for independent living, performed by an LTSS coordinator Reassessments take place annually, or more frequently with changes in health status The ICT creates a plan based on the comprehensive initial assessment, LTSS assessment and the doctor s treatment plan. Plans include the member s: Care plan with interventions and goals Support services Agreement on treatment plan 3/27/2017 17
What does inter-professionalism look like? MCO care manager Clinical view Assessment Care planning Care coordination Providers Services Inter-professional collaboration Shared strategy: assessment and care planning Collective action Common goal Interdependence Negotiated agreement Trusting relationships LTSS coordinator Social support view Assessment Care planning Social determinants Care coordination Wellness Independence Recovery The integrated model of care requires alignment between the MCO care manager and LTSS coordinator. An inter-professional collaboration framework can shift practice from individual contributions to shared goals and mutual accountability for member outcomes. 3/27/2017 18
2017 care management overview driven by complexity of care Complex Care management outreach: At least weekly ICT meetings: At least every 6-8 weeks High Care management outreach: At least every two weeks ICT meetings: At least every 6-8 weeks Medium Care management outreach: At least every 6-8 weeks ICT meetings: At least one meeting quarterly Low Care management outreach: At least quarterly ICT meetings: At least semi-annually 3/27/2017 19
Quality measurement and performance improvement programs Quality management is designed to address population health outcomes, utilization management priorities, disease management opportunities and provider and member satisfaction Performance improvement initiatives are prioritized based on internal and external benchmarks and regulatory requirements, including but not limited to: Improving access to care Affordable health service delivery Coordination of care and care planning Preventive services Health care transitions Operational work flows targeting efficiency and efficacy Quality improvement initiatives promote PCP engagement whenever feasible, including leveraging any existing programs and/or population/member-specific focus areas 3/27/2017 20
PCP collaboration and care management commitment PCP engagement is encouraged whenever possible, and includes the engagement of dedicated clinical and administrative staff, as necessary Shared strategies between the PCP and care management team will drive positive member experiences and promote their independence and compliance with medical and behavioral treatment plans Care management oversight, including effective and timely coordination of all services, will strive to ensure member stability in between office visits 3/27/2017 21
3/27/2017 22 Tufts Health Unify: Doing business with us
Doing business with us As a Tufts Health Public Plans contracted provider, you get: A comprehensive approach to care for your Tufts Health Unify patients A dedicated provider relations team to provide support and keep you informed Ability to check member eligibility, authorization status and claims status through our secure and online self-service tool, Tufts Health Provider Connect,* and by calling us at 888.257.1985. Educational materials for your patients (e.g., information about benefits and services and displays for your office) A dedicated claims team to ensure you get prompt payment for electronic and paper claims Multilingual, multicultural customer service for your patients * To access Tufts Health Provider Connect go to: https://thpprovider.healthtrioconnect.com/app/index.page? 23
What to do before patient care Verify patient eligibility Provide equal appointment availability Confirm patient is in your panel Check for thirdparty liability Request or check authorization status Request or check referral status 24
How to verify eligibility on date of service Check the Eligibility Verification System (EVS) MassHealth s EVS, 800.554.0042 Have your MassHealth provider number or National Provider Identification (NPI) number and password ready. Go online NEHEN Call us Tufts Health Provider Connect* New England Healthcare Exchange Network (NEHEN) or NEHENNet Our 24/7 member eligibility line, 888.257.1985 Call MassHealth 24/7 automated line, 888.665.9993 * To access Tufts Health Provider Connect, go to: https://thpprovider.healthtrioconnect.com/app/index.page? 25
What to do after patient care 1. Please file claims no later than 60 days after service Submit claims online using Tufts Health Provider Connect or on paper by mailing them to: Tufts Health Plan P.O. Box 859 Park Ridge, IL 60068-0859 You may submit claims through the EDI. Please contact the EDI Operations Department with any questions or requests for set up at 888.880.8699 ext. 54052 or email at EDI_Operations@tufts-health.com 2. Check the claim s status by going to Tufts Health Provider Connect (thpprovider.healthtrioconnect.com/app/index.page?) 3. File a request for the claim s review within 90 days of the EOP (Explanation of Payment) You may find the Request for Claim Review form on our website in the Provider Resource Center at tuftshealthplan.com. 3/27/2017 26
Provider checklist Have you taken the following actions? Register for Provider Update, our quarterly newsletter Go to: tuftshealthplan.com/provider/provider-email-capture Register to access our secure provider portal, Tufts Health Provider Connect, and enjoy one-stop access for member eligibility clams, authorizations and panel reports Go to: tuftshealthplan.com/provider/provider-register-for-secure-access Fill out the Medical or Behavioral Health Provider Information Form available in the Provider Resource Center at tuftshealthplan.com/provider Set up direct deposit and get paid faster: Go to emdeon.com to enroll or call Emdeon at 866.506.2830 for instructions on how to enroll by mail or fax Review the Tufts Health Provider Manual available in the Provider Resource Center at tuftshealthplan.com/provider Call Provider Services if you have any questions: 888.257.1985 3/27/2017 27
Provider resources Provider Resource Guide tuftshealthplan.com Provider Update Provider Manual Provider Connect A resource guide to help you get the information you need to do business with us. Read payment policies and coverage guidelines; use our searchable preferred drug list; find a doctor, hospital, or pharmacy; and download benefit summaries, coverage area maps, forms and clinical practice guidelines. Read our quarterly e-newsletter to get updates about pharmacy policies and coverage guidelines, pharmacy and preferred drug list changes, important business changes and regulatory requirements. Go here to sign up for Provider Update. The annually updated Provider Manual is a tool to keep you updated on policies and procedures, as well as information about federal and state regulatory requirements that may affect participating providers. Our secure online portal that allows you to check the status of a claim, verify member eligibility, check panel assignments, get remittance advice and view and download Explanations of Payment. 3/27/2017 28
Please remember Always bill Tufts Health Plan, not MassHealth or the member. Quarterly, you will receive a notification from Tufts Health Plan requesting that you verify whether your information is accurate. Please take the time to update your information if it is inaccurate. Be sure to register your email with us to receive important updates. (https://tuftshealthplan.com/provider/provider-email-capture) 3/27/2017 29
Thank you. Any questions? 30