Medicare Medicaid Alignment Initiative (MMAI) November 14, 2014
MMW work is supported by grants from: The Chicago Community Trust Michael Reese Health Trust The Retirement Research Foundation
Who We Are: Leadership AgeOptions Area Agency on Aging (AAA) for suburban Cook County Health & Disability Advocates Policy and advocacy group Progress Center for Independent Living Cross-disability, non-residential suburban Cook County
What We Do Gather and create practical, accessible information and materials Educate Medicare consumers, service providers and policymakers Problem solving individual and systemic Provide training and technical support for professionals and volunteers Advocate for consumer focused laws and policies Target underserved groups
What We Will Cover Today Background of Illinois Managed Care Transitions Medicare Medicaid Alignment Initiative (MMAI) Who does MMAI Affect? How Does MMAI Work? MMAI Enrollment Tips for Assisting Consumers with MMAI
Background of Illinois Managed Care 6
Background - Illinois Managed Care Transitions State Initiatives Public Act 96-1501, January 2011: Illinois must move 50% of all Medicaid recipients into risk-based care coordination by 2015 Save Medicaid Access and Resources Together Act (SMART Act), May 2012: Save $16.1 million by integrating care for most complex Medicaid beneficiaries (acute, primary, behavioral, and long-term services and supports)
Care Coordination vs. Managed Care Care coordination: Using a primary point of contact to establish communication and collaboration among a patient s health care providers to ensure that: Individuals receive appropriate care and information about his/her care services are not duplicated or conflicting patient receives appropriate follow-up to ensure improvement of condition(s) (http://www.wisegeek.com/what-is-carecoordination.htm) 8
Care Coordination vs. Managed Care Managed care: a system of financing and delivering health care, involves the use of a managed care organization (MCO) that is responsible for implementing techniques generally designed to reduce cost of care and improve quality. Techniques may include care coordination and/or integrated delivery systems (provider networks), utilization review, emphasis on preventive care, or financial incentives to encourage members to use care efficiently (http://en.wikipedia.org/wiki/managed_care) 9
Illinois Multiple Entities Involved Managed Care Organizations (MCO s) Managed Care Community Networks (MCCN s) Accountable Care Entities (ACE s) Care Coordination Entities (CCE s) Serve specific populations some for older adults and/or people with specific disabilities, some for children with complex medical needs Provider Based Entities 10
Illinois Multiple Entities Involved ACE s CCE s State Pays Care Coordination rate to entity, medical services still paid for separately by state (fee-for-service). MCO s MCCN s (MCCN s may start at full risk or may progress to full risk over time) Entity takes on full risk state pays a capitated rate to entity; entity pays providers for services. 11
Illinois Multiple Entities Involved See Department of Healthcare and Family Services (HFS) Rollout Chart and Map here: Fact Sheet: http://www2.illinois.gov/hfs/sitecollectiondocuments/ccrolloutfactsheet.pd f Chart: http://www2.illinois.gov/hfs/sitecollectiondocuments/cc_rolloutchart.pdf Map: http://www2.illinois.gov/hfs/sitecollectiondocuments/ccexpansionmap.pdf 12
Illinois Managed Care Initiatives Affecting Older Adults & People with Disabilities (AABD/SPD Medicaid) Integrated Care Program Medicare/Medicaid Alignment Initiative (MMAI) Innovations Project Care Coordination Entities (CCE s) Managed Care Community Networks (MCCN s) 13
Illinois Managed Care Initiatives Affecting Children, Families, and ACA adults Mandatory Managed Care Program Children, families, and the new Medicaid category known as ACA adults are also being rolled into managed care initiatives in certain areas of the state Managed care organizations (MCO s) Managed Care Community Networks (MCCN s) Provider-based Care Coordination Projects (CCE s, ACE s) 14
Medicare Medicaid Alignment Initiative (MMAI) 15
Background - MMAI Centers for Medicare and Medicaid Services (CMS) issued demonstration project to increase care coordination for dual eligibles (people with Medicare and Medicaid) Illinois application approved February 22, 2013 Memorandum of Understanding between CMS and state of Illinois available here: http://www.cms.gov/apps/media/press/factsheet.as p?counter=4547
Who Will MMAI Affect? Full benefit dual eligible beneficiaries (people with Medicare and full Medicaid benefits not spenddown ) who are: Over the age of 21 and in the Seniors and Persons with Disabilities (SPD) Medicaid category (also known as AABD) Do not have high level third-party (private) insurance Are not receiving Developmental Disability Waiver services Living in Chicago area or Central Illinois: Chicago: Cook, Lake, Kane, DuPage, Will, and Kankakee counties Central IL: Knox, Peoria, Tazewell, McLean, Logan, DeWitt, Sangamon, Macon, Christian, Piatt, Champaign, Vermilion, Ford, Menard, and Stark counties
How Does MMAI Work? HFS contracts with managed care companies to coordinate all medical, pharmaceutical, behavioral health, and long term services and supports (like Phase 1 and 2 of the ICP combined). One plan will cover all services (Medicare Parts A, B, D, and Medicaid) - members will no longer need to find providers who accept Medicare and Medicaid (will need to use plan s network instead)
How Does MMAI Work? Plans may not charge higher cost-sharing than traditional fee-for-service Medicaid Consumers must use plan network providers 180 day transition period Must cover out of network emergency care Plans will have some flexibility to provide services that are not currently covered by Medicare and Medicaid (if they choose)
How Does MMAI Work? Care Management Services will be offered to all enrollees to help coordinate medical services and long term services and supports (LTSS) All enrollees will be assigned a Care Coordinator and have access to an Interdisciplinary Care Team (ICT) within their MMAI plan. Care Coordinator standards/training, caseloads, and contact requirements are based on the individual s risk level (health risk screening conducted in first 60 days of enrollment) and specific Home and Community Based Service (HCBS) Waiver requirements High risk enrollees must be contacted by the ICT at least every 90 days
MMAI Enrollment Enrollment is conducted through the Client Enrollment Broker Call Client Enrollment Broker at 1-877-912-8880 to Enroll, opt out, or disenroll from program Compare provider networks Find plan s drug formularies
MMAI Enrollment Client Enrollment Broker is an objective third party entity no relationship to any plan Before calling the Client Enrollment Broker, client should have Social Security Number Name(s) of preferred primary care provider, hospitals and clinics Medication list Be able to say name and language needed in English (if needing to use teleinterpreter services) Can also use an authorized representative
Visit enrollhfs.illinois.gov/choose/compare-plans to compare benefits. Client Enrollment Broker will also assist with comparing plans and provider networks.
Go to plan website to view more detailed benefit information and find in network providers. Must call Client Enrollment Broker or fill out paper application to enroll. Scroll down to compare overview of plan benefits
MMAI Enrollment: For individuals who are not receiving Long Term Care Supports and Services (LTSS)
MMAI and LTSS Long Term Services and Supports (LTSS) Help individuals perform activities of daily living (eating, cooking, bathing, getting dress, cleaning, etc) May be provided in a long term care facility or through home and community based services 5 home and community based Medicaid waiver programs included in ICP (Aging Community Care Program, Disability, AIDS, Traumatic Brain Injury, Supportive Living Facility) 26
Voluntary Enrollment- Individuals not receiving LTSS Began March 2014 Letters were sent to individuals about 30 days before voluntary enrollment began explaining the program and their options Clients responded to letter by: 1) Choosing to voluntarily enroll in an MCO of their choice, OR 2) opting out of the program entirely
Passive Enrollment- Individuals not receiving LTSS Began June 2014 Individuals automatically enrolled into an MCO after June 2014 if they did not make a choice during Voluntary Enrollment Passive enrollment conducted in phases -maximum enrollment of 5,000 beneficiaries/month in the Chicago area, and a maximum of 3,000 beneficiaries/month in Central Illinois
Passive Enrollment- Individuals not receiving LTSS Clients received a notice about 60 days before they were passively enrolled into a plan. Clients had the option to 1) Not respond to the letter and be automatically enrolled in the MCO listed on the notice 2) Respond to the letters by choosing an MCO of their choice 3) Opt out of the program entirely to continue to receive regular Medicare and fee-for-service Medicaid
Once Enrolled- Individuals not receiving LTSS Once a client is enrolled into an MCO, they can change plans on a monthly basis throughout year will not be locked into a plan Can disenroll from the program at any time of the year to receive regular Medicare and feefor-service Medicaid (unless receiving LTSS) Can change PCP at any time (changes will occur within 30 days)
MMAI Enrollment: Individuals receiving LTSS 31
Passive Enrollment: Individuals receiving LTSS First letters mailed in September 2014 Same options as individuals not receiving LTSS: Choose an MMAI plan and enroll Opt out of the program to continue receiving medical services through regular Medicare and fee-for-service Medicaid Accept passive enrollment into MMAI plan Clients have about 60 days from receiving the notice to make their coverage decision or they will be passively enrolled into the plan listed on their letter BUT 32
Managed LTSS Program Individuals who opt out of MMAI will be put into Managed LTSS (MLTSS) Through MLTSS program, they will need to choose an MCO to cover their LTSS services (same plans as MMAI). Medical services will be covered by regular Medicare and fee-for-service Medicaid. Prescriptions will be covered under Medicare Part D. Will be locked in to MLTSS plan choice for one year from date of enrollment. Individuals can still choose to opt back into the MMAI program to receive ALL of their services through one plan at any time of the year 33
Options for Individuals with LTSS MMAI Medical and LTSS services covered by MCO Can change plan or opt out at any time Opt out of MMAI MLTSS LTSS services covered by MCO Medical services through FFS Medicare/Medicaid Locked in for 1 year 34
MMAI Plans Illinois Department of Healthcare and Family Services has chosen 8 plans to provide MMAI services: Chicago area (Chicago and surrounding suburbs)*: Aetna Better Health IlliniCare (Centene) Meridian Health Plan of Illinois HealthSpring Humana Blue Cross/Blue Shield of Illinois Central Illinois: Molina Healthcare Health Alliance * Note: Not all of these plans will be available in every county visit http://enrollhfs.illinois.gov to see which plans are available in a specific county 35
MMAI Tips for Assisting Clients - Letters Clients are receiving multiple letters from multiple sources about coverage transitions can be very confusing MMAI Enrollment Packet from Client Enrollment Broker Letters from Medicare Part D plans Letters from MMAI plans (that client will be auto-enrolled into if they do not make a voluntary choice) If a client gets the wrong letter (e.g., Integrated Care Program letter instead of MMAI letter), DHS system information may be incorrect! (Contact DHS caseworker to correct immediately.) 36
MMAI Tips for Assisting Clients - Navigating Plan Network, Services If client s providers are not in the plan s network, client can communicate with them to encourage network participation 180 day transition period Each client should be assigned a Care Coordinator make sure clients have contact with that person Utilize MMW Desktop Guide for Navigating MMAI Insurance Plans (in Managed Care Toolkit here: http://www.ageoptions.org/services-andprograms_mmw-medicaidandmanagedcare.html) 37
MMAI Tips for Assisting Clients - Navigating Plan Network, Services MMAI Ombudsman Unbiased advocate who can assist clients who are experiencing issues with their MMAI plan Contact the Illinois Department on Aging Senior Helpline at 1-800-252-8966 to be referred to a client s local MMAI ombudsman program 38
MMAI Tips for Assisting Clients - Opting Out of MMAI and Medicare Part D If an individual opts out of MMAI after being enrolled (either voluntarily or through auto-enrollment), s/he will need to re-enroll in a Medicare Part D plan (this will NOT happen automatically!) If the person does not re-enroll in a Part D plan, s/he can use the LINET program to get prescriptions at the pharmacy and be auto-enrolled into a Part D plan. For more information about LINET, see our MMW LINET fact sheet here: http://www.ageoptions.org/documents/limitedincome NetProgram-LOCKED.docx 39
For More Information 40 40
Resources on Illinois Managed Care and Care Coordination HFS website on Care Coordination: http://www2.illinois.gov/hfs/publicinvolvement/cc/pages/default.aspx (MMAI proposal and information, information about Innovations Initiative) Client Enrollment Broker Materials page: http://enrollhfs.illinois.gov/program-materials (informational materials about each program child/families/aca adults program is called Mandatory Managed Care Program ) Make Medicare Work Coalition Managed Care Toolkit http://www.ageoptions.org/services-and-programs_mmw- MedicaidandManagedCare.html (Includes ICP & MMAI fact sheets, recorded webinars, enrollment timelines, and other resources) 41
MMW Website Please visit our website at http://www.ageoptions.org/services-andprograms_makemedicarework.html to... Access our materials on Medicare, Medicaid, and the Affordable Care Act Sign up for our e-mail list to receive registration information for our webinars, trainings, and meetings and to receive our alerts, bulletins, and other healthcare related materials View our Calendar of Events 42
Thank you! If you have questions, contact: AgeOptions (800)699-9043 This presentation was supported in part by grants from the Chicago Community Trust, the Retirement Research Foundation, the Michael Reese Health Trust, and an anonymous donor. 43