Understanding and Leveraging Continuity of Care Cal MediConnect Providers Summit January 21, 2015 Moderator: Jane Ogle, Consultant, Harbage Consulting www.chcs.org
An Overview of Continuity of Care in Cal MediConnect Managed Care Quality and Monitoring Division (MCQMD) California Department of Health Care Services January 2015
186 Today s Presentation will Cover Different types of Continuity of Care: Same provider Same, or completion of, services Same medications
187 Duals Plan Letter (DPL) 14-004 Continued Access and Assessment The Medicare-Medicaid Plan (MMP) will ensure continued access to medically-necessary items, services, and medical and long-term services and supports providers. As part of the process to ensure continuity and coordination of care, MMPs must perform a Health Risk Assessment within 90, or 45, days of a beneficiary's enrollment. (See DPL 13-002 for details.)
188 DPL 14-004 Out-of-Network (OON) Provider Continuity An MMP is required to offer continuity of care to members who have an existing relationship with an OON provider. The member, their Authorized Representative, or provider makes a request to the MMP. The member must have seen the primary care provider at least once, or the specialist at least twice, in the prior 12 months. The MMP verifies existing relationship with Medicare or Medi-Cal data, or other provider documentation. The MMP works with the provider to sign a Letter of Agreement for service for the single member. The provider continues to serves the member and is paid by the MMP.
189 OON Provider Continuity Requirements MMP required timeline for requests: Begin work on request within 5 working days. Complete the request process within 30/15/3 calendar days, depending on the urgency of the member s need. The MPP must also make information available: Inform member of continuity of care protections and the process to initiate. Train call center and other staff who regularly contact beneficiaries. Notify members: (1) of an approved request; and (2) about the transition process 30 days before the end of the COC period.
190 OON Provider Continuity Criteria The provider must: Agree to FFS rate. Not have quality issues that would disqualify them from the MMP s provider network. Agree to abide by the MMP s Utilization Management policies. The duration is up to: Six months for a Medicare provider and 12 months for Medi-Cal. OON Provider Continuity is not available for: DME, ancillary services, transportation, MMP carve-outs or services not covered by Medicare or Medi-Cal.
191 OON Provider Continuity Telephone and Retroactive Req. The member may make a request over the telephone, if that is the member s preference. The MMP must have the ability to take all necessary member information for the request over the telephone. Members and providers may make retroactive requests for OON provider continuity reimbursement within certain requirements: Services occurred after the member s enrollment into the MMP. Member/provider relationship prior to MMP enrollment. Services occurred after September 29, 2014 (date of the DPL). Limited to a duration of 30 days of retroactive services from start date of services.
192 Nursing Facility Continuity The previously stated OON provider continuity requirements apply for nursing facility providers. In addition: A member who is a resident of a nursing facility prior to enrollment in Cal MediConnect will not be required to change nursing facilities for the duration of the Cal MediConnect Demonstration Program. This provision is automatic, meaning the member does not have to make a request to the MMP to invoke this provision.
193 OON Provider Continuity and MMP Enrollment Changes If the member changes MMPs, the continuity of care period may start over one time. If the member returns to FFS and later reenrolls in Cal MediConnect, the continuity of care period does not start over. If the member changes MMPs, the continuity of care policy does not extend to OON providers that the member accessed through their previous MMP.
194 Continuity in the MMP s Network When a member: (1) transitions into an MMP; and (2) has an existing relationship with a provider that is in the MMP s network: The MMP shall allow the member to continue treatment with a Primary Care Provider (PCP). If the MMP contracts with delegated entities, the MMP shall assign the member to a delegated entity that has the member s preferred PCP in its network. The MMP shall allow the member to continue treatment with a doctors for a 12-month period regardless of whether the doctor is in the network of the prime plan s delegated entity to which the member is assigned.
195 Health and Safety Code 1373.96 State law also allows for OON provider continuity (part of Knox Keene Act): Not limited to members transitioning from fee-for-service Medi-Cal. Limited to those receiving treatment for a complex condition or pregnancy. Applies when the member s doctor leaves the plan. Does not apply when a member changes plans by choice (otherwise applicable for plan changes).
196 Medication Continuity Medicare Part D transition rules and rights will continue as provided for in current law and regulation for the entire integrated formulary associated with the Cal MediConnect Plan. These transition rules and rights noted above include: The Contractor must provide an appropriate transition process for Enrollees who are prescribed Part D drugs that are not on its formulary (including drugs that are on the Contractor s formulary but require prior authorization or step therapy under the Contractor s utilization management rules). This transition process must be consistent with the requirements at 42 C.F.R. 423.120(b)(3).
197 Medication Transition Process Transition process of 42 C.F.R. 423.120(b)(3) Ensure access to a temporary supply of drugs within the first 90 days of coverage under a new plan. Ensure the provision of a temporary fill when an enrollee requests a fill of a non-formulary drug (including drugs that are on a plan's formulary but require prior authorization or step therapy under a plan's utilization management rules). Ensure written notice is provided to each affected enrollee after adjudication of the temporary fill (according to specified requirements and timeframes). Ensure that reasonable efforts are made to notify prescribers of affected enrollees who receive a transition notice. See actual 42 C.F.R. section for more detail on the requirements.
198 Welfare and Institutions Code 14185 and Medication Requires specific timelines for plan processing of authorization requests for drugs. When the plan denies the pharmacist s payment request because prior authorization is lacking, the pharmacist is allowed, in an emergency, to dispense a 72-hour supply (and the plan must pay). This allows time to complete prior authorization. Plans must allow the continued use of single-source drugs that are part of a prescribed therapy (by a contracting or non-contracting provider) in effect for the beneficiary immediately prior to the date of enrollment, whether or not the drug is covered by the plan, until the prescribed therapy is no longer prescribed by the contracting physician.
199 Contact Information If you think of questions later, email: DHCSMediConnect_MLTSS@dhcs.ca.gov
Provider Completion of Care Coordination and Hand-Offs Bill Barcellona Sr. VP Government Affairs CAPG Sacramento 1215 K Street, Suite 1915 Sacramento, CA 95814 (916) 443-4152
DHCS Policies and Rules 201 Continuity of Care (COC) for dually-eligible beneficiaries differs from the Knox Keene Standard there are new rules for Duals! Cal MediConnect COC requirements are set forth in these three documents: Welfare & Institutions Code Sect. 14182.17 CMS-DHCS Memorandum of Understanding (MOU) Duals Plan Letter 13-005 (Revised) Dec. 13, 2014 Detailed FAQs and beneficiary materials also help
Pre-Existing State Requirements 202 Cal MediConnect standards apply in addition to existing, underlying continuity of care rights: Welfare & Institutions Code 14185(b) protects access to any single-source drug that is part of a prescribed therapy in effect immediately prior to enrollment, whether or not it is covered by the Cal MediConnect Plan formulary until the therapy is no longer prescribed by the contracting physician Health & Safety Code 1373.96 Knox Keene Act protections apply for managed care enrollees in an active course of treatment for acute or serious chronic conditions, scheduled procedures, terminal illness, and pregnancy. Differing time frames apply under these rights
Safe Transition is the Goal 203 COC concerns Physician-Patient relationships that exist because of an active course of treatment or scheduled procedure for: An acute episode requiring treatment A chronic condition requiring ongoing treatment Continuity of care protections work a little differently for various types of providers under the CCI. Beneficiaries have the right to continue to receive needed services, but eventually, they must get all covered services from providers who work with the plan. Source: http://www.calduals.org/providers/#carecoordination.
Provider s Role in Care Transition 204 Physicians should cooperate for the good of the patient and in compliance with their ethical standard of care, recognizing the transition of coverage: Transitioning Provider: Consider a plan network relationship Communicate with the Cal MediConnect Plan or network doctor Detail remaining course of treatment to be completed Request, review and execute the COC agreement Delegated Receiving Provider: Know the Plan process Complete the 90-day patient assessment Request periodic updates from the COC provider Plan for a full transition of care and keep the patient advised
Terms of Cal MediConnect Continuity of Care 205 Either a beneficiary or his/her treating out-of-network physician/provider may request continuity of care A Cal MediConnect Plan must allow a beneficiary to maintain an existing provider relationship and service authorizations at the time of enrollment for: Up to six months for Medicare services under W&I Code 14132.275(k)(2)(A) Up to 12 months for Medi-Cal services under W&I Code 14182.17(d)(5)(G) Medicare Part D transition rules continue as provided for the entire integrated formulary associated with the Cal MediConnect Plan COC providers can agree to shorter time periods
Eligible Provider Relationships 206 If your beneficiary enrolls in a Cal MediConnect or Medi- Cal managed care health plan and you are not part of the network, your beneficiary has a right to see you for up to six months for Medicare services and 12 months for Medi-Cal services if you and the plan reach agreeable terms. You must: Have seen the beneficiary at least once in the 12 months before his or her enrollment in the plan for primary care, and twice for specialists Be willing to work with the plan; Accept payment from the plan;* and Not be excluded from the plan s network for quality or other concerns. *The higher of the Medicare or plan rate for services
Excluded Provider Relationships 207 Continuity of care protections do not apply to: Suppliers of medical equipment Medical supplies Transportation services and providers Home health providers Physical therapy providers Plans may choose not to provide COC where An existing provider relationship cannot be proven The out-of-network provider refuses to accept the fee schedule Documented quality of care concerns And remember that no COC rights exist for services not covered by Medi-Cal or Medicare
COC for Medi-Cal Benefits 208 Nursing Facilities: Beneficiaries have the right to stay in their current nursing home under Cal MediConnect, unless it is excluded from the plan s network for quality or other concerns. Long Term Supports & Services (LTSS): Beneficiaries won t have to change In-Home Supportive Services (IHSS), Community-Based Adult Services (CBAS) or Multipurpose Senior Services Program (MSSP) providers.
Mechanisms to Identify COC needs 209 Plans and their network providers are required to identify and facilitate COC needs: Health Risk Assessments (HRAs): Plans will conduct HRAs to identify higher risk beneficiaries who could benefit from care coordination. Interdisciplinary Care Teams: Teams composed of the beneficiary, the plan care coordinators and key providers will help manage and coordinate care for the higher risk beneficiaries. Individualized Care Plans: Care plans will facilitate timely access to care and services needed by beneficiaries. Plan Care Coordinators: Coordinators will help facilitate communication among a beneficiary s providers, including physicians, long-term supports and services providers and behavioral health providers. They will also help connect beneficiaries to social services to help them live as independently as possible. 90-day Patient Assessment Visit: Once the beneficiary is enrolled into the Cal MediConnect plan, the in-network physician must conduct an assessment visit within 90 days.
Handling the Request 210 Once made, the Plan has three deadlines under which to process the COC request: 30 calendar days from date of receipt of the request 15 calendar days if the beneficiary s medical condition is more urgent, or there is an upcoming appointment or other pressing care need 3 calendar days if there is risk of harm to the beneficiary Common requests Beneficiaries have grievance and appeals rights
Retroactive Continuity of Care 211 Plans will retroactively approve and reimburse physicians for continuity of care for services that were already provided if requirements are met. All physician continuity of care requirements continue to apply, including a validated preexisting relationship between the beneficiary and physician. The beneficiary, authorized representative or physician providing continuity of care must request the continuity of care within 30 calendar days of the first service provided after the beneficiary joins the Cal MediConnect plan. The physician can continue to treat the beneficiary for those 30 days and will be reimbursed if all continuity of care requirements are met. Once the plan and physician have agreed to terms, the physician must agree to follow the Cal MediConnect plan s utilization management requirements.
Information Sources 212 Beneficiary Fact Sheet: http://www.calduals.org/wp- content/uploads/2014/02/continuityofcare_14-02- 131.pdf. Provider Fact Sheet: http://www.calduals.org/wp- content/uploads/2014/11/phystoolkit- ContOfCare_11.10.14.pdf. COC Reference Page: http://www.calduals.org/continuityof-care-under-cal-mediconnect/.
213 Thank You! Bill Barcellona Sr. VP Government Affairs CAPG Sacramento 1215 K Street, Suite 1915 Sacramento, CA 95814 (916) 443-4152 wbarcellona@capg.org.
Cal MediConnect Continuity of Care The Consumer Experience Cal MediConnnect Ombudsman for LA County Neighborhood Legal Services of Los Angeles 214
The Role of the Ombudsman Neighborhood Legal Services of Los Angeles (NLSLA), the Cal MediConnect Ombudsman for Los Angeles County, works to ensure that beneficiaries can access all needed medical care. This includes consumer education and direct consumer assistance with continuity of care requests for Medicare and Medi-Cal covered services. Neighborhood Legal Services of Los Angeles 215
Special Considerations Regarding Continuity of Care for Dually Eligible Beneficiaries Dually eligible beneficiaries are among our most vulnerable community members and face many challenges to accessing care: Elderly and frail individuals Complex medical conditions Cognitive impairment Mental health issues Language barriers Low literacy Many dually eligible beneficiaries are unable to request continuity of care on their own behalf without significant assistance Neighborhood Legal Services of Los Angeles 216
Continuity of Care Challenges Non-Contracted Providers Require CoC authorizations Time limits Connecting member with network services Contracted Providers Specialists may require CoC authorizations Connecting member with network services Neighborhood Legal Services of Los Angeles 217
Continuity of Care Challenges Passive enrollment surprise Retroactive authorizations Durable Medical Equipment (DME) and supplies Physical, speech and occupational therapy Transportation Neighborhood Legal Services of Los Angeles 218
Case Example Stella Passively enrolled in a Cal MediConnect plan 82 years old: diabetes, cancer Same oncologist for past six years PCP is contracted with Stella s Cal MediConnect plan Needs testing strips, incontinence supplies, and transportation to appointments Wants to continue seeing oncologist Neighborhood Legal Services of Los Angeles 219
Case Example Gilbert Passively enrolled in a Cal MediConnect plan effective 12/1/14 DOB 12/17/43; 71 years old Appointment in PCP office 12/1/14 PCP is not contracted with Gilbert s Cal MediConnect plan Needs: chemotherapy, transportation to appointments Neighborhood Legal Services of Los Angeles 220
Case Example Gilbert Passively enrolled in a Cal MediConnect plan effective 12/1/14 DOB 12/17/43; 71 years old Appointment in PCP office 12/1/14 PCP is not contracted with Gilbert s Cal MediConnect plan Treated by PCP PCP does not run insurance during visit PCP seeks payment Neighborhood Legal Services of Los Angeles 221
What Can Providers Do to Help Their Patients? Contract with Cal MediConnect plans Comply with CoC authorization process Forward prescriptions and treatment authorization requests (TARs) to plans, as requested Educate patient on Cal MediConnect network and accessing plan resources Engage with the state and health plans to provide feedback and recommendations to improve the continuity of care process Neighborhood Legal Services of Los Angeles 222
David Kane, Staff Attorney davidkane@nlsla.org (800) 896-3202 Neighborhood Legal Services of Los Angeles 223
Provider Summit Cal MediConnect Los Angeles January 21, 2015 Susan Therese Bell, RN, MBA Director of CCI
Care1st Health Plan Care1st was created in 1994 by three medical groups & a disproportionate share hospital dedicated to providing health care services to vulnerable populations through State and Federal government programs One of the only Traditional and Safety Net provider-owned Health Maintenance Organizations (HMOs) in California Awarded contracts for Medicare and Medi-Cal Care1st offers 7,000+ provider networks & serves approximately 480,000 members in California and Arizona, and recently expanded into Texas NCQA Commendable Accreditation. Ranked as a top Medicaid health plan in California by Consumer Reports.
Early Intervention Member Service Provider Member HRA & ICP Member Outreach Care Manager
Caring for Complex Members Working with our delegated provider groups Transitioning the member s care Providers per DPL 14-004 Vendors, Agencies, DME and LTSS providers Completing HRA and ICP, if needed Referrals to Programs and Resources Behavioral Health Case Management HCBS Services
Delegated COC Care Navigator speaks with beneficiary about their COC needs Care Navigator provides education to the beneficiary regarding COC Provider relationship is validated COC request is forwarded to the Provider Group Provider group provides authorization and notifies beneficiary
Care Coordination Member Story New member transitioning out of Hospice Care Required seamless coordination of services previously provided by Hospice agency Provider appointments and new orders Multiple vendors Durable Medical Equipment Oxygen Home Health Nurses Incontinence Supplies Dually eligible beneficiary coverage
Questions and Discussion 230