Medi-Cal Managed Care CBAS Program Transition Presented to: The Sacramento Medi-Cal Managed Care Stakeholder s Advisory Committee By: the Sacramento GMC Plans Revised 01/25/13 1
Outline What is CBAS? Who is Eligible for CBAS Services? What is Available for those Who Aren t Eligible for CBAS? How are Beneficiaries Enrolled in CBAS? CBAS Participant Protections Preparation by the Health Plans The First Month Numbers Challenges The Months Ahead Opportunities 2
What is CBAS?- Basic Benefits The following services will be provided to all eligible CBAS beneficiaries: Nutrition service one balanced, safe, and appetizing meal that meets the nutritional needs of the individual including beverage and/or other hydration. Special meals will be provided by the CBAS Center when required by the enrollee s physician. Professional nursing care, including RN and LVN services. Professional nursing will be organized, appropriately staffed, and equipped to provide skilled nursing care to CBAS Beneficiaries receiving CBAS services. Therapeutic activities aimed at enhancement of the social, physical, or cognitive functioning of the CBAS Beneficiary. Facilitated participation in group or individual activities for CBAS Beneficiaries whose physical frailty or cognitive function precludes them from independent participation in activities. Social services provided by a social worker to facilitate and assist the CBAS Beneficiary and his/her family and/or caregivers in providing necessary home care and to cope with issues related to aging and disability. Personal care services provided primarily by program aides to assist the CBAS Beneficiary with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). Source:http://www.dhcs.ca.gov/services/medi-cal/Documents/ADHC Transition/California STCs (3-30-12).pdf 3
What is CBAS? Community-Based Adult Services (CBAS) Community Based Adult Services is an outpatient, facilitybased program that delivers skilled nursing care, social services, therapies, personal care, family/caregiver training and support, nutrition services, and transportation to certain State Plan beneficiaries. Source:http://www.dhcs.ca.gov/services/medi-cal/Documents/ADHC Transition/California STCs (3-30-12).pdf 4
What is CBAS?- Additional Benefits The following additional benefits will be provided to all eligible CBAS beneficiaries when specified on the person s IPC: Physical therapy provided by a licensed, certified, or recognized physical therapist within his/her scope of practice. Occupational therapy provided by a licensed, certified, or recognized occupational therapist within his/her scope of practice. Speech therapy provided by a licensed, certified, or recognized speech therapist within his/her scope of practice. Behavioral health services for treatment or stabilization of a diagnosed mental disorder provided by licensed, certified, or recognized mental health specialist under scope of practice statutes. Individuals experiencing symptoms that are particularly severe or whose symptoms result in marked impairment in social functioning will be referred by CBAS staff to County Mental Health programs, or psychiatrists or psychologists, other mental health specialists, or emergency mental health services. Registered dietician services provided by a registered dietician for the purpose of assisting the CBAS Beneficiary and/or family caregivers in assuring proper nutrition and good nutritional habits in the CBAS center and in the recipient s home. Transportation to and from the CBAS Beneficiary s place of residence and the CBAS center through its transportation, or via a transportation service in vehicles accessible to the CBAS Beneficiary that are properly licensed and maintained pursuant to applicable laws. Drivers will be appropriately licensed and maintain a good driving record which will be verified by the CBAS administrative staff at least annually. Source:http://www.dhcs.ca.gov/services/medi-cal/Documents/ADHC Transition/California STCs (3-30-12).pdf 5
Who is Eligible for CBAS Services? Individuals who: Are age 18 years and older; Derive their Medicaid eligibility from the State Plan and are either aged, blind, or disabled; including those who are recipients of Medicare. 6
What is the Enrollment Criteria for CBAS Services? The CBAS benefit will be available to all CBAS beneficiaries who qualify based on the following medical criteria and comply with the requirement to enroll in managed care for CBAS services: Meet medical necessity criteria as established by the State; Meet Nursing Facility Level of Care (NF-A) criteria as set forth in the California Code of Regulations, or above NF-A Level of Care; or Have a moderate to severe cognitive disorder such as Dementia, including Dementia characterized by the descriptors of, or equivalent to, Stages 5, 6, or 7 of the Alzheimer s Type; or Have a mild cognitive disorder such as Dementia, including Dementia of the Alzheimer s Type, AND needs assistance or supervision with two of the following: bathing, dressing, self-feeding, toileting, ambulation, transferring, medication management, or hygiene, or; Have a developmental disability. Developmental disability means a disability which originates before the individual attains age 18, continues, or can be expected to continue, indefinitely, and constitutes a substantial disability for that individual as defined in the California Code of Regulations, or; Have a chronic mental disorder or acquired, organic, or traumatic brain injury. Chronic mental disorder means the enrollee shall have one or more of the following diagnoses or Source:http://www.dhcs.ca.gov/services/medi-cal/Documents/ADHC Transition/California STCs (3-30-12).pdf 7
What is the Enrollment Criteria for Cont. CBAS Services? Cont. Have a developmental disability. Developmental disability means a disability which originates before the individual attains age 18, continues, or can be expected to continue, indefinitely, and constitutes a substantial disability for that individual as defined in the California Code of Regulations, or; Have a chronic mental disorder or acquired, organic, or traumatic brain injury. Chronic mental disorder means the enrollee shall have one or more of the following diagnoses or its successor diagnoses included in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association: (a) Pervasive Developmental Disorders, (b) Attention Deficit and Disruptive Behavior Disorders, (c) Feeding & Eating Disorder of Infancy, Childhood, or Adolescence (d) Elimination Disorders, (f) Schizophrenia and Other Psychiatric Disorders, (g) Mood Disorders, (h) Anxiety Disorders, (i) Somatoform Disorders, (j) Factitious Disorders, (k) Dissociative Disorders, (l) Paraphilias, (m) Gender Identity Disorders, (n) Eating Disorders, (o) Impulse Control Disorders Not Elsewhere Classified (p) Adjustment Disorders, (q) Personality Disorders, or (r) Medication-Induced Movement Disorders. In addition to the presence of a chronic mental disorder or acquired, organic, or traumatic brain injury, the enrollee shall need assistance or supervision with either: Two of the following: bathing, dressing, self-feeding, toileting, ambulation, transferring, medication management, or hygiene; or One need from the above list and one of the following: money management; accessing community and health resources; meal preparation, or transportation. Source:http://www.dhcs.ca.gov/services/medi-cal/Documents/ADHC Transition/California STCs (3-30-12).pdf 8
What is available for those who aren t t eligible for CBAS? Enhanced Case Management (ECM) Enhanced Case Management is a service consisting of Complex Case Management and Person-Centered Planning services including the coordination of eligible Medi-Cal beneficiaries individual needs for the full array of necessary long-term services and supports including medical, social, educational, and other services, whether covered or not under the Medicaid program, and periodic in-person consultation with the enrollees and/or his designees. Source:http://www.dhcs.ca.gov/services/medi-cal/Documents/ADHC Transition/California STCs (3-30-12).pdf 9
Enhanced Case Management (ECM) cont. From April 1, 2012, through August 31, 2014, the ECM benefit will be available to all Medi-Cal beneficiaries who: Received ADHC services through the California Medicaid program at any time from July 1, 2011 through February 29, 2012. Have been determined to be ineligible for CBAS or who are eligible for CBAS but exempted from enrolling in managed care and choose to receive ECM as a fee-forservice benefit rather than the CBAS benefit through a managed care plan. A Medi-Cal beneficiary determined to be eligible for ECM may, at a later date, be determined eligible for CBAS. If the enrollee then receives CBAS, he/she will no longer receive ECM. If at a later time the enrollee no longer receives CBAS, he/she will be eligible to receive ECM. An ECM-eligible enrollee who receives CBAS at some time between April 1, 2012, and August 31, 2014, is eligible to receive ECM for any time period during which they do not receive the CBAS benefit. A beneficiary shall not receive ECM and CBAS concurrently. Source:http://www.dhcs.ca.gov/services/medi-cal/Documents/ADHC Transition/California STCs (3-30-12).pdf 10
How are Beneficiaries Enrolled in CBAS? Existing ADHC Participant A. CBAS Center Re-Assesses participant and sends Prior authorization request, including IPC with Level of Service recommendation is created and sent to Plan. B. Plan receives Prior Authorization request from CBAS center, which includes a completed IPC and Level of Service recommendation. Plan will handle recommendation through existing prior authorization process which includes: Plan will approve, modify or deny prior authorization request within 5 business days, in accordance with Health and Safety Code 1367.01. If Plan cannot make a decision within 5 business days a 14-day delay letter will be sent to the member and center. Plan notifies Center within 24 hours of decision. Plan notifies member within 48 hours of decision. C. To deny or decrease the Prior Authorization request, the plan must conduct a F2F with the member. Process must be completed in accordance with Health and Safety Code 1367.01and ensure timelines are met. D. CBAS services begin 11
How are Beneficiaries Enrolled in CBAS? New Participant A. Provider identifies a potential need for CBAS services and submits a request for inquiry to begin the CBAS assessment process B. Plan schedules Face to Face (F2F) with member using the following process Plan acknowledges, in writing, to requestor and member, the inquiry and makes first attempt to schedule F2F within 5 business days. Plan makes two additional attempts via telephone to schedule between 5 and 8 business days of request. Plan makes final attempt in writing giving the member until 14th calendar day to schedule F2F. If m ember does not schedule within 14 days from inquiry, plan will send a follow-up letter to member and requestor that if services are still needed a new inquiry must be submitted to begin the process again. Managed Care Plan conducts Face to Face (F2F) with member using the following guidelines Plan must schedule F2F within 14 calendar days. F2F must be completed, using CEDT tool, with in 30 days from initial inquiry. Approval or denial of eligibility for CBAS to conduct IPC will be sent to the Center with in 1business day of decision. Member has the right to choose a center. 12
How are Beneficiaries Enrolled in CBAS? New Participant cont. C. CBAS Center Completes & Submits Prior Authorization Request Receives authorization from Plan to conduct I PC/LOS assessment CBAS center multi-disciplinary team performs assessment Prior authorization request, including IPC with level of Service recommendation is created and sent to Plan. D. Plan receives Prior Authorization request from CBAS center, which includes a completed IPC and Level of Service recommendation. Plan will handle recommendation through existing prior authorization process which includes: Plan will approve, modify or deny prior authorization request within 5 business days, in accordance with Health and Safety Code 1367.01 If Plan cannot make a decision with in 5 business days a 14-day delay letter will be sent to the member and center. Plan notifies Center within 24 hours of decision. Plan notifies member within 48 hours of decision. E. CBAS services begin 13
How are Beneficiaries Enrolled in CBAS? Expedited Participation Request A. Nursing Facility or Hospital identifies a potential need for expedited CBAS services within the discharge plan and provider submits a request for inquiry to begin the CBAS assessment process. Expedited process will be conducted with 5 business days. B. Managed Care Plan schedules Face to Face at the Nursing Facility or Hospital with member/facility immediately Managed Care Plan conducts F ace to Face with member using the following guidelines Plan must complete F2 F within 5 business days. F2F must be completed, u sing CE DT tool, within 5 business days from initial inquiry. Approval or denial of C BAS eligibility to conduct IPC will be sent to the Center within 1business day of decision. Member has the right to chose a center. C. CBAS Center Receives approval from Plan to conduct IPC assessment CBAS center multi-disciplinary team performs IPC assessment Prior authorization request, including IPC with Level of Service recommendation is created and sent to Plan. 14
How are Beneficiaries Enrolled in CBAS? Expedited Participation Request cont. D. Plan receives Prior Authorization request from CBAS center, which includes a completed IPC and Level of Service recommendation. Plan will handle recommendation through existing prior authorization process which includes: Plan will approve, modify or deny prior authorization request within 72 hours, in accordance with Health and Safety Code 1367.01(h)(2) Plan notifies Center within 24 hours of decision. Plan notifies member within 48 hours of decision. E. CBAS services begin 15
CBAS Participant Protections No Disruptions in Care Beneficiaries who previously received Adult Day Health Care Services between July 1, 2011 and February 29, 2012 must have a face to face assessment to determine CBAS enrollment qualification, but there will be no disruption in care until the face to face assessment has been conducted. Second Level Review Beneficiaries who previously received Adult Day Care Services between July 1, 2011, and February 29, 2012 and have been determined not to meet the level of care for CBAS by the Department or a managed care plan may request a second level review. The second level review may be requested by the beneficiary, their family or guardian. An individual must continue to receive CBAS services if the individual was receiving CBAS prior to being determined ineligible for CBAS until the second level review has been completed by an entity/agency independent of the initial assessment reviewer. Individuals determined not eligible must have a Discharge Plan of Care completed and provided in writing to the individual, family member or guardian. Continuity of Care In referring a beneficiary for CBAS services consideration will be given to the CBAS beneficiary s relationship with previous providers of similar services Source:http://www.dhcs.ca.gov/services/medi-cal/Documents/ADHC Transition/California STCs (3-30-12).pdf 16
CBAS Participant Protections cont. Discharge Plan of Care State Plan and CBAS beneficiaries determined not in need of CBAS services will be provided a written Discharge Plan of care to be completed by a CBAS center. The Discharge Plan of care must contain: a) The name(s) of the patient s physician(s) and the patient s ID number. b) The date the Notice was issued. c) The date the CBAS services are to end. d) Specific information about the patient s current medical condition, treatments and medication regime. e) A statement about Enhanced Case Management Services and how they will be provided to those eligible State plan beneficiaries f) A statement of the right to file a Grievance or Appeal, or to request a second level review. g) A space for the beneficiary or representative to sign and date the document. Grievances and Appeals Individuals who receive a notice of adverse action are entitled to file a Grievance or Appeal as they are entitled under State and Federal law. Source:http://www.dhcs.ca.gov/services/medi-cal/Documents/ADHC Transition/California STCs (3-30-12).pdf 17
Preparation by the Health Plans CAADS Partnership GMC Coalition/ ADHC Center Partnership ADHC Center Meet and Greet Visits Provider Education/ Communication Member Education/ Communication Executed Contracts with CBAS Centers WEBINAR Trainings for ADHC staff Review of sampletars, IPCs Claims system modifications 18
Our First Month Enrollment November 2012 Existing New Total ECM CBAS (10/12) CBAS CBAS Anthem 86 1 87 13 Health 186 88 274 21 Net Molina 147 6 153 Kaiser 38 1 39 0 19
The First Month- Challenges Health Net s Perspective Things have been quiet out of Sacramento County but overall first month challenges are: Higher than expected opt out rate back into FFS Medi-Cal CBAS software and clearing house issues with errors and rejections Medicare FFS Providers guiding beneficiaries back into FFS Medi-Cal and cancelling appointments for colonoscopies, doctor appointments, cataract surgeries, and collecting copays Plan s response: Dedicated Health Net associates for CBAS Increase the number of providers for transportation, Durable Medical Equipment to maintain access to care Performed 6 webinars with 4 more scheduled Outreach to 300 physicians and 3 hospital systems Health Net has been able to get appointments and surgeries rescheduled, and have been able to get copays refunded 20
The Months Ahead In the Months Ahead the Plans will: Continue with provider outreach Use webinars as temperature check to assess the needs of CBAS centers Continue to communicate and collaborate with the CBAS centers collectively and individually as needed to indentify problems and initiate timely resolution. Convene a workgroup of internal staff from each of the plans to discuss program implementation and identify best practices/ successful models of practice that me be shared, replicated and or modified. 21
CBAS Transition: The Trouble Shooters Members are encouraged to contact their Plan Member Services Department first Available via toll-free number 24hours a day, 7 days/wk, 365 days/yr Multi-lingual staff that can communicate with Member in their preferred language. Have all the needed resources and tools to facilitate Member requests (ie: appointment scheduling, PCP change, Member grievance, link with after hours nurse advice line, new ID card, health education resources, information about programs/services in the community.) Sacramento GMC Plan Member Services Departments can be reach at: 1-800-407-4627 1-888-665-4621 1-800-675-6110 1-800-464-4000 22
CBAS Transition: The Trouble Shooters Provider Services WriteFax for IPCs Status for DME Ambulatory Case Mgmt (status of service notifications) Contracts 916-325- 4200 855-336- 4042 or CBAS- Renewal- SM@WellPoin t.com 855-336-4043 or UrgentCBAS@W ellpoint.com 855-336-4041 or New_CBAS@Well Point.com Cora Ross 818-234-5959 Cora.Ross@well point.com 800-641- 7761 866-581- 0540 800-421- 8578 866-801- 6294 Lissette Mendoza 626-683- 6332 Lissette.x.men doza@healthn et.com 916-561- 8543 Ext 126220 800-811- 4808 888-562- 5442 ext 127640 888-562- 5442 ext 127604 Linda Baez 916-561- 8543 Linda.baez@m olinahealthcar e.com 800-464- 4000 866-551- 9619 800-464-4000 800-464-4000 23
Questions? 24 24