Engaging AAAs in the Financial Alignment Initiative. Rina Kitazawa Office of Duals Demonstration Ombudsman Technical Assistance Program

Transcription

1 Engaging AAAs in the Financial Alignment Initiative Rina Kitazawa Office of Duals Demonstration Ombudsman Technical Assistance Program

2 Overview Background Info on the Financial Alignment Initiative Funding to Support Implementation Options Counseling for Medicare-Medicaid Enrollees Ombudsman Programs Various Roles of the Area Agencies of Aging

3 Background Info on the Financial Alignment Initiative

4 What is the Financial Alignment Initiative? Partnership between CMS and select states to test models to better align the financing of Medicare and Medicaid and integrate primary, acute, behavioral health, and long term services and supports for dual eligible individuals Two models: Capitated Model Managed Fee for Service Model

5 Key Objectives of the Financial Alignment Initiative Improve beneficiary experience in accessing care Deliver person-centered care Promote independence in the community Improve quality Eliminate cost shifting between Medicare and Medicaid Achieve cost savings through improvements in care and coordination.

6 State Demonstration Approval Process To participate a State had to submit a proposal outlining its proposed approach in 2012 (26 states). CMS evaluated each proposal to determine whether it has met the CMS standards and conditions. Memorandum of Understanding in place once a State proposal has met certain standards and conditions For States pursuing Capitated Model, States must work with CMS to select qualified health plans that will result in a Three Way Contract.

7 Signed MOUs - Status Capitated Model California, Illinois, Massachusetts, New York, Ohio, South Carolina, Texas, Virginia, Michigan Managed Fee for Service Colorado, Washington Alternative Model Minnesota Pending: Connecticut, Rhode Island

8 Funding to Support Implementation of State Financial Alignment Initiative

9 Support for Options Counseling for Medicare-Medicaid Enrollees Funding to State Health Insurance Assistance Programs (SHIPs) and Aging and Disability Resource Centers (ADRCs) to provide Options Counseling to duals To ensure individuals have access to unbiased information and can make informed decisions about how to receive Medicare and Medicaid benefits Available to states that have signed MOU with CMS

10 Options Counseling for Medicare-Medicaid Enrollees Initial funding opportunity in August 2012 California, Illinois, Massachusetts, Virginia, and Washington Second funding opportunity in June 2014 States with funding could apply for funding if they identified new project New York, Virginia Additional application date in July 2015

11 Support for Ombudsman Programs Funding to support the creation of Ombudsman Programs for beneficiaries of the Financial Alignment Initiative To ensure that the beneficiaries of these models have access to person-centered assistance and support they need to resolve problems related to the Initiative To inform States, Plans, CMS, and other stakeholders regarding beneficiary experience with Plans and make systemic recommendations

12 States Participating in Ombudsman Grant Available to states that have signed MOU with CMS to implement an approved Financial Alignment model at the time of award Current Grantees: California, Virginia, Illinois, Ohio, Massachusetts, Washington, Colorado, Michigan Application Pending: South Carolina Potential Grantees Awaiting Signed MOU: Connecticut, Rhode Island

13 Various Roles of AAAs in the Financial Alignment Initiative

14 Various Roles of the AAAs Providing Information and Options Counseling to Dual Eligible Beneficiaries Delivering Ombudsman Services to Demonstration Enrollees Financial Alignment Initiative Contracting with Demonstration Plans to Provide Plan Services

15 ADRC/SHIP Options Counseling CalMediConnect involves AAAs in 7 counties: San Mateo, Santa Clara, Orange, Riverside, San Bernardino, Los Angeles, and San Diego AAAs receive funding from CA Department of Aging. AAAs provide outreach, education, Options Counseling to dual eligible individuals.

16 ADRC/SHIP Options Counseling Continued AAA Accomplishments: Participate in Department of Health Care Services stakeholder calls and webinars Provide numerous counselor trainings in all participating counties Participated in county-based workgroups, trainings, and meetings Provided outreach and educational events for Cal MediConnect beneficiaries and medical providers

17 Demonstration Ombudsman Grant East Central Illinois AAA received funding from IL Department of Aging (IDoA) Demonstration Ombudsman Program builds on Long Term Care Ombudsman Program Staffing: 4.5 FTE providing ombudsman services Beneficiary Issues: Reduction in services by MMAI Plans

18 Developing Contracts with Demo Plans Detroit AAA built a network of 60 to 70 providers Plans: AmeriHealth, Fidelis, Molina, Midwest Services: Assessment, Care Coordination, Home and Community Based Services (HCBS) Payment Model: Price per case for Assessments Per member, per month (PMPM) for Care Coordination Uniform pricing for HCBS

19 Summary The Financial Alignment Initiative is a demonstration designed to better serve individuals with Medicare and Medicaid. Federal and State partnership AAAs play various roles in the Financial Alignment Initiative.

20 For More Information Office of Duals Demonstration Ombudsman Technical Assistance Program U.S. Department of Health and Human Services Administration for Community Living Washington DC Website:

21 Karla Warren Office of the State Long-term Care Ombudsman Ombudsman System Liaison, serves as MyCare Ohio Ombudsman Demonstration Coordinator

22 Integrates Medicare and Medicaid services into one program, capitated model, operated by a managed care plan. MyCare Ohio went live in first region on May 1, 2014 and all regions were live by July 1, Passive enrollment into Medicare portion began Jan. 1, The official start date for CMS for Ohio s demo.

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24 Geographic Area MyCare Ohio operates in 7 geographic regions covering 29 counties & include more than 90,000 beneficiaries. Beneficiaries include those enrolled on an HCBS waiver, those in NFs and/or those receiving traditional community Medicaid.

25 7 regions Plan and Geographic Breakdown 5 plans selected through a competitive bidding process. No plan has more than 3 regions. Members have choice of 2 plans except in Northeast (Cleveland) area choice of 3 plans.

26 Eligibility Requirements In order to be eligible for MyCare Ohio an individual must be: Eligible for all parts of Medicare (Parts A, B and D) and be fully eligible for Medicaid; and Over the age of 18; and Reside in 1 of the demonstration counties. This includes: Individuals in nursing facilities, in some home care programs and who are receiving behavioral health services in community settings.

27 Benefits Benefit package includes all benefits available through the traditional Medicare & Medicaid programs, including LTSS, and behavioral health. MyCare Ohio Plans may elect to include additional value-added benefits in health care packages. LTSS and behavioral health services are new to managed care

28 Benefits Also Include One point of contact for care Care management support 24/7 Interdisciplinary team Waiver services coordinator One ID card Focus on prevention and wellness Nurse advice line Better coordination = Better health outcomes

29 AAA Role in MyCare Ohio Only state demo where AAA involvement is mandated. Plan required to request LOC determinations from their local AAA for members, of any age, needing waiver services. Plan is required to contract with AAAs to perform Waiver Service Coordination (WSC) for, at a minimum, members age 60 and older. Although plans must offer a WSC alternative for members age 60 and older.

30 Where is the authority? Three-way contract state of Ohio Centers for Medicare Medicaid & managed care plans Delineated with individual contracts b/w plans and AAAs. State hands off with relationships.

31 Level of Care (LOC) Determination Plan will request AAA to perform the LOC assessment for waiver services. AAA will perform the in-person LOC assessment. AAA will communicate LOC result to the plan. Plan will communicate waiver approval or waiver denial to AAA. Plan approves waiver enrollment communication to AAA will include: Waiver enrollment effective date. Total cost of waiver services authorized by the plan. Also perform annual redeterminations, significant change in condition and waiver disenrollment.

32 Waiver Service Coordinator (WSC) Professional responsible for developing the waiver plan with member; sharing the plan with the interdisciplinary team; coordinating approved services; assuring the member s health, welfare and adequacy of service delivery; and integrating the plan into the ICP. Plan is required to contract with AAAs to perform WSC for, at a minimum, individuals age 60 and older. Plan must offer another choice beyond the AAA for WSC. Plan may perform WSC as part of comprehensive care management and/or contract with entities that have experience working with people with disabilities, including, but not limited to centers for independent living and disability-oriented case management agencies, etc. This could be the WSC for members under age 60, as well as the additional choice for those members 60 and older.

33 Additional Responsibilities Patient liability calculation for assisted living waiver members and collection of patient liability for HCBS waiver members. List management. At beginning of demo involved in enrollment assistance. Screeners and front door staff assisted people with selecting plans and signing up. AAAs also performed the initial assessment of members for some plans.

34 Above and Beyond AAA Involvement Some Ohio AAAs have additional responsibilities that plan has delegated to organization. All functions AAA performs are spelled out in an unique contract between the plan and the AAA. Additional responsibilities: care management function, waiver service coordination for members under age 60, initial member assessment and provider management role.

35 Why did AAAs become involved in demo? Financial impact Recognition that use of managed care will only grow Better customer service to members; AAA know long-term services and supports Plans are new to long-term services and supports

36 Why having the AAAs in Ohio demo is a plus: Kaiser Report found: Plans relied on them for their connection to communitybased resources and their knowledge of services, service authorizations, and assessments. The requirement to including the AAAs in the demonstration as well as the continuity of care provisions built into the demonstration helped maintain continuity of care for seniors during the transition to managed care. One plan noted that working closely with the AAAs helped increase the opt-in percentage for Medicare services.

37 Plans are NOT hands off. Limitations Limited or no access to plans databases. Lots of monitoring occurring by plan and state. Plans give monetary cap AAA representative has to work with.

38 Enrollment list issues. Challenges AAA staff leaving for positions at plans; lured by $. Loss of MyCare eligibility and disjointed transition to legacy waiver. Member confusion. Delays in approval by plans.

39 Ombudsman Demonstration The MyCare Ohio Ombudsman are active on behalf of the entire program enrollment, for all plan-administered services, including for the NF population and services. Received a $1.2 million, 3-year grant in spring 2014 from CMS. Incorporated into state s traditional long-term care ombudsman program. Good fit because state s ombudsman program has had authority with home care consumers for more than 20 years.

40 Ombudsman Role The go-to consumer advocate for responding to complaints Inform and educate consumers Investigate and help facilitate and resolve complaints Identify systemic issues and opportunities for improvement Maintain an independent role

41 MyCare Ohio Ombudsman Data 5/1/14-6/30/ cases 575 complaints Complaint type benefits/access most prevalent 276 times Second and third customer service and enrollment/disenrollment 245 inquiry entries 89% resolution rate 58 days average length of time to close a case About 5.5 hour invested into a case

42 ACL and CMS Ombudsman Partnerships Ohio Department of Medicaid Area agencies on aging Managed care plans Ohio Consumer Voice for Integrated Care

43 Ombudsman Feedback Transportation Care management Enrollment issues Provider billing issues when it impacts members Person-centered planning

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