MI Health Link. Medicaid Overview. Medicaid Waivers 9/17/2015. Michigan Department of Health & Human Services

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1 Michigan Department of Health & Human Services MI Health Link Heather Hill SNF Regulatory Day Lansing, MI September 17, 2015 Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life. Medicaid Overview Each state has a Medicaid State Plan which governs the various Medicaid services offered to eligible populations. The Social Security Act (SSA) requires that services must be provided to all eligible individuals on a statewide basis and from any willing and qualified provider the traditional feefor service approach to health care delivery, and the most common means of providing long term care services to the Medicaid population in Michigan. 2 Medicaid Waivers If states wish to deviate from the traditional requirements of the SSA, they must obtain special approval from the Centers for Medicare & Medicaid Services Within the Social Security Act, there are provisions or authorities that permit a State to request waiver of certain requirements to meet the unique needs of the State while using Medicaid funds. Section 1915 waivers Section 1115 waivers 3 1

2 1915 Waivers Social Security Act, Title XIX, Section 1915 offers authority for capitated managed care programs (1915(b) and home and community based services programs (1915(c)): 1915(b) waivers States may apply for a 1915(b) waiver (also referred to as a b waiver ) to operate a capitated managed care plan. The b waiver authority also allows the use of an enrollment broker and limits the State s contracted providers to entities like the Medicaid Health Plans, Integrated Care Organizations (ICOs) and Prepaid Inpatient Health Plans (PIHPs). Michigan s b waiver programs are: MI Health Link program Comprehensive Health Care Program operated by Medicaid Health Plans Managed Specialty Services and Supports Program (MSS&SP) operated by Prepaid Inpatient Health Plans (PIHPs) for individuals with a need services related to serious and persistent mental illness, developmental disability, and/or substance use disorder Waivers 1915(c) waivers The federal authority of 1915(c) enables a State to offer home and community based long term supports and services that individuals could not otherwise receive under the Medicaid State Plan. A c waiver may operate concurrently with a b waiver to make it a managed care program and/or to limit the provider network to certain providers. To qualify, individuals must meet the level of care for an institution (either a hospital, nursing facility, or Intermediate Care Facility for Individuals with Intellectual or Developmental Disability (ICF/IID) level of care), depending on the State s requirements for each waiver. Some of Michigan s current c waivers are: MI Health Link HCBS Waiver for the MI Health Link program MI Choice (for elderly and/or disabled adults) Habilitation Supports Waiver (for individuals with developmental disabilities) (operates concurrently with the Managed Specialty Services and Supports Program b waiver) Waivers Another authority under which states can offer managed care programs is under Section 1115 of the Social Security Act Intended for experimental, pilot or demonstration programs 6 2

3 Future of Managed Long Term Care Managed long term care is a topic that is receiving attention around the country, and the service delivery system here in Michigan is not immune to that discussion. Section 105d(4) of PA 107, which is the authorizing legislation for the Healthy Michigan Plan, states that By September , the department of community health shall develop and implement a plan to enroll all existing fee for service enrollees into contract health plans... Even though there are several eligibility groups that continue to receive coverage under fee for service, one could certainly interpret the language in this section as intending to move the department towards a transition to managed long term care. While this section of the law does not specify such change, a large portion of the aged and disabled group has not been converted to a managed care model and there are references in that section of the law that can only be applied to long term care services. 7 Future of Managed Long Term Care MI Health Link is a first step towards complying with the intent of this language. In addition, the MI Choice waiver uses full risk based capitation to reimburse waiver agents. PACE (Program of All Inclusive Care for the Elderly) is also full risk capitation that includes payments from both Medicare and Medicaid. Discussions to this point have been strictly conceptual, and no decisions have been made to expand the scope of managed long term care. We will continue to learn from our experience with MI Health Link and to observe the progress of other states with regard to the management of long term care services. As we plan for the future, rest assured that the department will all engage with all of its stakeholders before any decision is made to change how long term care services are paid for and managed. 8 MI Health Link A new program that joins Medicare and Medicaid benefits, rules and payments into one coordinated delivery system New MI Health Link health plans and current Michigan Prepaid Inpatient Health Plans (PIHPs) receive payments to provide covered services 9 3

4 MI Health Link Three way contract between CMS, MDHHS, and Integrated Care Organizations (ICOs) (otherwise called MI Health Link health plans) MI Health Link health plans hold contracts with PIHPs for Medicare behavioral health services Operates under a capitated financial model Letter of Intent for extension of the MI Health Link program for an additional two years approved by MDHHS and submitted to CMS 10 MI Health Link Waivers 1915(b) and 1915(c) waiver applications submitted to CMS Approved effective January 1, 2015 for a five year period 11 Proposed Policy Manual There is a new MI Health Link policy chapter that will be added to the Medicaid Provider Manual The public comment period ended September 3, I am incorporating pertinent changes and finalizing the document, and the final version should be released next week (hopefully). 12 4

5 MI Health Link Available in four regions in the state: Region Counties in the Region Integrated Care Organizations (ICOs) 1 Alger, Baraga, Chippewa, Delta, Dickinson, Gogebic, Houghton, Iron, Keweenaw, Luce, Mackinac, Marquette, Menominee, Ontonagon, and Schoolcraft 1) Upper Peninsula Health Plan 4 Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. 1) Aetna Better Health 2) Meridian Health Plan Joseph, and Van Buren 7 Wayne 1) AmeriHealth 2) Aetna Better Health 3) Fidelis 4) HAP Midwest Health Plan 5) Molina Healthcare 9 Macomb 1) AmeriHealth 2) Aetna Better Health 3) Fidelis 4) HAP Midwest Health Plan 5) Molina Healthcare 13 MI Health Link Prepaid Inpatient Health Plans (PIHPs) in each region: Region 1: NorthCare Network Region 4: Southwest Michigan Behavioral Health Region 7: Detroit Wayne Mental Health Authority Region 9: Macomb 14 MI Health Link Eligibility Criteria People may be eligible for MI Health Link if they: Live in one of the four regions Are age 21 or older Are eligible for full benefits under both Medicare and Medicaid, and Are not enrolled in hospice Adults age 21 or older who are enrolled in the Children s Special Health Care Services program are not eligible for MI Health Link 15 5

6 MI Health Link Eligibility Criteria People enrolled in PACE and MI Choice are eligible, but must leave their programs before joining MI Health Link People with Medicaid deductible/spend down are not eligible for MI Health Link People in nursing home are eligible and must continue to pay their patient pay amount to the nursing home People with Medigap (Medicare supplemental insurance) may enroll in MI Health Link if they meet all other eligibility criteria 16 MI Health Link Enrollment Update Enrollments as of 9/15/15: Region 1 4,040 Region 4 8,693 Region 7 23,297 Region 9 5,934 Total 41,964 Enrollees with LOC 05 (NH and HLTCU) Region Region Region 7 1,487 0 Region Total 2, Enrollees with LOC 15 (CMCF) 17 Enrollment and Guardians/DPOA/POA Legal guardian, Durable Power of Attorney (DPOA), or Power of Attorney (POA) may act on a beneficiary s behalf for MI Health Link enrollment matters as long as the required documentation (DCH 1183) is on file with MDHHS MI ENROLLS will only speak with individuals who are listed in the Bridges or CHAMPS systems as legal representatives for a beneficiary 18 6

7 Reimbursement Rates MI Health Link capitation rates for Medicare and Medicaid paid to ICOs, not nursing facilities ICOs pay nursing homes for Medicare covered stays based on an established negotiated rate in the contracts ICOs have with the nursing homes Medicaid rates ICOs pay to nursing homes are established by the MDHHS nursing facility rate setting area Medicaid nursing facility payment must not be lower that this rate unless approved by the state 19 Level of Care Codes Four level of care codes for the MI Health Link program: Level of Care Code Description 03 Individual meets Nursing Facility Level of Care, lives in the community, and participates in the MI Health Link HCBS (home and community based services) waiver program. 05 Resident of any nursing facility or hospital long term care unit (private or county owned) that is not a County Medical Care Facility. 07 General population in the community. 15 Resident of a County Medical Care Facility. 20 Care Coordination MI Health Link health plans, or ICOs, are responsible for ongoing, comprehensive care coordination, but this includes working with any LTSS or PIHP Supports Coordinators or identified nursing facility staff in coordinating all care. Nursing facilities will have these coordinators to work with to ensure quality care is provided and reduce unnecessary hospitalizations. 21 7

8 Assessment Initial Screen conducted within 15 days of enrollment to identify immediate needs and prioritize Level I Assessments Initial screen is a series of a few yes/no questions 22 Level I Assessment The first assessment conducted with the enrollee is the Level I Assessment, or may be more commonly known as a health risk assessment. A broad assessment used to identify and evaluate current health and functional needs Completed within 45 days of enrollment start date MI Health Link health plans are allowed to conduct this assessment up to 20 days prior to the enrollment start date if the enrollee agrees Serves as the basis for further assessment Triggers assessments for personal care services, nursing facility level of care determination, and Level II assessments 23 Level II Assessment Completed within 15 days of the Level I Assessment for people identified with Mental health or substance use disorder needs Intellectual/Developmental Disability (I/DD) needs Long term supports and services (LTSS) needs Health Plans will collaborate with PIHPs, LTSS agencies and nursing facilities Additional supports and services will be coordinated to meet the needs identified 24 8

9 Nursing Facility Level of Care Consistent with current Medicaid policy in Michigan, the Michigan Nursing Facility Level of Care Determination (LOCD) tool will be completed for any enrollee who appears to need nursing facility services The LOCD is conducted by the MI Health Link health plans until the state can identify a conflict free entity ICO Care Coordinators will be working with the nursing facilities to provide proper care coordination Any Minimum Data Set assessment information may be utilized by the MI Health Link health plans to complete other assessments and reassessments 25 Adopting Assessments If a newly enrolled individual has already had a Level II Assessment or Nursing Facility Level of Care Determination conducted, the ICO may adopt the assessments and LOCD until a reassessment is needed. 26 Reassessments Assessments should be conducted at least annually or sooner if the enrollee has a significant change in condition 27 9

10 Individual Integrated Care and Supports Plan (IICSP) Each enrollee will help develop his or her own Individual Integrated Care and Supports Plan (IICSP) Existing plans of care will be incorporated into the IICSP to avoid disruption of services The goal of the IICSP is to identify gaps in services to ensure the enrollee s needs are met 28 Individual Integrated Care and Supports Plan (IICSP) Each enrollee may choose the people he or she wants to participate in the IICSP process Family, friends and providers Existing care coordinators or case managers Members of the Integrated Care Team 29 Individual Integrated Care and Supports Plan (IICSP) Follows the person centered planning process Is completed within 90 days of enrollment Is the single plan that coordinates care for all services and providers and includes the PIHP and LTSS service plans Is the plan for addressing the enrollee s concerns, goals, as well as any measure for achieving them Identifies specific providers, supports and services including amount, scope and duration Lists the person responsible and timelines for specific interventions, monitoring and reassessment 30 10

11 Integrated Care Team Each enrollee will have an Integrated Care Team (ICT) consisting of the enrollee, his/her chosen allies, ICO Care Coordinator, primary care physician, and LTSS or PIHP Supports Coordinator. Also included in the ICT, as appropriate: Personal care providers or other caregivers Primary care nurse care manager Specialty providers Hospital discharge planner Nursing facility representative Others 31 Integrated Care Team Responsibilities are: Ensure the IICSP is developed, implemented, and revised according to the person centered planning process Participate in the person centered planning process at the enrollee s discretion to develop the IICSP Collaborate with other ICT members to ensure the personcentered planning process is maintained Assist the enrollee in meeting his/her goals and ensure any accommodations are made as appropriate so the enrollee can have full participation in the ICT to the extent he or she desires 32 Integrated Care Team Additional responsibilities: Update the Integrated Care Bridge Record (ICBR) as needed Review assessment, test results and other information in the ICBR Address transitions of care when a change between care settings occurs Ensure continuity of care requirements are met Monitor for issues related to quality of care and quality of life 33 11

12 Integrated Care Bridge Record The Integrated Care Bridge Record (ICBR) is the platform and means through which ICOs and PIHPs and their subcontractors share information related to an enrollee s care. The Consolidated Clinical Document Architecture (C CDA) is planned to be available beginning October 1, Integrated Care Bridge Record The ICBR includes the following: Current integrated condition list; Contact information for the ICO Care Coordinator and ICT members; Current medications list; The date of service and the name of the provider for the most recently provided services; Historical and current utilization and claims information; Historic Medicaid and Medicare utilization data Initial screening, Assessments (Level I and Level II), nursing facility LOCD and Personal Care Assessment results Service outcomes, including specialty provider reports, lab results, and emergency room visits; IICSP; and Notes and correspondence across provider settings. 35 Quality Measures There are many MI Health Link health plan quality and performance measures required by MDHHS and CMS. These are currently being finalized between MDHHS and CMS. The health plans have had input in the process as well

13 Continuity of Care Continuity of care requirements for many different services, including nursing facility services Out of network nursing facilities must be offered Single Case Agreements by the ICO to continue to care for the enrollee through the life of the program if the nursing facility does not participate in the ICO s network and the enrollee: 1) resides in the nursing facility at the time of enrollment; 2) has a family member or spouse that resides in the nursing facility; or 3) requires nursing facility care and resides in a retirement community that includes a nursing facility. This continuity of care protection is automatic and available as long as the enrollee resides in the nursing facility. 37 Covered Services Medicare services Medicaid services Dental services Long term supports and services Nursing facility services State Plan personal care services Supplemental services MI Health Link HCBS waiver (home and community based services) 38 State Plan Personal Care Services Historically, this benefit has been provided through the Adult Home Help program For individuals enrolled in MI Health Link, the personal care services offered under the Medicaid State Plan will be assessed, authorized, provided and paid for through the MI Health Link health plans rather than directly through MDHHS 39 13

14 State Plan Personal Care Services For individuals residing in Adult Foster Care homes or Homes for the Aged who qualify for personal care services, these homes will receive the personal care supplement as authorized by the Michigan Legislature 40 Supplemental Services Four additional services are available for individuals living in the community: Adaptive Medical Equipment and Supplies Community Transition Services Personal Emergency Response System Respite 41 MI Health Link HCBS Waiver Available for qualifying individuals who meet nursing facility level of care as determined through the LOCD and have a need for at least one of the following services: Adaptive Medical Equipment and Supplies Adult Day Program Assistive Technology Chore Services Community Transition Services Environmental Modifications Expanded Community Living Supports Fiscal Intermediary Home Delivered Meals Personal Emergency Response System Private Duty Nursing Respite 42 14

15 Appeals and Grievances Appeals and grievances Medicare appeals process Medicaid appeals process Additional information can be found in the three way contract and member materials at Medicaid Coordination/Medicare and Medicaid Coordination/Medicare Medicaid Coordination Office/FinancialAlignmentInitiative/Michigan.html 43 Ombudsman There will be an Ombudsman program specific to MI Health Link that will be operational very soon and will be handling matters related to enrollment and services. 44 Lessons Learned Involving advocates and various stakeholders with diverse expertise throughout the planning and implementation process is very worthwhile and has helped us immensely Trying to get many different systems to coordinate enrollment is very difficult and extremely time consuming Good working relationships are being established and we work very hard every day with our health plan and CMS partners to work out any implementation bugs so we can have the best program possible 45 15

16 Resources MI Health Link website: My contact information: Heather Hill Phone: Questions 47 16