MI Health Link. Integrated Care Dual Eligible Demonstration. Nora Barkey MDCH Audrey Smith DWMHA

Transcription

1 MI Health Link Integrated Care Dual Eligible Demonstration Nora Barkey MDCH Audrey Smith DWMHA *

2 Today s Agenda Welcome and Introductions Nora Barkey MI Health Link: Features and Status Nora Barkey Care Coordination - Audrey Smith Quality Protections & Advisory Group - Audrey and Nora Questions All

3 What is MI Health Link? New CMS-MDCH demonstration program that will integrate Medicare and Medicaid benefits, rules and payments into one coordinated delivery system Capitated payment using new health plans called Integrated Care Organizations (ICOs) and existing Michigan Pre-paid Inpatient Health Plans (PIHPs *

4 Who is Eligible? People who Are age 21 or over AND are eligible for full benefits under both Medicare and Medicaid Reside in one of the four demonstration regions Are not enrolled in hospice People enrolled in PACE and MI Choice are eligible but will not be passively enrolled in MI Health Link and must leave their programs before joining MI Health Link *

5 Covered Benefits All acute and primary health care covered by Medicare and Medicaid All behavioral health services covered by Medicare and Medicaid Medications (no co-payments) Dental and vision

6 Covered Benefits Home and community-based services Nursing home care Other benefits offered by the health plans

7 What is Good About MI Health Link? Improving Care No co-payments or deductibles for services, including prescriptions One health plan to manage Medicare & Medicaid services Care coordinator and integrated care team for all enrollees

8 What is Good About MI Health Link: Improving Care Holistic, person-centered care, not just doctor-driven medicine Increased data sharing capacity Simplified billing with single payer source The delivery system will work together, not separated by silos

9 Who Will Administer the Services? Health plans with experience providing Medicare and/or Medicaid services will manage acute, primary, pharmacy, dental, and long term supports and services Regional PIHPs will continue to coordinate services for people with mental illness, intellectual/developmental disabilities and substance use disorders

10 Who Will Administer the Services? Four (4) Regions of the State were selected to implement the Demonstration Program. Eight (8) ICOs were awarded. Region 1: Upper Peninsula- ICO- UP Health Plan Region 4: Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph, and Van Buren ICOs- Meridian Health, Aetna/CoventryCares Health Plan Region 7: Wayne; and Region 9: Macomb ICOs- Aetna/CoventryCares, AmeriHealth of Michigan; Fidelis SecureCare; Hap/Midwest Health Plan; Molina Healthcare; *

11 Status of Memorandum of Understanding Signed by CMS and MDCH on April 3, 2014 Three Way Contracts Issued September 25, Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/Michigan.htmled Readiness Review Site Visits Complete Enrollment process beginning soon Waiver applications submitted Implementation Grant Training/Ombudsman/Quality

12 MI Health Link Workgroups There are multiple state workgroups with PIHP and ICO participation. Care Coordination which has been focused on developing the process for Level 1 and Level 2 assessments Quality- which has been focused on the 94 measures identified as part of the Demonstration project Care Bridge- which has been focused on the interface between IT systems and sharing data Behavioral Health- which has been looking at the process supporting people with behavioral health needs *

13 When will Enrollment for the MI Health Link program start? Phased Enrollment Process *

14 Phase 1- Upper Peninsula & Southwest Michigan No earlier than... December 1, Voluntary Enrollment Begins for the MI Health Link Program -MME can Opt- In -MME can Opt- Out No earlier than... January 1, MMEs who have Opt- In - The MI Health Link Program Begins (MME can Opt- Out, Opt-In, Change ICO at any point) No earlier than... April 1, 2015 IF... - MME has not Opt-In -MME has not Opt- Out - Have not been passively enrolled into a M Care Part D MME will be passively enrolled into the MI Health Link Program- Includes 60-day and 30-day notification letters Service s start no 14 No earlier than April 1, 2015, remaining MMEs will be passively assigned to an ICO State will use Michigan ENROLLS to enroll beneficiaries Options counseling will be available through Michigan Medicare/Medicaid Assistance Program (MMAP)

15 Phase 2- Wayne and Macomb No earlier than... March 1, Voluntary Enrollment Begins for the MI Health Link Program -MME can Opt- In -MME can Opt- Out No earlier than...may 1, MMEs who have Opt- In - The MI Health Link Program Begins (MME can Opt- Out, Opt-In, Change ICO at any point) Nno earlier than...july 1, 2015 IF... - MME has not Opt-In -MME has not Opt- Out - Have not been passively enrolled into a M Care Part D MME will be passively enrolled into the MI Health Link Program- Includes 60-day and 30-day notification letters No earlier than, July 1, 2015 remaining MMEs will be passively assigned to an ICO State will use Michigan ENROLLS to enroll beneficiaries Options counseling will be available through Michigan Medicare/Medicaid Assistance Program (MMAP) 15

16 Can I Stay with My Current Doctors? Continuity of Care Transition of care standards have been developed to assure continuity of care for people enrolling Existing relationships with out-of-network providers will be maintained by the health plan during the transition to MI Health Link People living in out-of-network nursing facilities at the time of MI Health Link enrollment can continue to stay

17 After Enrollment Care Coordination MME agrees to participate in the MI Health Link Program, Selects an ICO, and Completes an Initial Screen (in 15 days of enrollment) ICO Care Coordinator completes (in 45 days of enrollment) LEVEL I ASSESSMENT (HRA) Behavioral Health Needs and/or Long Term Supports Services Identified LEVEL II ASSESSMENT - PIHP completes Appropriate Assessments - ICO Care Coordinator completes NFLOC (within 90 days of enrollment) CONTINUOUS CARE COORDINATION with communication, alerts of ER, Hospitalizations through the Care Bridge (Health Information Exchange platforms) INTEGRATED INDIVIDUAL CARE & SUPPORTS PLAN develop to support the health and quality of life goals of the MME. INTEGRATED CARE TEAM MEETING (MME, ICO Care Coordinator, PCP, BH Case Manager/LTSS Care Coordinator, other Natural Supports) to develop Integrated Care Plan. 17

18 MME agrees to participate in the MI Health Link Program, Selects an ICO, and Completes an Initial Screen (in 15 days of enrollment) Enrollment & Initial Screening Enrollment State will use Michigan ENROLLS (Maximus) to enroll beneficiaries Options counseling will be available through Michigan Medicare/Medicaid Assistance Program (MMAP) Enrollees may change plans or opt out or in at any time Initial Screening Nine yes or no questions Identify current services Identify immediate or unmet needs Will be completed within 15 days of enrollment start date

19 MME agrees to participate in the MI Health Link Program, Selects an ICO, and Completes an Initial Screen (in 15 days of enrollment) Initial Screening Have you spent the night in a hospital since <date 90 days prior to enrollment call>? Have you used the emergency room more than once within <date 90 days prior to enrollment call>? Do you currently receive Physical or Occupational Therapy? Do you use oxygen at home? Do you currently receive Dialysis? Does a nurse, therapist or nurse aide visit you in your home? Are you currently living in a nursing home? Do you need help with any personal services such as bathing, dressing or assistance making meals? Have you had health problems because you cannot get the services you need?

20 ICO Care Coordinator completes (in 45 days of enrollment) LEVEL I ASSESSMENT (HRA) Level I Assessment A broad assessment used to identify and evaluate current health and functional needs The DSM-5 Level 1 Cross-Cutting Symptom Measure is a self- or informant-rated measure that assesses mental health domains that are important across psychiatric diagnoses. Completed within 45 days of enrollment start date Serves as the basis for further assessment

21 LEVEL II ASSESSMENT - PIHP completes Appropriate Assessments - ICO Care Coordinator completes NFLOC (within 90 days of enrollment) Level II Assessment ICOs are required to contract with PIHPs to jointly coordinate and manage care for enrollees with BH, SUD, and/or I/DD needs. Level II Completed for enrollees to identify additional community based needs related to LTSS, MI, SUD, I/DD services or complex medical needs. Conducted in person within 15 days of completion of Level I by PIHP supports coordinator. The Level II Assessment tools determined by MDCH include interrai home care assessment system (interrai HC) for Enrollees needing MI Health Link waiver services; Supports intensity scale (SIS) for Enrollees with I/DD needs; Level of care utilization system (LOCUS) forenrollees with behavioral health needs; and American Society of Addiction Medicine (ASAM) tool for Enrollees with SUD needs. *

22 LEVEL II ASSESSMENT - PIHP completes Appropriate Assessments - ICO Care Coordinator completes NFLOC (within 90 days of enrollment) PIHP Supports Coordinator will (examples): Supports Coordinator Support the person-centered planning process. Participate in the Level I Assessment when the enrollee has an identified BH, SUD, and/or I/DD need. Complete a Level II Assessment of enrollees identified as having need for community based long term BH/SUD and/or I/DD service and support. Develop, with the enrollee and the ICT, an IICSP. Coordinate resources and authorize services. Coordinate psychiatric, psychopharmacological, rehabilitative, and hab services and supports in response to needs identified in the Level I Assessment, the Level II Assessment, and IICSP. Manage transitions among psych acute and sub-acute levels of care and the community. *

23 INTEGRATED CARE TEAM MEETING (MME, ICO Care Coordinator, PCP, BH Case Manager/LTSS Care Coordinator, other Natural Supports) to develop Integrated Care Plan. Treatment Planning Meeting Integrated Care Team A team including the enrollee, enrollee s chosen allies or legal representative, Primary Care Physician, ICO Care Coordinator, LTSS Coordinator or PIHP Supports Coordinator (as applicable) and others as needed. The ICT works with the enrollee to develop, implement, and maintain the IICSP and to coordinate the delivery of services and benefits as needed for each enrollee. Integrated Care Team (ICT): Works collaboratively with enrollee and other team members to ensure the Individual Integrated Supports Care Plan (IISCP) is fulfilled according to the person-centered planning process and the enrollee s stated goals. An ICT will be offered to the enrollee. The ICT will honor the enrollee s choice about his or her level of participation. *

24 INTEGRATED INDIVIDUAL CARE & SUPPORTS PLAN develop to support the health and quality of life goals of the Enrollee. Individual Integrated Care Supports Plan/Individual Plan of Service The plan of care developed by an Enrollee, the Enrollee's ICO Care Coordinator and the Enrollee's Integrated Care Team which incorporates the following elements: assessment results; summary of the Enrollee s health; the Enrollee s preferences for care, supports and services; the Enrollee s prioritized list of concerns, goals and objectives, and strengths; specific services including amount, scope and duration, providers and benefits; the plan for addressing concerns or goals; the person(s) responsible for specific interventions, monitoring and Reassessment; and the due date for the intervention and Reassessment. The IICSP is also referred to as person-centered plan or plan of care. The IICSP will be maintained in the Integrated Care Bridge Record.

25 INTEGRATED INDIVIDUAL CARE & SUPPORTS PLAN develop to support the health and quality of life goals of the Enrollee. General Explanation of Waivers: Medicaid 1915(b) and (c) Waiver Explanation The Social Security Act requires that services must be provided to all eligible individuals on a statewide basis and from any willing and qualified provider. 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. Within the Social Security Act are two authorities, sections 1915(b) and 1915(c), that Michigan is seeking to implement the Integrated Care Demonstration. 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 the Integrated Care Organizations (ICOs) and Prepaid Inpatient Health Plans (PIHPs). Michigan s current b-waiver programs are: 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.

26 INTEGRATED INDIVIDUAL CARE & SUPPORTS PLAN develop to support the health and quality of life goals of the Enrollee. Medicaid 1915(b) and (c) Waiver Explanation 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 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) For the Integrated Care Demonstration, MDCH is applying for 1915(b) and (c) waivers, herein referred to as ICO b and c-waivers

27 Waiver Program Arrangements Related to the Integrated Care Demonstration ** A person cannot be enrolled in two 1915(c) waivers at the same time. If the person meets level of care for both waivers, he or she must choose one in which to enroll. ICO 1915(b) Waiver ICO 1915(c) Waiver** Managed Specialty Services and Supports Program 1915(b) Waiver (MSS&SP) - Operated by ICOs - Includes wide array of physical health services including Medicare, Medicaid State Plan - Operated by ICOs - Includes home and communitybased long term services and supports for adults who are elderly and/or disabled and meet nursing facility level of care - Services include: - Adaptive Medical Equipment and Supplies - Adult Day Program - Assistive Technology - Chore Services - Environmental Modifications - Expanded Community Living Supports - Fiscal Intermediary - Home Delivered Meals - Non-medical Transportation - Personal Emergency Response System - Preventive Nursing Services - Private Duty Nursing - Respite - Operated by PIHPs - Serves individuals who meet medical necessity criteria for serious and persistent mental illness, Intellectual/Developmen tal Disability, and/or Substance Use Disorder. Habilitation Supports Waiver 1915(c) Waiver Program (HSW)** - Operated by PIHPs - Includes home and community based services and supports for individuals with developmental disabilities and who meet ICF/IID level of care - Services include: - Community Living Supports - Enhanced Medical Equipment and Supplies - Enhanced Pharmacy - Environmental Modifications - Family Training - Goods and Services - Out-of-Home Non-Vocational Habilitation - Personal Emergency Response System - Prevocational Services - Private Duty Nursing - Respite - Supported Employment - Supports Coordination

28 Possible Waiver Participation Scenarios Under the Integrated Care Demonstration Scenario Receives Services from: Needs and ICO/PIHP responsibility: 1 ICO b-waiver Enrolled in ICO b-waiver for physical health care needs No behavioral health (BH), developmental disability (DD), or substance use disorder (SUD)needs 2 ICO b and c-waivers Enrolled in ICO b-waiver for physical health care needs, AND Meets ICO c-waiver criteria(nursing Facility Level of Care (NFLOC) & needs at least one c-waiver service), AND No behavioral health, developmental disability, or substance use disorder needs 3 ICO b-waiver and the Enrolled in ICO b-waiver for physical health care needs, AND Managed Specialty Services Does not meet NFLOC for ICO c-waiver, AND and Supports Program Meets medical necessity criteria for MSS&SP through the PIHP as described on page 2 (MSS&SP) b-waiver 4 ICO b and c-waivers and the Enrolled in ICO b-waiver for physical health care needs, AND Managed Specialty Services Meets criteria for ICO c-waiver -- NFLOC & needs at least one c-waiver service, AND and Supports Program (MSS&SP) PIHP b-waiver Meets medical necessity criteria for MSS&SP through the PIHP b waiver as described on page 2 Care coordination is very important to avoid duplication of services across ICO and PIHP waiver programs (some services are very similar in definition) 5 ICO b-waiver and the Enrolled in ICO b-waiver for physical health care needs, AND Managed Specialty Services Meets medical necessity criteria for MSS&SP through PIHP as described on page 2, AND and Supports Program (MSS&SP)b-waiver and the Habilitation Supports Waiver (HSW) Meets eligibility for HSW (as described on page 2) and is enrolled through PIHP 6 ICO b waiver and PIHP mild to moderate behavioral health services Enrolled in ICO b-waiver for physical health care needs, AND Individual needs mild to moderate behavioral health services through PIHP 7 ICO b and c-waivers and PIHP mild to moderate behavioral health services Enrolled in ICO b-waiver for physical health care needs, AND Meets criteria for ICO c-waiver -- NFLOC & needs at least one c-waiver service, AND Individual needs mild to moderate behavioral health services through PIHP

29 INTEGRATED INDIVIDUAL CARE & SUPPORTS PLAN develop to support the health and quality of life goals of the Enrollee. CMS Intent of the Final Rule To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c), 1915(i), and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate To enhance the quality of HCBS and provide protections to participants

30 INTEGRATED INDIVIDUAL CARE & SUPPORTS PLAN develop to support the health and quality of life goals of the Enrollee. Impact for Michigan s System Based on CMS guidance to-date, Michigan s State Transition Plan applies to the following existing waivers: 1. MI Choice Waiver 2. Habilitation Supports Waiver (HSW) 3. Children s Waiver Program (CWP) 4. Waiver for Children with Serious Emotional Disturbances (SEDW) 5. State Plan Amendment for Autism (ispa) (b) Managed Specialty Supports and Services Program(MSS&SP) operating concurrently with the 1915(c) HSW NOTE: The new 1915(b)/(c) concurrent waiver for MI Health Link must ensure that HCBS are only delivered in settings that meet the new requirements in order to be approved by CMS. 8/12/2014

31 Technology to Share Data is on the Horizon

32 CONTINUOUS CARE COORDINATION with communication, alerts of ER, Hospitalizations through the Care Bridge (Health Information Exchange platforms) Health Plans (more coming) Federal Other SOM Sources MSSS HIEs (Qualified sub-state HIEs) MiHIN Shared Services MDCH Data Hub Data Warehouse State LABS Doctors & Community Providers Patient Portal Virtual Qualified Organization DIRECT HISP Medicaid Derived from MDCH Data Sharing Project, Cynthia Green Edwards 32

33 CONTINUOUS CARE COORDINATION with communication, alerts of ER, Hospitalizations through the Care Bridge (Health Information Exchange platforms) Integrated Care Bridge Record An individualized Enrollee record generated and maintained within the electronic Care Coordination platform. It allows secure access for Enrollees and the ICT to use and (where appropriate) update information.

34 MI Health Link- Enrollee Protections Choice of providers and coordinators will be offered Health plans will be required to include enrollees on ICO advisory councils MI Health Link Advisory Committee will be formed A MI Health Link Ombudsman Program is being created

35 Appeals An appeal process that incorporates and coordinates Medicare and Medicaid requirements Standard documents and language will be developed to clearly explain membership, appeal rights and other protections

36 Outcome Measures 94 Quality Measures monitored by DCH & CMS 40 c-waiver performance measures Independent review of outcomes across states by a national research agency (RTI, International)

37 Stakeholder Involvement MDCH is expanding its stakeholder engagement efforts - Quarterly Regional Open Forums - MI Health Link Advisory Committee - Enrollee Participation in ICO Advisory Council *

38 MI Health Link Advisory Committee Organized by MDCH Provides a way for enrollees and stakeholders to offer suggestions and feedback Membership will represent the diverse interests of stakeholders, especially enrollees

39 Advisory Committee Application A completed application form is required; a letter of reference is optional The form will be available on our website soon [email protected] or call if you need the form mailed to you The completed form can either be sent to MDCH by , fax or regular mail *

40 ICO Advisory Council ICOs required to have separate advisory council specific to the demonstration Membership: 1/3 enrollees, majority comprised of enrollees, family members, and advocates State requested grant funds to support enrollee participation on the advisory council *

41 Questions and Contact Information MAIL Integrated Care Medical Services Administration PO Box Lansing, MI WEBSITE