Presentation on theme: "WHAT DO I NEED TO KNOW ABOUT MSHO? Jeff Goodmanson website: 651-431-2530"— Presentation transcript:
WHAT DO I NEED TO KNOW ABOUT MSHO? Jeff Goodmanson website: www.dhs.state.mn.us/healthcare/MSHO-MNDHO 651-431-2530 firstname.lastname@example.org
Common Acronyms l CMS - Centers for Medicare and Medicaid Services l CBP - County Based Purchasing Plans l MA-PD - Medicare Advantage Prescription Drug plan l MA - Medicare Advantage l MMA - Medicare Modernization Act l MnDHO - Minnesota Disability Health Option l MSC - Minnesota Senior Care (formerly PMAP for seniors) l MSC+- Minnesota Senior Care Plus l MSHO - Minnesota Senior Health Option l PMAP - Prepaid Medical Assistance Plan l SNP - Special Needs Plan l TPA - Third Party Administrator l ESRD – End Stage Renal Disease
Managed Care Options For Seniors l MSC - Minnesota Senior Care l MSC+ - Minnesota Senior Care Plus l MSHO – Minnesota Senior Health Options
MSHO, MSC+, MSC MSHO (83 counties) MSC + (25 counties) Expanding in 2008 MSC (58 counties) Medicare Part A & B Medicare Special Needs Plan (SNP) Fee for ServiceFee for Service (FFS) Medicare Part D Drugs SNPSeparate Free standing Medicare PDP Remaining Medicaid Drugs SNPMedicaid MCO Medicaid Basic Care SNPMedicaid MCO Medicaid NFSNP (180 days for new community enrollees) remainder FFS MCO (180 days for new community enrollees) remainder FFS MCO (90 days for new community enrollees) remainder FFS) Medicaid EWSNPMedicaid MCOMedicaid Fee for Service
MSHO Overview l CMS Payment Demonstration since 1997 l Combines Medicare and Medicaid services l Includes Elderly Waiver l Includes 180 days of nursing home care l Enrollment is voluntary instead of mandatory enrollment in MSC or MSC+ l Operating statewide (83 of 87 counties) l All nine PMAP plans participate l 35,000+ enrolled
Overview Continued l Care Coordinator assigned to each enrollee. l Some plans contracting with counties for CC functions while others are using clinics/care systems.
MSHO Key Features l Simpler, seamless care for enrollees l Improved management of chronic conditions, clinical care coordination across primary, acute and long term care and Medicare and Medicaid benefits l Simplifies access to ALL Medicare A,B, D and Medicaid benefits l Integrated Medicare and Medicaid member materials and enrollment, providers bill one place for all services l Care Coordination: Each enrollee assigned a care coordinator or health service coordinator who assists with coordination of primary, acute and LTC services
How Do I Identify The Care Coordinator? l The Care Coordinator can be found on RMGR in MMIS. PF4 to navigate l If no information is listed on RMGR or no screening document has been entered, please contact the health plan to get the Care Coordinator contact information. l The contacts for identifying Care Coordinators for MSHO and MSC can be found on the DHS website.
Communication Form l DHS is developing a communication form that will be used by counties, managed care plans (Care Coordinators), and DHS to help improve communication. l The new communication form is being developed in a workgroup that includes DHS, counties, and managed care staff. l A bulletin will be issued once the form is finalized.
Typical Dual Eligible Drug Coverage Medicaid pays 20% cost sharing, pharmacy or provider bills DHS separately
Integrated Drug Coverage MSHO Enrollee Takes 1 Card to Pharmacy Medicare Part D drugs Medicare Part B drugs 20% Medicare Cost Sharing covered Medicaid drugs
Participating MSHO SNPs and MSC/MSC+ Health Plans for Seniors l Blue Plus l First Plan l Health Partners l Itasca Medical Care ** l Medica * l Metropolitan Health Plan * l Prime West ** l South Country Health Alliance ** l UCare Minnesota * * Original MSHO plans ** Current MSC+ plans
Who can Enroll into MSHO? l People 65 or over, and l Are eligible for Medicare Part A and B or who do not have Medicare, and l Live in a participating MSHO county, and l Are eligible for MA without a medical spenddown, or l Are Eligible for SIS EW with a waiver obligation. l Effective 6/1/05 applicants with a medical spenddown are not eligible to enroll. People who acquire a medical spenddown after MSHO enrollment are allowed to continue MSHO enrollment if the spenddown is paid directly to DHS.
What Happened 1/06? l Medicare Part D started l On 1/1/06 nine MSHO plans became Medicare Special Needs Plans (SNPs) offering Medicare A, B and D services l 1/1/06 CMS passively enrolled 23,000 dually eligible seniors into MSHO SNPs due to new Part D system l Most Medicaid seniors are now enrolled in MSHO instead of MSC/MSC+
What Happened Continued l More services (like SNF stays and Part B) now subject to coverage under Medicare managed care l MSHO plans began new contracting partnerships with counties for care management l Most MSHO plans have $0 premiums for Part D l Duals pay co-pays of $1-3.10 or $2.15-5.35 depending income level. l NF residents pay $0 co-pays
Standard Part D Benefits 200620072008 Deductible$250$265$275 Initial Coverage Limit $2,250$2,400$2,510 Out of pocket (OOP) threshold $3,600$3,850$4,050 Total Covered Drugs at OOP $5,100$5,451.25$5726.25 Copays at Catastrophic Level $2/generic $5/brand $2.15/generic $5.35/brand $2.25/generic $5.60/brand
Copays for Full Benefit Dual Eligibles 200620072008 Copays for institutionalized FBDE (SNF and ICF/MR) does not apply to assisted living $0 Income < 100% FPG $1/generic $3/brand name $1/generic $3.10/brand name $1.05/generic $3.10/brand name Income > 100% FPG $2/generic $5/brand name $2.15/generic $5.35/brand name $2.25/generic $5.60/brand name
What Was Passive Enrollment l Was a one time option for SNPs that also have Medicaid managed care contracts. l Allowed SNPs to transfer their Medicaid dual eligibles into their Medicare SNP plan to facilitate Part D coverage. l CMS approved passive enrollment for all MSHO SNPs.
Passive Enrollment-Continued l MSHO eligible seniors enrolled in PMAP as of 8/05 were offered opportunity to be passively enrolled. l 9/05 enrollees were sent letters by current PMAP plans explaining the benefits and the “opt-out” option. l Enrollees had the option to “opt-out” by contacting DHS by 10/31/05. l About 23,000 people passively enrolled.
What happens with Medicare coverage if MSHO is closed? l MSHO contract states that health plans will continue to cover Medicare services for up to 3 months when MSHO eligibility ends. l The up to 3 months only applies to enrollees who lose eligibility with a disenrollment reason of “EE” on RPPH. (Closed for review) l People who close for voluntary disenrollment “VL” or because they move “MV” DO NOT get the 3 months. l The up to 3 months of additional Medicare coverage was negotiated to allow the recipient an opportunity to choose another Part D plan if MA/MSHO is not reopened.
Retro enrollment into MSHO l If MSHO closes due to loss of MA, once MA is reopened, the client will be retro enrolled into MSHO with no gap in enrollment as long as the gap in MA is less than three months and the enrollee did not enroll into a different Part D plan. l This policy does NOT apply to MSC/MSC+
Living Arrangement Impact on Part D Co-Pays l DHS provides NF information to CMS for dual eligibles on a monthly file based on what is listed in MMIS for the living arrangement l It is important that the NF submit the 1503 to the county timely l The county must update the living arrangement immediately so the correct information gets sent to CMS l Once the living arrangement is updated, the NF information is submitted to CMS on the next monthly file l CMS processes the DHS file and then tells the health plan how much to charge for the co-pay l The amount of time it takes for all actions to occur may result in delays in the resident getting charged the correct co-pay.
More About Part D Co-Pays l It is important that all providers bill timely l If the enrollee has a spenddown, the enrollee is not considered a dual eligible until the spenddown has been reached once in the calendar year for Medicare Part D purposes l DHS will not submit the enrollee for dual status until the spenddown has been reached even if the enrollee is a NF resident l Timely billing is a key factor in the enrollee getting changed the correct co-pay level
Medical Spenddowns l People who acquire a medical spenddown after MSHO enrollment has started are allowed to remain enrolled in MSHO only if they pay the full spenddown amount directly to DHS. l DHS (SRU) bills the enrollee each month l Enrollees with AMM’s should only remain enrolled if medical expenses are routinely more then the amount of the spenddown.
Waiver Obligations l Enrollees with waiver obligations are allowed to enroll in MSHO l Waiver obligations are paid directly to the provider similar to fee-for-service l Providers bill the health plan for EW services l MSHO health plans pay the provider after deducting the waiver obligation amount l DHS informs the health plan of the waiver obligation amount monthly
Institutional Spenddown l Institutional spenddowns for people enrolled in MSHO are collected by the provider just like all other Medicaid enrollees l See Bulletin 06-21-05 for more information about institutional spenddowns for people on MSHO
Designated Providers l Designated provider numbers should not be used for waiver obligations and medical spenddowns for MSHO l Exception: People who are in a nursing home and elect hospice should be coded as AMM with the hospice provider as the designated provider. (See MMIS User Manual) l Designated Providers should be used for institutional spenddowns.
Why can’t we use a designated provider for waiver obligations and medical spenddowns? l The health plans do not use our designated provider data l DHS is paying a cap to the health plan to pay claims l DHS bills the client directly for the medical spenddown amount because claims are being paid by the health plan in full l The health plans can only deduct the waiver obligation amounts based on DHS provided information but they do not use our designated provider data
Why can we have designated providers for Institutional and Hospice Spenddowns? l When the health plan has the NF liability for an MSHO enrollee, the plan pays the facility the full charges for the 180 days. l DHS will deduct the amount of the AIM spenddown from the provider on the remittance advice DHS pays to the provider l Once the 180 liability ends, the claims are submitted to DHS fee-for-service and the amount is reduced on the submitted claims l Hospice room and board charges are submitted to DHS fee-for-service so DHS can reduce the spenddown amount when the claim is submitted
Enrollment Hassles l MSHO enrollments may come in either through the counties, health plans, or through changes that CMS makes directly with notification to the plan/State l Dual eligibles can change plans or disenroll each month per CMS policy l Signing an enrollment in a freestanding Prescription Drug Plan or another type of Medicare plan (Medicare Private FFS Plan) automatically terminates an MSHO SNP enrollment per CMS policy
Enrollment Hassles l Loss of Medicaid eligibility also may change enrollment l Counties DO NOT control MSHO enrollment l The State tracks the MSHO Medicare SNP enrollments because we coordinate the Medicare and Medicaid enrollment to the best extent possible l SOME enrollment changes MUST be made retroactively due to CMS SNP rules
2007 Changes l MSHO enrollments are allowed until the last day of the month for Medicare and Medicaid dual eligibles only l This change is needed to match up with CMS enrollment for Part D that allow enrollment up to the end of the month l Non-duals who want to enroll into MSHO will continue to follow current enrollment dates (on or before cut-off). l It is important that enrollment forms get sent to DHS timely to make sure proper enrollment dates are applied
2007 Changes l People who are ESRD will not be allowed to enroll in MSHO l This change matches CMS policy for ESRD l People who are already enrolled in MSHO and are ESRD will be allowed to maintain MSHO enrollment l ESRD information can often be found on the RSVL screen in MMIS
2008 Changes – MSC+ l MSC + will be expanding in 2008 statewide except in the 7 county metro area. l People in affected counties that are currently enrolled into MSC will be automatically transitioned to MSC+. l The managed care exclusions for MSC still apply for MSC+. l MSC+ includes EW and 180 days of NF liability.
MSC+ Continued l Designated providers should not be used for AWM waiver obligations for people on MSC+. l The waiver obligation will be deducted on the claims paid by the health plans similar to fee-for-service claims.