Presentation on theme: "Community Care Medical Home EnrollmentFor Adult Care Homes Hosted by: In conjunction with:"— Presentation transcript:
Community Care Medical Home EnrollmentFor Adult Care Homes Hosted by: In conjunction with:
Medicaid Medicaid is a health insurance program for low-income individuals and families As of September 2012, there are nearly 1.6 million beneficiaries of Medicaid Medicaid budget exceeds $11Billion
Medical Home Enrollment Project Goal: To enroll each eligible Medicaid beneficiary with a Community Care of North Carolina medical home to improve their overall health and ensure their access to high quality, medically necessary health care in the most cost effective manner. Project Focus Increase the number of beneficiaries enrolled with a medical home Increase enrollment among the Aged, Blind, and Disabled (ABD) beneficiaries to 75% of the total ABD population.
Medicaid Managed Care Programs Carolina ACCESS (CA) and Community Care of North Carolina (CCNC)
Community Care of NC Community Care of NC Benefits to the beneficiary and ACH: Primary Care Doctor who will lead their medical home team 24-hour medical advice A care manager to help manage the health care needs of the beneficiary Follow-up appointments Beneficiary education on self management Special help monitoring and managing medications Help when patients are transitioning from the hospital back to the facility
Medical Home Referrals: Required when seeking care for most specialty services. Made at the discretion of the Community Care medical home. Made by telephone or in writing Should be obtained as needed prior to rendering services Additional Information regarding Community Care of North Carolina / Carolina ACCESS is available at http://www.ncdhhs.gov/dma/basicmed/Section4.pdf http://www.ncdhhs.gov/dma/basicmed/Section4.pdf Community Care of NC
Primary Goals Improve the care of Medicaid population while controlling costs A “medical home” for beneficiaries, emphasizing primary care Community networks capable of managing beneficiary care Local systems that improve management of chronic illness in both rural and urban settings Community Care of NC Community Care of NC
How it Works: Coordination of local community providers (hospitals, health departments, LMEs and others) and primary care physicians Provides clinical and performance improvement data through CCNC Informatics Center Provides support for physician driven quality improvement initiatives regionally and statewide Each network provides local care managers, and at least one pharmacist, psychiatrist, and medical director to improve local health care delivery Community Care of NC Community Care of NC
Networks: Provide resources for care management, quality improvement, and cost containment Seek to incorporate all providers, including safety net providers Have Medical Management Committee oversight Community Care of NC Community Care of NC
Behavioral Health Integration Disease Management Dental Screening and Fluoride Varnish Pharmacy Management ED Utilization Management High Cost –High Risk Care Management Chronic Care Program (ABD) Palliative Care Pain Management Person Centered Medical Home Pregnancy Care Management Care Coordination for Children Additional Information available at http://www.communitycarenc.org/ http://www.communitycarenc.org/
Medicaid Managed Care Programs Enrollment Process
Enrollment Prior to rendering services: Verify the beneficiary’s eligibility for Medicaid Use online verification tools like NCECS Webtool
Enrollment Determine if the beneficiary is enrolled with a medical home If yes, verify that the medical home is correct
Enrollment If the beneficiary is not linked to a medical home: Determine the beneficiary’s Medicaid Coverage Category. Are they eligible for CCNC enrollment?
Enrollment MANDATORYOPTIONALINELIGIBLE AAF/WorkFirstMPWMQB MIC (N and 1) HSFMIC-L MAFIASRRF/MRF MAABD (w/o Mcare) MAABD (w/ Mcare) “D” status beneficiaries SAD /SAA(w/o Mcare) SAD/SAA (w/ Mcare) MAF-D MICA, MICJ, MICK, MICS (NC Health Choice) End Stage Renal Disease beneficiary CAP cases w/ monthly deductible SSI under age 19 Aliens eligible for emergency Medicaid Special Needs (Self- Identified Nursing Facility residents Native Americans MAF-W Benefit Diversion Yes No
Enrollment Once you confirm eligibility for Medicaid: If the beneficiary is not enrolled with a medical home: Explain the benefits of managed care Ask for information about their primary care provider Complete the enrollment form Fax the enrollment form to DMA at 919-715-0844
Enrollment Once you confirm eligibility for Medicaid: If the beneficiary does not have a medical home: Explain the benefits of managed care Use the provider directory to help them choose a primary care provider Complete the enrollment form Fax the enrollment form to DMA at 919-715-0844
Enrollment Start by locating the county where your ACH is located. Use the provider name and demographic information to identify a provider and complete the enrollment form.
Enrollment Once you confirm eligibility for Medicaid: If the beneficiary’s medical home is incorrect : Obtain information about the correct medical home Complete the enrollment form Fax the enrollment form to DMA at 919-715-0844
Enrollment For residents with both Medicare and Medicaid. Explains benefits and options of Community Care enrollment.
Enrollment When a resident chooses a new medical home, it is imperative that they establish a relationship with that new provider Immediately call the new medical home to make an appointment to establish a relationship, complete paperwork, and transfer records If a resident has not seen their chosen medical home within the past year, also call to make an appointment to maintain that relationship
Enrollment Resources Community Care of North Carolina http://www.communitycarenc.org/ http://www.communitycarenc.org/ Link to webinar presentation and enrollment form DMA CCNC/CA webpage http://www.ncdhhs.gov/dma/ca/ccncproviderinfo.htm http://www.ncdhhs.gov/dma/ca/ccncproviderinfo.htm CCNC/CA Recipient Handbook http://www.ncdhhs.gov/dma/ca/carechandbook.pdf http://www.ncdhhs.gov/dma/ca/carechandbook.pdf email: email@example.com firstname.lastname@example.org Benefits of Being a CCNC/CA Member http://info.dhhs.state.nc.us/olm/forms/dma/dma-9016.pdf http://info.dhhs.state.nc.us/olm/forms/dma/dma-9016.pdf Additional questions: Melanie.email@example.com Melanie.firstname.lastname@example.org 828-304-2345