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Integrated Care Program and Medicare Advantage 1.

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Presentation on theme: "Integrated Care Program and Medicare Advantage 1."— Presentation transcript:

1 Integrated Care Program and Medicare Advantage 1

2 Company Overview Parent Company Established 1995 Serving TANF Population Over 90,000 enrollees and growing Not for Profit Wholly Owned Subsidiary of FHN Integrated Care Program (ICP) Medicare Advantage Serving the Greater Chicago and Rockford Areas 2

3 FHN Company Overview Not-for-profit created in 1995 by five safety-net hospitals Mt. Sinai Hospital Norwegian American Hospital Presence Health (Originally St. Mary of Nazareth) St. Anthony Hospital St. Bernard Hospital Only not-for-profit Managed Care Community Network in the State of Illinois Illinois company with locally dedicated resources History of successful provider-incentive programs 3

4 FHN Program Overview Medicaid TANF Population Over 90,000 members Targeted Patient-Centered Care Management Disease Management programs with a Medical Home model, to coordinate care and provide education, support and monitoring Pay for Quality for providers and Healthy Incentives for members to encourage preventive care, early diagnosis and healthy behaviors Member Value-Added Benefits No copayments for physician visits and hospital services No copayment for prescription drugs Free Adult Dental, Weight Watchers membership, Transportation Pregnancy Tests Jewel-Osco Coupons Health Education Programs and Children’s Book Club 4

5 CCAI History and Partners Seeking a better alternative for Medicaid health care and financing, Family Health Network took a grassroots approach and joined with the following allies to develop CCAI: Access Living of Metropolitan Chicago a nationally recognized advocacy group for people with disabilities Health & Medicine Policy Research Group an independent policy center that conducts research, educates and collaborates with other groups to advocate policies and impact health systems to improve the health status of all people Sinai Health System and Schwab Rehabilitation Hospital recognized as national models for urban health care delivery 5

6 CCAI Company Overview 6 Mission The Community Care Alliance of Illinois is a health plan dedicated to consumer-directed, community-based innovative health services, specializing in the care of Seniors & Persons with Disabilities. Vision To be the leader in Choice, Access, and Quality of Health Services for the people we serve. CCAI Philosophy Empowerment of the consumer voice and use of community peer resources Prevention of complications through our Care Coordination Model Incorporation of Long Term Services & Supports Decreased Emergency Department visits and Hospitalizations

7 CCAI Program Overview Medicaid Integrated Care Program (ICP) Expansion – Seniors & Persons with Disabilities (SDP) Rockford Roll-Out July ,100 eligible in Boone, McHenry and Winnebago Counties Chicago Roll-Out March 2014 voluntary enrollment June 2014 mandatory enrollment 60,000 eligibles in Cook County Medicare Advantage – New! Effective 01/01/2014 Community Advantage (HMO) – Medicare only (HMO and Part D) Community Complete (DSNP) - Medicare-Medicaid (Dual-Eligible Special Needs Plan) 7

8 Program Exclusions Populations Excluded from ICP Children (under the age of 19) Those eligible for Medicare Part A or enrolled in Medicare Part B American Indians/Alaskan Natives (may voluntarily enroll) Enrollees currently in a spend-down status Individuals aligned with presumptive eligibility Individuals in the Breast/Cervical Cancer Program Participants with comprehensive third-party coverage 8

9 ICP Initial Enrollment Process Mandatory Enrollment Eligibility determined by the State Enrollment managed by Client Enrollment Broker (CEB): Maximus CEB responsible for initial PCP assignment Enrollees required to select a MCO/MCCN within 60 days Enrollees who do not choose are auto-assigned Enrollees are given an additional 90 days to switch plans Enrollees who make no changes will remain with their health plan until their next Open Enrollment Period Open Enrollment occurs two months prior to the Enrollee’s anniversary date Enrollees may switch PCPs within their health plan at any time 9

10 Bonus Benefits for ICP Enrollees Integrated Care Team to assist with the coordination of services, including both a nurse care coordinator and long-term services and supports (LTSS) coordinator No copayments for office visits, prescriptions, hospital services, emergency department visits Pharmacy: 90-day mail order Nurse Advice Line Dental Services – semi-annual exam and cleaning, x-rays, fillings, extractions Vision Benefits -- annual exam plus $100 for optical Weight Watchers membership Healthy Perks Incentive Reward Program (Debit Card) Transportation to medical services 10

11 Transportation Enrollees are eligible for transportation to receive covered medical services, with a stop at a pharmacy on the way home if needed Transportation arrangements are made through Enrollee Services at Transportation must be scheduled at least two business days prior to appointment There is no cost associated with this benefit 11

12 Model of Care 12

13 CCAI Model of Care Person Centered with Six Domains Medical Functional Environmental Financial Social Support Psychological/Behavioral Health Focus on the Whole Person 13

14 CCAI Model of Care (cont.) Person-centered care plan Wraparound “all-in” care, integrating medical, psychosocial and LTSS Focus on prevention, health, and wellness Disability-competent primary care services with Integrated Care Teams Integral role for disability-trained primary care nurse practitioners Flexible sites of service, including more home care and fully accessible sites of care (Anchor Health Homes) 14

15 Interdisciplinary Care Team Disability Competent Primary Care Primary Care Provider (MD, DO or NP specializing in family medicine or internal medicine) Nurse Care Coordinators Long Term Services and Supports Coordinator (social worker) Specialty Care Rehabilitation professionals Behavioral/mental health providers Other specialists as appropriate 15

16 Long-Term Supports & Services (LTSS) Home & Community-Based Services/Waiver Programs serving the following SPD populations: Elderly/Aging HIV/AIDS Physical Disability Supportive Living Facilities Traumatic Brain Injury Long Term Care Facilities – Nursing Facilities 16

17 Anchor Health Homes: Gold Star Designation Fully accessible and user-friendly environment for people with disabilities and complex needs. Anchor Health Homes will provide the following: Onsite Nurse Practitioners, Nurse Care Coordinators, and LTSS Coordinators Physical accessibility (parking, entrance, clinic space, bathrooms) Communication access including interpreter services Accessible medical equipment including exam tables, wheelchair accessible scales, transfer equipment Staff trained on disability care and accommodations Commitment to incorporating health information technologies and enhancements Team meetings, case reviews, etc. 17

18 Anchor Health Homes Rockford Rockford Health Physicians Crusader Community Health Center (FQHC) Chicago Mile Square Health Center – Humboldt Park Mercy Family Health Center PrimeCare Community Health Schwab Rehabilitation Hospital Mount Sinai Hospital Outpatient Psychiatry & Behavioral Health St. Bernard Hospital Swedish Covenant Hospital 18

19 Mental Health & Substance Abuse All mental health and substance abuse (MHSA) services are sub-contracted to PsycHealth. PsycHealth manages both inpatient and outpatient services, as well as all UM processes related to MHSA. CCAI nurse and LTSS care coordinators work closely with PsycHealth care coordinators to ensure that the Enrollee’s MHSA treatment is coordinated with their medical and LTSS care. No referral or prior authorization is required for an Enrollee to seek MHSA. However, if any provider feels the Enrollee needs such services, they can refer them to PsycHealth at Enrollees may self-refer to PsycHealth at any time, using the number on their ID card MHSA claims should be submitted to PsycHealth, Ltd. P.O. Box 5312 Evanston, Illinois

20 Pharmacy CCAI has chosen CVS Caremark as its Pharmacy Benefits Manager. Enrollees may contact the Customer Care Line at or visit the CCAI website and click the CVS Caremark button on our Home Page to find a nearby participating pharmacy. Mail Order Option Prescriptions for up to a 30-day supply are available in the pharmacy. Enrollees who need long- term medication can send their prescriptions to CVS Caremark’s mail-order pharmacy for up to a 90-day supply. CVS Caremark PO Box Palatine, IL Formulary, Prior Authorization and Step Therapy CCAI utilizes a Preferred Drug List, which can be found on the CCAI website. There are medications that require Prior Authorization or are only accessible through Step Therapy. These rules, along with instructions for obtaining authorization, can be found by calling the CVS Caremark Customer Care Line at

21 Medicare Advantage 21

22 Medicare Advantage Medicare Advantage is a Medicare Replacement program offered by the Centers for Medicare and Medicaid Services (CMS). CCAI pursued the Medicare Advantage contract in order to provide continuity of care to our SPD Enrollees who age into Medicare. CCAI’s Medicare Advantage plans are Community Advantage (HMO) - HMO with Part D (MAPD) Community Complete (DSNP) - Dual-Eligible Special Needs Plan (DSNP) MAPD is for Medicare eligible entitled to Part A and Part B DSNP is for those who are fully eligible for both Medicare and Medicaid Small population at this time (enrollment projected to reach 1000 by the end of 2014) Plans are based on the same Model of Care as for ICP. However, Medicare Advantage benefits do not include LTSS/Waiver services 22

23 Medicare Advantage (cont.) Community Advantage (HMO) HMO plan with Part D pharmacy benefits Enrollees do not have Medicaid as secondary insurance Bonus Benefits offered include transportation, dental, vision and health club membership Copayments Medicare Pharmacy $5 PCP visit $5 T1 generics $35 Specialist visit 25% T2 branded $65 ER 20% coinsurance for all other services 23

24 Medicare Advantage (cont.) Community Complete (DSNP) HMO plan that includes Medicaid and Part D pharmacy benefits Enrollees qualify for both Medicare and Medicaid ICP Enrollees who age into Medicare can choose this plan to remain with CCAI and continue with their care uninterrupted Bonus Benefits include transportation, dental, vision, and health club membership There are no copayments for medical services for DSNP Enrollees. 24

25 Provider Materials 25

26 ICP Sample ID Card 26

27 Medicare Advantage Sample ID Cards The Enrollee’s ID number is not the same as the one on their Medicare card. 27

28 Covered Authorization List Available on the website at and in the Provider Orientation Packet 28

29 Quick Reference Guide Available on the website at and in the Provider Orientation Packet 29

30 Verifying Medicaid Eligibility Providers are able to verify Enrollee eligibility via CCAI Secure Web Portal (must be a contracted provider and registered user) at Enrollee & Provider Services Monthly Eligibility List (text file) HFS MEDI system for ICP 30

31 Prior Authorization Authorizations Providers may request authorizations from our Utilization Management team. Authorizations may be obtained via Telephone Fax Services Requiring Authorization Inpatient Admissions LTC/SNF admissions (hospital face sheet is acceptable and may be faxed in) Outpatient surgeries High-Tech radiology PT/ST/OT after initial evaluation Diagnostic Testing DME over $500 (per the Medicaid fee schedule) Out-of-network providers Specialty care after initial consultation All LTSS services (ICP only) Please refer to our online Prior Authorization requirements for a comprehensive listing 31

32 Prior Authorization (cont.) Services that DO NOT require prior authorization Labs at a participating hospital or lab X-rays and ultrasounds Initial consult with specialty provider Initial consult for PT/ST/OT (authorization is required after treatment plan is in place) Emergency services 32

33 Claims Timely Filing Guidelines Best efforts to submit claims within 60 days from the date of service ICP: No later than 180 days from the date of service Medicare Advantage: No later than one year from the date of service CCAI follows CMS guidelines for clean claims Complete all data fields accurately Complete CMS 1500 for Professional Services Complete UB for Institutional Services Include NDC numbers for J and Q codes 33

34 Claim Forms These forms are available on the website at ICD-10 form required for dates of service starting 4/1/14 ICD-10 diagnosis codes mandatory for dates of service starting 10/1/14 CMS 1500 UB-04 Institutional ServicesProfessional Services 34

35 Claims (cont.) Electronic Submissions PREFERRED 837 batches may be submitted through Availity using Payor ID “CCAI” Individual claims and PDF attachments are also accepted via secure web portal at Paper claims may be mailed to Community Care Alliance of Illinois PO Box 1105 Elk Grove Village, IL Claims Inquiries may be directed to Enrollee and Provider Services at

36 Claims (cont.) Corrected Claims May be submitted via the secure portal May be dropped to paper and mailed to claims address Must be clearly marked to avoid duplicate denial Claim Appeals or Payment Disputes CCAI will consider claims-payment disputes received within 90 days of the date on the EOP Disputes may be submitted through the Provider Portal or by mail at the address below Include original CCAI claim number and supporting documentation CCAI will process Claims Payment Disputes within 45 days of receipt. After consideration by CCAI, the resubmitted claim will be processed as a new claim. The resolution will be reflected in the EOB. The EOB may be accompanied by a letter, if further explanation is warranted. Community Care Alliance Appeals Dept. 322 S. Green St., Suite 400 Chicago, Illinois

37 Common Claim Rejection Reasons The following items will cause a claim to be rejected prior to processing Enrollee unknown to CCAI Eligible dates of service (i.e., future service dates, etc.) Incorrect claim form Missing Enrollee information, such as name, date of birth, ID number Missing Provider information, such as name, tax ID or NPI number (for medical providers) Missing any of the following fields – Valid diagnosis – Admission type – Patient status – Occurrence code or date – Valid revenue or CPT code Rejected claims will be returned to the provider with an applicable explanation 37

38 Value for Providers Timely and accurate claims processing 99% of claims are adjudicated within 30 days Average clean claim adjudicated within 22 days Access to the CCAI Secure Web Portal for Contracted Providers Electronic Eligibility Electronic Submission of Outpatient Authorization Requests (coming soon) Electronic Claims Submissions (837 batch submission capability) Electronic Funds Transfers – available by April 15, 2014 Electronic EOBs Online Resources on CCAI Website Authorization List Online Forms Provider Directory Provider Manual 38

39 CCAI Website Visit us at and register today to access our secure portal!www.ccaillinois.com 39

40 Cultural Competency CCAI works to Value diversity Assess ourselves and our processes Manage the dynamics of difference through compassion and human-rights framework, as well as legal compliance Acquire and institutionalize cultural knowledge through ongoing education, diverse staff and learning from our Enrollees Adapt to diversity and the cultural contexts of individuals and communities served via quality processes: ongoing review, grievances, provider network, and other resources available to support our interfaces 40

41 Cultural Diversity in Health Care We are aware that some cultures are not comfortable going to see a health care provider Some cultures prefer to see a health care provider of the same gender Some cultures are not comfortable with self examinations Some cultures have sensitivity around Mental Health issues 41

42 CCAI Resources Available Bilingual written materials Language Line Multi-Faceted Provider Network – PCPs – 45% Female and 55% Male – Specialists – 35% Female and 65% Male – PCP 43 different languages spoken – Specialists 38 different languages spoken – TTY (teletypewriter) is available through Enrollee & Provider Services at

43 Abuse, Neglect, Exploitation & Critical Incidents What is Abuse? Abuse is any negligent act by a caregiver or other adult that causes harm or serious risk of harm to a vulnerable adult. Abuse can include -Physical -Sexual -Emotional or Mental Abuse -Confinement -Neglect -Financial Exploitation 43

44 Abuse, Neglect, Exploitation & Critical Incidents (cont.) What are the Reporting Requirements? An allegation of Abuse, Neglect or Exploitation must be reported to Adult Protective Services minimally within 4 hours of its initial discovery , (TTY) CCAI should also be notified of Critical Incidents or Abuse, Neglect or Exploitation of Enrollees by calling Enrollee Services at:

45 Abuse, Neglect, Exploitation & Critical Incidents (cont.) When Should You Report to the Hotline Number? Whenever you believe that an individual with disabilities or an older adult has been abused or neglected. Some examples of abuse or neglect are if you see someone hitting or otherwise injuring a person with disabilities in a domestic setting or in a facility if you see an injury on the body of a person with disabilities that does not appear to have been caused by an accident if a person with disabilities tells you that he or she has been harmed by a care giver if a person with disabilities appears or seems to be neglected, emotionally abused, or financially exploited 45

46 Abuse, Neglect, Exploitation & Critical Incidents (cont.) Where should you report Abuse or Neglect? Adult Protective Services Hotline at , (TTY) Adults 18 years and older with Disabilities and Adults 60 years of age and older Illinois Department of Public Health Hotline at Abuse, neglect, exploitation of an adult 60 years of age older in a Nursing Home Supportive Living Facility (SLF): Enrollees residing in SLFs Community Care Alliance of Illinois at Enrollee Services Office of the Inspector General (OIG): Enrollees aged receiving mental health or developmental disability services in DHS operated, licensed, certified or funded programs are to be made to the Illinois Department of Human Services Office of the Inspector General Hotline 46

47 Questions? 47


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