1. Integrated Care Program and Medicare Advantage

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

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

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

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

6. CCAI Company Overview Mission Vision CCAI Philosophy
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 2013
5,100 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)

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

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

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

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

12. Model of Care

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

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)

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

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

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.

18. Anchor Health Homes Rockford Chicago 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

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 94467
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

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

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 % T2 branded
$65 ER
20% coinsurance for all other services

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.

25. Provider Materials

26. ICP Sample ID Card

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

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

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

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

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

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

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

34. Institutional Services
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
UB-04
CMS 1500
Professional Services
Institutional Services

35. Community Care Alliance of Illinois
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. Community Care Alliance Appeals Dept.
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 60607

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

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

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

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

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

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

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

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

47. Questions?