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Donald Mack, M.D. Ohio State University Medical Center Gregg Warshaw, M.D. University of Cincinnati College of Medicine.

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Presentation on theme: "Donald Mack, M.D. Ohio State University Medical Center Gregg Warshaw, M.D. University of Cincinnati College of Medicine."— Presentation transcript:

1 Donald Mack, M.D. Ohio State University Medical Center Gregg Warshaw, M.D. University of Cincinnati College of Medicine

2 Dual eligible beneficiaries comprise 20% of the Medicare population and 15% of the Medicaid population in 2008 Dual Eligible Beneficiaries 9 million Medicare 37 million Medicaid 51 million SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64. Total Medicare beneficiaries: 46 millionTotal Medicaid beneficiaries: 60 million

3 Dual eligible beneficiaries are a diverse population NOTE: Mental impairments were defined as Alzheimer’s disease, dementia, depression, bipolar, schizophrenia, or mental retardation. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey, 2008

4 Dual eligible beneficiaries are sicker than other Medicare beneficiaries SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, Chronic Conditions In Fair or Poor Health Cognitively or Mentally Impaired Functionally Impaired

5 The Problem Limited care coordination Fragmented Care Current system is confusing and difficult to navigate Multiple health care needs and high cost The health care and long-term care systems are not connected very well, even though people use both 5

6 MyCare Ohio Demonstration to test integrated care and financing model for individuals with Medicare and Medicaid May 2014 to December 2017 Federal and State partnership How it will work: Approved ICDS Plans will provide integrated benefits to Medicare and Medicaid enrollees in seven targeted geographic areas Plans must provide all necessary Medicare and Medicaid-covered services, including Medicaid waiver services Single identification card to access services

7 MyCare Ohio

8 Three-way contract (Health plan, CMS, State) Rolling start in mid-2014; passive enrollment in Medicare delayed until January 1, 2015 Capitated rates adjusted for State and CMS upfront savings; also quality withhold Comprehensive care plans required incorporating client and family goals

9 Medicare Passive Enrollment (I) Beneficiaries must participate in MyCare Medicaid; but Medicare is optional On , individuals who have not indicated a choice, will be passively enrolled in MyCare Medicare with the same health plan as their MyCare Medicaid (integrated benefits and funding)

10 Medicare Passive Enrollment (II) Individuals can choose to stay with traditional Medicare or another Medicare Advantage plan Beneficiaries can switch from MyCare Medicare to traditional Medicare, or vice versa at anytime This is all very confusing to consumers and public education has been poor

11 MyCareOhio

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13 Benefits for Primary Care Providers Identifiable care manager – phone and contact Access to all benefits and services Opportunity to enhance home and community-based services WEB portal to access patient’s care plan Assistance for your most complex patients Opportunity to participate as part of Integrated Care Team Potential to shift hospital dollars to community-based services

14 Continuity of Care and Transition Requirements Health plans must ensure individuals have access to current providers and service levels at the time of enrollment. Length of transition period differs by service. For prescription drugs, Medicare Part D transition requirements apply. Health Plans must provide a one-time fill- 30 day supply- of an ongoing medication within the first 90 days of plan membership. Residents in long term care facilities can receive multiple fills.

15 Continuity of Care Requirements (Continued) During the transition, Health Plans will advise enrollees and providers that they have received care that would otherwise not have been covered. Ongoing basis, Health Plans must contact providers not part of their network with information on being credentialed as in-network providers. Health Plans must always reimburse an out-of- network provider of emergent or urgent care. Details: Plan Payment RequirementsPlan Payment Requirements

16 Ohio UHCAN (Ohio Consumer Voice for Integrated Care) Engaged in Monitoring implementation; influencing consumer protections Passive enrollment Clinical networks; benefit limitations LTSS, transportation Consumer engagement in plan implementation UHCANOhio.org

17 MyCare Ohio Observations (I) Disruptive change: Impact on large number of patients and their provider networks Very complex and the Ohio Medicaid office is also expanding Medicaid CMS-State Medicaid Office-Health Plan negotiations complex Ohio has agreed to involve Area Agencies on Aging Half of the enrollees will be under 65; mental health and disability groups very engaged

18 MyCare Ohio: Observations (II) Physician and provider reimbursement stable, but for how long? Networks broad, but for how long? Health plans have limited experience with this population across all settings of care Primary care and geriatrics providers have received limited education about upcoming changes

19 Critical Role of Provider and Consumer Engagement Dual eligible patients will benefit from your participation in planning and direct care provision in MyCare Ohio If MyCare Ohio is not successful, the alternatives may be less desireable for patients and providers Primary care and Geriatrics providers’ clinical leadership, when combined with consumer advocacy efforts, is more likely to have an impact

20 How can Providers Get Involved? (I) Learn about MyCare Ohio Discuss good and bad observations with your health system, Area Agency on Aging, health plan medical directors, and State Medicaid office leadership Join advocacy organization list-serves Voices for Better Health:

21 Why Learn More about MyCare Ohio? YOU ARE: An important source of health system info A reliable and authoritative source Aware of the clinical needs of the person Aware of the functional needs of the person Aware of the social needs of the person

22 To Achieve the Triple Aim: Better Care, Better Health, Lower Cost Must form a partnership of Health Care Providers; Home and Community- Based Providers, and Public


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