Presentation is loading. Please wait.

Presentation is loading. Please wait.

Seniors and Persons with Disabilities Service Package II: Long Term Services & Supports 1.

Similar presentations

Presentation on theme: "Seniors and Persons with Disabilities Service Package II: Long Term Services & Supports 1."— Presentation transcript:

1 Seniors and Persons with Disabilities Service Package II: Long Term Services & Supports 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 Part of ICP Expansion Medicare Advantage and D-SNP Serving: Chicago Rockford Collar Counties 2

3 FHN Program 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 enrollees Targeted Patient-Centered Care Management Disease Management Programs to coordinate care and provide education, support and monitoring, as well as appropriate medical home Pay for Quality for Providers and Healthy Incentives for Enrollees to improve HEDIS scores and to encourage preventive care, early diagnosis and healthy behaviors Member Value-Added Benefits No copayments for physician visits and hospital services Free Adult Dental, Weight Watchers membership, Transportation Pregnancy Tests and Jewel-Osco Coupons Health Education Programs and Children’s Book Club Drug co-pay reimbursement for prescription copays ($2-$5) 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 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 and Supports Decreased Emergency Department Visits and Hospitalizations

7 CCAI Program Overview Integrated Care Program Expansion – 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 – Medicare-only (HMO and Part D) – Medicare-Medicaid (Dual-Eligible Special Needs Plan) 7

8 SPD 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 SPD Initial Enrollment Process Eligibility determined by the State Enrollment managed by Client Enrollment Broker (CEB) 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 If Enrollees make no changes, will remain with their health plan until the 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 Mandatory Enrollment 9

10 Bonus Benefits for CCAI Enrollees Integrated Care Team to assist with the coordination of services, including access to both nurse and long-term services and supports (LTSS) care coordinators No copayments for office visits, prescriptions, hospital services, emergency room visits Pharmacy: 90 day mail order Nurse Line Preventive Dental (2 visits/year) Vision benefits ($100 for optical) Weight Watchers Membership Healthy Perks Incentive Reward Program (Debit Card) Transportation 10

11 Transportation Enrollees are eligible for transportation to receive covered medical services Transportation arrangements are made by the Enrollee Services Department Enrollee Services can be reached at 1-866-871-2305 Enrollee Services will coordinate the service Please schedule 48 hours prior to the appointment time 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 (continued) Person-centered care plan Wraparound “all-in” care, integrating medical, psychosocial, and long-term supports and services 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 (PCP): MD/DO or Nurse Practitioner (NP) specializing in family medicine or internal medicine Nurse Care Coordinators Long Term Services and Supports (LTSS) Coordinator: social worker Specialty Care Rehabilitation professionals Behavioral/mental health providers Specialists 15

16 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, and staff training Knowledgeable staff regarding disability care and accommodations Commitment to incorporating health information technologies and enhancements Team meetings, case reviews, etc. 16

17 Anchor Health Homes Rockford Rockford Health Physicians Crusader Community Health Center (FQHC) Chicago Mile Square Health Center – Humboldt Park PrimeCare Community Health Mount Sinai Hospital Outpatient Psychiatry & Behavioral Health St. Bernard Hospital Swedish Covenant Hospital Schwab Rehabilitation Hospital Mercy Family Health Center 17

18 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 1-800-753-5456. Mental Health Claims should be submitted to: PsycHealth, LTD. PO Box 5312 Evanston, Illinois 60204 -5312 18

19 Pharmacy CCAI has chosen CVS Caremark as its Pharmacy Benefits Manager. Enrollees may contact the Customer Care Line at 1-855-248-3446 or visit the CCAI website and click the CVS Caremark button on our Home Page to find a participating pharmacy nearby. Mail Order Option Prescriptions will be filled for up to a 90-day supply. Enrollees who need long-term medication can send their prescriptions to CVS Caremark’s mail-order pharmacy: CVS Caremark PO Box 94467 Palatine, IL 60094-4467 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, along with instructions for obtaining authorization, can be found by calling the CVS Caremark Customer Care Line at 1-855-248-3446. 19

20 Long-Term Services & Supports (LTSS) Home & Community-Based Services (Waiver Programs) serving the following populations: Elderly HIV/AIDS Physical Disability Supportive Living Facilities Traumatic Brain Injury Long Term Care Facilities – Nursing Facilities 20

21 Long Term Supports and Services 21

22 LTSS in Home/Community Setting The State completes Determination of Eligibility (DOE) for home/community ‘waiver’ services; eligibility shared with CCAI Dept. of Human Services/Division of Rehab Services (DHS/DRS) = Brain Injury, HIV/AIDS, Disability waivers Care Coordination Units (CCUs) = Elderly and Supportive Living Program waivers CCAI develops and implements a Waiver Service Plan for Enrollees who are LTSS waiver-eligible. The Waiver Services Plan Addresses the Enrollee’s LTSS needs in the home or community-based setting Is incorporated into the Enrollee’s Care Plan 22

23 Working with Existing LTSS Entities CCAI contracts with CCUs and Centers for Independent Living (CILs) to ensure that Enrollees’ LTSS needs are met in the home/community setting CCAI buildings from the expertise in the community in order to best serve Enrollees CCU and CIL case managers work directly with CCAI care coordinators to ensure integration of LTSS home/community services with medical and MHSA care 23

24 Prior Authorizations for LTSS All Long Term & Support Services require Prior Authorization Services Requiring Authorization LTC/SNF admissions (Patient face sheet is acceptable and may be faxed in) Home and Community Based Services under the following waivers Elderly HIV/AIDS Physical Disability Supportive Living Facilities Traumatic Brain Injury Authorizations may be obtained one of the following ways The web portal (participating providers only) Telephone 1-866-871-2305 Fax 1-312-491-9856 24

25 Home & Community Based Waiver Services Elderly Waiver Adult Day Service Adult Day Transportation Homemaker Personal Emergency Response System People with HIV or AIDS Waiver Adult Day Care Adult Day Transportation Home Modifications Home Delivered Meals Home Health Aide Homemaker Nursing: Skilled & Intermittent Personal Assistant Personal Emergency Response System Occupational/Physical/Speech Therapies Respite Specialized Medical Equipment Supplies Persons with Disabilities Waiver Adult Day Service Adult Day Transportation Home Modifications Home Delivered Meals Home Health Aide Homemaker Nursing: Skilled & Intermittent Personal Assistant Personal Emergency Response System Occupational/Physical/Speech Therapies Respite Specialized Medical Equipment & Supplies Supportive Living Program Waiver Nursing Services Personal Care Medication Assistance Laundry Housekeeping Maintenance Social and Recreational Programming Personal emergency Response System Management of Resident Funds Persons with Brain Injury Waiver Adult Day Service Adult Day Transportation Home Modifications Home delivered Meals Home Health Aide Homemaker Nursing: Skilled & Intermittent Personal Assistant Personal Emergency Response System Occupational/Physical/Speech Therapies Respite Specialized Medical Equipment & Supplies Supported Employment Prevocational Services Day Habilitation Behavioral Services 25

26 CCAI Sample ID Card The Enrollee’s ID number is the same as their Medicaid Recipient ID number 26

27 Verifying Eligibility Providers are able to verify Enrollee eligibility via: HFS MEDI system CCAI secure web portal (must be a registered user) Enrollee & Provider Services 1-866-871-2305 27

28 Claims Timely Filing Guidelines Best efforts to submit claims within 60 days from the date of service No later than 180 days from the date of service CCAI follows CMS guidelines for clean claims Complete all data fields accurately Complete CMS 1500 for Professional Services 28

29 Claims (continued) Electronic Submissions Claims may be submitted online via the CCAI web portal ( Individual or batch claim submissions in 837P/837I format are accepted Submit through Availity using Payor ID “CCAI” Submission of 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 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 EOP. The EOP may be accompanied by a letter, if further explanation is warranted. Community Care Alliance C/0 Appeals Dept. 322 S. Green St., Suite 400 Chicago, Illinois 60607 29

30 Claim Forms These forms are available on the website at CMS 1500 Professional Services 30

31 Common Claim Rejection Reasons The following items will cause a claim to be rejected prior to processing Enrollee unknown to CCAI Illogical 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 31

32 Claim Submissions and Inquires Mail paper claims to: Community Care Alliance of Illinois PO Box 1105 Elk Grove Village, IL 60009-1105 Claim inquiries may be made to: Enrollee and Provider Services at 1-866-871-2305 32

33 Value for Providers Timely and accurate claims payment 99.96 % of claims are processed within 30 days Average clean claim paid within 30 days Online Resources on CCAI Website Provider Manual Provider Directory Authorization List Online Forms Access to the CCAI Secure Web Portal for Contracted Providers Electronic Eligibility Electronic Submission of Outpatient Authorization Requests Electronic Claims Submissions (837 batch submission capability) Electronic Funds Transfers Electronic EOBs 33

34 Secure Web Portal Please visit us at and register today! 34

35 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 35

36 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 36

37 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 1-888-461-2378 37

38 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 38

39 Abuse, Neglect, Exploitation & Critical Incidents (continued) 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 1-866-800-1409, 1-800-544-5304 (TTY) CCAI should also be notified of Critical Incidents or Abuse, Neglect or Exploitation of Enrollees by calling Enrollee Services at: 1-866-871-2305 39

40 Abuse, Neglect, Exploitation & Critical Incidents (continued) 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 40

41 Abuse, Neglect, Exploitation & Critical Incidents (continued) Where should you report Abuse or Neglect? Adult Protective Services Hotline at 1-866-800-1409, 1-888-206-1327 (TTY) Adults 18 years and older with Disabilities and Adults 60 years of age and older Illinois Department of Public Health Hotline at 1-800-252-4343 Abuse, neglect, exploitation of an adult 60 years of age older in a Nursing Home Supportive Living Facility (SLF): 1-800-226-0768 Enrollees residing in SLFs Community Care Alliance of Illinois at 1-866-871-2305 Enrollee Services Office of the Inspector General (OIG): 1-800-368-1463 Enrollees aged 18-59 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 41

42 Questions? 42

Download ppt "Seniors and Persons with Disabilities Service Package II: Long Term Services & Supports 1."

Similar presentations

Ads by Google