State of Vermont Demonstration to Integrate Care for Dual Eligible Individuals Service Delivery Workgroup Meeting #2: August 10, 2010

Agenda Enrollment Enrollment Populations to be included in Demonstration Populations to be included in Demonstration Voluntary, Mandatory or Passive Mandatory enrollment Voluntary, Mandatory or Passive Mandatory enrollment What Services will be included? What Services will be included? Medicaid Medicaid Medicare Medicare Other new services? Other new services? Overview: What do we mean by “Integrated Care”? Overview: What do we mean by “Integrated Care”? What does this look like? What does this look like? How does it work (e.g., service planning, service authorization, service coordination, notice and appeals)? How does it work (e.g., service planning, service authorization, service coordination, notice and appeals)? 2Service Delivery Workgroup, Meeting 2 (August 10)

Possible Populations Program Dual Eligible Enrollees (July 2010) Dual Eligible Enrollees (CY2010) CRT1,3991,620 Development Services1,5361,600 TBI4650 Choices for Care4,5565,870 Choices for Care (without MNG)3,7165,015 CfC Moderate Needs Group (MNG) Employed people with Disabilities VPharm 1, 2, and 312,84015,129 QMBI, SLMB, QI5,7688,443 Attendant Services Program91143 PACE77119 Others8,1448,236 3Service Delivery Workgroup, Meeting 2 (August 10)

Services (Benefit Package, State assumes Risk)) All existing Medicaid services All existing Medicaid services All existing Medicare Services All existing Medicare Services Part D? Part D? New services? New services? 4 Include ImmediatelyInclude if savings Curative w/Hospice Care Tele-health Dentures Eyeglasses Others? Service Delivery Workgroup, Meeting 2 (August 10)

Non-Covered Services From MyCare: From MyCare: Any service not authorized by the Interdisciplinary Care Team, unless it is an emergency service. Any service not authorized by the Interdisciplinary Care Team, unless it is an emergency service. Cosmetic surgery, unless required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction after mastectomy. Cosmetic surgery, unless required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction after mastectomy. Experimental, medical, surgical, or other health procedures not generally available in the area unless authorized by the Interdisciplinary Care Team. Experimental, medical, surgical, or other health procedures not generally available in the area unless authorized by the Interdisciplinary Care Team. Any service rendered outside of the United States with the exception of emergencies experienced while in Canada. Any service rendered outside of the United States with the exception of emergencies experienced while in Canada. Private room or private duty nursing while in a nursing home or hospital, unless medically necessary. Non-medical items such as radio or TV are also excluded unless authorized by the ICT. Private room or private duty nursing while in a nursing home or hospital, unless medically necessary. Non-medical items such as radio or TV are also excluded unless authorized by the ICT. 5Service Delivery Workgroup, Meeting 2 (August 10)

What is Integrated Care? MyCare Guiding Principles: MyCare Guiding Principles: Person-Centered Care: Consumers will be treated with dignity and respect and be active partners in their care. Services should be timely and delivered where and when they are needed. The consumer (and family) will work with an interdisciplinary team to develop a mutually acceptable plan of care. Coordinated Care: All the people involved with a consumer’s care will communicate with each other, balancing the sharing of appropriate information with the consumer’s right to privacy. As a result, transitions across care settings will be smoother and better coordinated. Quality of Care: Quality of care will be reinforced by utilizing best practice standards. Quality of services will be routinely monitored and assessed. Caregiver Support: The essential role of informal/unpaid caregivers will be acknowledged and actively supported. Integrated Funding: Funding streams for acute and long term care will be integrated to allow more flexibility to purchase services that enable consumers to live in the least restrictive setting for as long as possible and desired. 6Service Delivery Workgroup, Meeting 2 (August 10)

What is Integrated Care, cont.? MyCare Core Concepts: MyCare Core Concepts:   Provision of an Integrated and Coordinated Delivery System for all health services needed by an individual, ensuring access to and integration of preventive, primary, acute, post acute, rehabilitation, social and long-term care services   Coordinated care planning through a Person-Centered Interdisciplinary Care Team, comprised of the Participant, the Participant’s primary care provider, a non-medical service coordinator, and a registered nurse   Facilitate communication and coordination through the use of a common Centralized Comprehensive Record (ensuring patient privacy)   A Primary Contact Person for each person who will assist them in accessing services, information and decision-making 7Service Delivery Workgroup, Meeting 2 (August 10)

Interdisciplinary Team From MyCare Model From MyCare Model Ensures a comprehensive interdisciplinary services delivery system that addresses both health care and long term care needs though an Interdisciplinary Care Team consisting of, at a minimum: Ensures a comprehensive interdisciplinary services delivery system that addresses both health care and long term care needs though an Interdisciplinary Care Team consisting of, at a minimum: The participant, or family member/caregiver designee selected by the participant; The participant, or family member/caregiver designee selected by the participant; Primary Care Provider, (a primary care physician, nurse practitioner, or specialist physician) who agrees to serve as a primary care physician for the participant; Primary Care Provider, (a primary care physician, nurse practitioner, or specialist physician) who agrees to serve as a primary care physician for the participant; Case Manager/Masters Level Social Worker; and Case Manager/Masters Level Social Worker; and Registered Nurse Registered Nurse When appropriate, other members shall be added to an individual participant’s ICT, based on the participant’s condition and/or needs. The composition of the ICT should be appropriate to a participant’s age and physical condition. When appropriate, other members shall be added to an individual participant’s ICT, based on the participant’s condition and/or needs. The composition of the ICT should be appropriate to a participant’s age and physical condition. 8Service Delivery Workgroup, Meeting 2 (August 10)

Service Authorization MyCare Process: MyCare Process: Service Authorization shall mean authorization of a Participant’s request for the provision of a service (through the Individual Care Plan) Service Authorization shall mean authorization of a Participant’s request for the provision of a service (through the Individual Care Plan) Signatures confirming the Individual Care Plan will be obtained from the applicant/representative and the primary care physician Signatures confirming the Individual Care Plan will be obtained from the applicant/representative and the primary care physician Approval Process for services not in Individual Care Plan? Approval Process for services not in Individual Care Plan? 9Service Delivery Workgroup, Meeting 2 (August 10)

Appeal Process MyCare Process: MyCare Process: If the ICT determines it cannot approve the participant’s or designated representative’s request for care/services, the participant/caregiver also will be advised of his or her right to appeal, and the procedures for filing an appeal If the ICT determines it cannot approve the participant’s or designated representative’s request for care/services, the participant/caregiver also will be advised of his or her right to appeal, and the procedures for filing an appeal 10Service Delivery Workgroup, Meeting 2 (August 10)