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1 What’s Ahead for Ohio Medicaid?: Connecting Medicare and Medicaid Services April 2013 John McCarthy Ohio Medicaid Director.

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Presentation on theme: "1 What’s Ahead for Ohio Medicaid?: Connecting Medicare and Medicaid Services April 2013 John McCarthy Ohio Medicaid Director."— Presentation transcript:

1 1 What’s Ahead for Ohio Medicaid?: Connecting Medicare and Medicaid Services April 2013 John McCarthy Ohio Medicaid Director

2 2 Integrated Care Delivery for Individuals Enrolled in both Medicare and Medicaid

3 3

4 INTEGRATED CARE DELIVERY SYSTEM: Seamless Experience Person-Centered Care Quality Management Efficient Utilization Community Partnerships Service System Development INTEGRATED CARE DELIVERY SYSTEM: Seamless Experience Person-Centered Care Quality Management Efficient Utilization Community Partnerships Service System Development 4

5 5 The Vision for Better Care Coordination The vision is to create a person-centered care management approach – not a provider, program, or payer approach Services are integrated for all physical, behavioral, long-term care, and social needs Services are provided in the setting of choice Easy to navigate for consumers and providers Transition seamlessly among settings as needs change Link payment to person-centered performance outcomes

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7 7 Target Population of 114,000 individuals in 29 counties Two plans chosen per region with no plan having a presence in more than three regions Northeast Region: home to the greatest number of eligibles and will be the only region that is served by three plans NorthwestSouthwest West Central CentralEast Central Northeast Central Northeast 1 Aetna BuckeyeAetnaCareSource Buckeye 2 Molina United CareSource 3 United Region-by-Region

8 8  October 1 – Northeast Region  November 1 – Northwest, Northeast Central, and Southwest Regions  December 1 – East Central, Central, and West Central Regions 2013 Enrollment Schedule

9 Newly Eligible Receive Medicare and full Medicaid benefits Adults 18+ with disabilities and persons 65+ yrs Persons with serious mental illness will be included in the program 9

10 Exempt Groups The following groups are not eligible for enrollment into the ICDS demo: Individuals with an ICF/ID level of care served either in an ICF/ID facility or on a waiver are exempt from enrollment Individuals who are eligible for Medicaid through a delayed spend-down Individuals who have third party insurance 10

11 Enrollment Enrollees will be able to opt out of the Medicare part of the program in which case they would stay with their current Medicare providers, but receive all Medicaid payments and services through the ICDS  Voluntary enrollment is set to begin on September 1, 2013 11

12 Enrollment Process 12 The enrollment process will encourage and facilitate choice by the individual. We will conduct a robust and comprehensive outreach effort that will include: Partnering with community resources, our enrollment broker, OSHIIP, the AAAs and others to reach out to the different communities represented within the dual eligible population Conducting regional forums for beneficiaries and providers Providing appropriate educational materials that will supplement and facilitate the outreach process

13 Benefit package includes all benefits available through the traditional Medicare and Medicaid programs, including LTCSS and behavioral health In addition, ICDS Plans may elect to include supplemental “value-added” benefits in their benefit packages 13 Benefits

14 Inpatient Hospital Inpatient Mental Health (including Freestanding and State Operated Hospitals) Skilled Nursing Facility Home Health Hospice Physician Services Out-Patient Hospital Services --emergency room --outpatient clinic/surgery --mental health care including partial hospitalization Laboratory, X-Ray and Imagining Chiropractic Podiatry Outpatient Mental Health Care/including Independent Psychologist Outpatient Substance Abuse Services Outpatient Surgery-Hospital Outpatient Facility or Ambulatory Surgical Center Ambulance and Ambulette Services Urgent Care Outpatient Rehabilitation Services (OT,PT,ST) Cardiac and Pulmonary Rehab Services DME and Supplies (enhanced wheel-chair service per proposal) Prosthetics Diabetes Self Management/Training and Diabetes Services and Supplies Outpatient Diagnostic Tests Vision Care Preventive Services Medical Nutritional Therapy Renal Dialysis Services Part B Prescription Drugs Family and Pediatric Nurse Practitioner Family Planning Services and Supplies Dental FQHC and RHC Services Prescription Drugs Private Duty Nursing Pharmacological Management 14 ICDS Medical Services

15 ICDS Behavioral Health Services Behavioral Health Assessment (Physician and Non-Physician for MH Only) Behavioral Health Counseling and Therapy (Individual and Group) Crisis Intervention (24-hour availability) Partial Hospitalization Community Psychiatric Support Treatment (Individual and Group) Ambulatory Detox Targeted Case Management for AOD Intensive Outpatient Laboratory Urinalysis Med-Somatic Methadone Administration 15

16 ICDS Community Based Services Out of Home Respite Services Adult Day Health Services Home Medical Equipment & Supplemental Adaptive & Assistive Devices Waiver Transportation Chore Services Social Work Counseling Emergency Response Services Home Modification Maintenance and Repair Personal Care Services Homemaker Services 16 Waiver Nursing Services Home Delivered Meals Alternative Meals Service Pest Control Assisted Living Services Home Care Attendant Choices Home Care Attendant Enhanced Community Living Services Nutritional Consultation Independent Living Assistance Community Transition

17 17 Comprehensively manage benefits across the continuum of care, including linkages to social & community services All individuals enrolled in an ICDS plan will receive care management and have an assigned, personal care manager Model promotes a person-centered, culturally sensitive approach to care management Care Management

18 18 Identification Strategy ICDS Plan prioritizes order in which individuals will receive their comprehensive assessment Comprehensive Assessment Includes assessment of individual’s medical, behavioral, social, and long term care needs Input from the individual, family/caregiver, and providers Care Management

19 19 Risk/Acuity Stratification Level Adhere to a minimum contact schedule and staffing ratio established by OMA Individualized, Integrated Care Plan Person-centered plan based on comprehensive assessment Developed with the individual, family/caregiver, and providers, as appropriate Care Management

20 20 Care Management Team Use a team-based approach led by the care manager to effectively coordinate the individual’s services, and respond to assessed needs Comprised of the individual, the primary care provider, the care manager, the waiver service coordinator, as appropriate, the individual’s family/caregiver/supports, and other providers based on the individual’s needs Access to care management supports 24/7 via a toll free number Care Management

21 Care management tracking system Captures assessment and care plan content to facilitate information sharing and communication Program Effectiveness and Impact ICDS plan will evaluate effectiveness of its comprehensive care management model—i.e., health outcomes, functional status, consumer satisfaction, etc. Results of the evaluation will be integrated into the plan’s continuous quality improvement program 21 Care Management

22 22 Measures required by CMS which will be used by all demonstration projects Evaluate access, wellness & prevention, quality of life, care coordination/transitions, behavioral health, and patient experience National measurement sets – e.g. HEDIS, NQF Ohio-specific measures focused on transition, diversion and balance Quality Measures

23 In order to serve individuals enrolled in the ICDS plans must contract with providers during required transition periods During transition periods, if there is no contract, the plan must make authorization and payment arrangements with the provider 23 Provider Contracting 23

24 24 Questions

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