Medicaid Managed Care: Serving Children with Special Health Care Needs Dawn McCree, Buckeye Community Health Plan Toni Bigby, CareSource Greg Meredith, Molina Health Care Kim Crandall, United Community Health Plan Julie Hoskins, Paramount Advantage Today’s Agenda • General Overview – Who, What, Where, When, Why Moving Children with Special Health Needs into managed care • Enrollment – How ODM worked with Managed Care Plans to ensure successful enrollment • Transitioning into Managed Care – Special considerations employed to ensure success • Care Coordination – Cornerstone of the Medicaid Managed Care program and how it will benefit these children • Respite Benefit – NEW! • Q&A General Overview Dawn McCree Buckeye Community Health Plan New Medicaid Managed Care Regions Beginning 2013 Ohio’s Medicaid Managed Care Plans Medicaid Children w/ Special Health Needs • State budget included provision to enroll 37,000 children with special health needs into Medicaid health plans • Impacts children who are Medicaid eligible due to disability and receive monthly fee-for-service medical card • This does not include: • • • • Children enrolled in a Medicaid waiver; or Medicaid-eligible children who reside in institutional settings; or Children who receive both Medicare AND Medicaid benefits Also, Medicaid-eligible children with cystic fibrosis, cancer or hemophilia are not obligated to enroll • Enrollment began on July 1, 2013 6 Once Enrolled, children now have… • All of the medically necessary Medicaid benefits plus: – – – – – – – – Single Point of Contact Expansive provider and hospital network Personal member card Member Service Center 24-hour nurse advice line Additional Transportation Benefits Case management and outreach programs Disease Management programs 7 New Managed Care Requirements to Benefit Children w/ Special Health Needs • Family Advisory Councils: MCPs are required to convene Family Advisory Councils (consisting of current members) at least quarterly. The purpose of the Council is to engage members and elicit input related to the MCP’s strengths and opportunity for improvement. • MCPs are required to participate in Individualized Education Program (IEP) meetings, when contacted and invited by the child’s parents or school district. 8 Enrollment Toni Bigby CareSource How Does Managed Care Enrollment Work? • Notification letters sent by Ohio Department of Medicaid (ODM) • Letters direct consumers to contact the Medicaid Consumer Hotline to enroll – 1-800-324-8680/TTY 800-292-3572 – http://www.ohiomh.com/ • Hotline provides unbiased information about providers, extra benefits, plan contact information and answer general questions • Voluntary vs Auto-Assignment: • Consumers have 90 day to change plans, if needed 5/16/2014 10 Ohio Medicaid Managed Care Enrollment Process Timeline of Events Notice of Mandatory Enrollment (60 days in advance – 90 days for children with special health needs) Reminder Notice w/ date and plan assignment (30 days in advance) Final Notice of Enrollment w/ plan assignment (15 days in advance) Enrolled! 90 days to make a change State Actions to Ensure Managed Care Enrollment Success! • ODM took great strides to ensure impacted families were aware of 7/1 changes • Facilitated stakeholder workgroup – met regularly to determine process • Crafted “friendly letter” to introduce concept of managed care • Allowed plans to provide approved educational materials and speak to members prior to normal enrollment timeframes • Allowed additional time for families to make plan selection ODM Communication Tactics • January 2013 - State Notice to Trade Associations • March 2013 – “Soft” letter to families advising of the opportunity to enroll their child into Managed Care – Enrollment Packets mailed to families • April 2013 - Families began to choose a MCP – ODM posted FAQs to www.medicaid.ohio.gov • May 2013 – “Tentative” auto assignment file to health plans • New! - MCP encouraged to reach out to members before effective date • July 1, 2013 – New membership began! – Have until November 30th to make plan changes 13 Children with Special Healthcare Needs Characteristics Where they live: Language: • • • • • • • • • • Cuyahoga County-10,374 (20.55%) Franklin County – 5725 (11.34%) Hamilton County- 5683 (9.28%) Lucas County- 3578 (7.09%) Montgomery – 2539 (5.03%) Summit – 2446 (4.85%) Race: • • • • • White- 51% Black or African American – 47.91% Asian-0.54% American Indian/Alaskan Native- 0.09% Native Hawaiian/Pacific Islander – 0.03% *Source 14 – Office of Medical Assistance, March 2013 English – 97.91% Spanish – 1.30% Spanish/English bilingual - 0.21% Somali - 0.21% Services: • • • • • • Mental Health Services – 27.85% Medicaid School Program – 19.68% FQHC – 8.41% Targeted Case Management – 7.31% Home Health – 4.84% Ohio Dept. ALC/Drug Addictive Services – 1.32% Transition Requirements Greg Meredith Molina Health Care History Children with Special Health Care (CSHCN) effective 7-1-13 state wide for all Managed Care Organizations (MCO’s) Moves children from Fee for Service (FFS) to a managed care environment MCO’s develop Transition of Care (TOC) plans Purpose To ensure continuity of care for members that have chronic or catastrophic illness and are in an active course of treatment. To provide care coordination for prescheduled health services, access to preventive and specialized care, care management, member services, and education with minimal disruption to members’ established relationships with providers and existing care treatment Improve service and decrease cost Who will be covered? Aged, Blind and Disabled (ABD) Members under the age of 21 with Supplemental Security Income (SSI) indicator What will be covered? Scheduled health care appointments Prescribed drugs Scheduled lab/radiology tests Planned and/or approved surgeries (inpatient or outpatient) Home health care services Necessary durable medical equipment (DME) Ancillary or medical therapies Private duty nursing (PDN) Medical Supplies How will services be covered? Scheduled Health Care Appointments d a y s 3 0 m e m b e r C F C ABD under 21 or SSI – 90 days up to 180 days if needed unless in Care ABD 21years or older – 90 days Management – 90 days Planned and/or approved surgeries (inpatient or outpatient) – If prior approved Ancillary or medical therapies – Ongoing Chemotherapy or radiation treatment Prescribed Drugs – No prior Authorization (PA) for 30 days or one refill Scheduled lab/radiology tests – If prior approved Dental and Vision Services – If prior approved Organ, bone marrow or hematopoietic stem cell transplants, MCP must receive prior approval from ODM to transfer services to a par provider. Management – 90 days continued Home Health Care Services/Private Duty Nursing, DME/Medical supplies • Current level with current provider • Home visit by RN • Medical necessity • The ABD member is in her third (3) trimester of pregnancy and has an established relationship with an obstetrician and/or delivery hospital. Care Coordination Kim Crandall United Healthcare Community Plan Care Management Model • A member is assessed within 30 days of the point of identification and a Care Plan is created. Person M • MCP reviews the member’s records and pharmacy information from ODM’s FeeFor-Service encounter data. S P Health Plan Caregiver Clinicians, Facilities • The Care Manager holds a minimum of quarterly visits with the member. The Field Care Manager • Licensed Registered Nurse or Social Worker  Expertise in case management, coordination of care and community resources  Intensive classroom orientation plus additional self guided learning experiences & ongoing in-service/educational programs on topics related to member needs, Care Coordination activities, & resources  Community based RN or SW in field to conduct assessments, develop care/service plans, & access resource information  Teams grouped by geography in close proximity to members served  Coordinates plan covered benefits, in collaboration with local medical and behavioral health providers, along with familiarity with local community resources 25 Connected care is all about you. • 26 As our member, you get to decide who is included as part of their care team with support from the care manager. Your Primary Care Physician is a part of the core team, along with family, caregivers and other specialists important to your care. Members Matters 27 Care Coordination and Follow-up • Effective care coordination includes the member, the current treating practitioner or facility, the practitioner or facility at the next level of care, and, as appropriate, the member’s family, the Primary Physician, Psychiatrist and relevant community resources • Coordinated activities include: – Ongoing assessment of the member’s clinical needs – Communication with the member and their family about the treatment process – Coordinating, with the member’s consent and in a timely manner, a discharge or transfer plan to the treating practitioner or facility at the next level of care and to the Primary Physician and Psychiatrist – Identifying the needs of the member following discharge from facility-based treatment, and, as appropriate, ensuring that the member has the means to meet those needs; – Ensuring that the facility has scheduled for the member an outpatient appointment for follow-up care within 7 days of discharge 28 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Respite Julie Hoskins Paramount RESPITE CARE • Effective January 1, 2014 • Offered by Ohio’s five managed care plans, through ODM • Offered to members and their families who meet the criteria • • under the age of 21 who are determined eligible for social security income for children with disabilities; OR supplemental security disability income for adults disabled since childhood • Prior Authorization is required for all Respite Care Services • Provide short-term, temporary relief to the informal, unpaid caregiver of an individual in order to support and preserve the primary caregiving relationship. • Provided on a planned or emergency basis and shall only be furnished in the member's home. • The provider must be awake during the provision of respite services and the services shall not be provided overnight. ELIGIBILITY CRITERIA • Member must reside with informal, unpaid primary caregiver • Member must reside in a home/apartment that is not controlled by any health-related treatment or support service • Member must not be in foster care • Member must be enrolled in the MCP’s care management program • Member must be determined by the MCP to meet an institutional level of care as set forth in Administrative Code rules 5160-3-07, 5160-3-08 • Member must require skilled nursing or rehabilitative services at least weekly • Member must receive at least 14 hours per week of home health aide services • For at least six consecutive months preceding the request for respite care COVERAGE/LIMITATIONS • Services are limited to no more than 24 hours per month/250 hours per year • Services must be provided by enrolled Medicaid providers who meet the qualifications of the program, including a competency evaluation program and first-aid training • Services must not be delivered by the child’s legally responsible family member or foster caregiver • MCP staff trained to increase awareness of member’s who may benefit from this service; to facilitate referrals/requests • Provider education regarding new benefit • Allows caregivers the opportunity to “refuel and replenish” TAKE AWAYS/OPPORTUNITIES • Few actual requests to date • Likely have respite services within current home health care authorizations • Recognize the importance of this service • Opportunities through transition process • Continued comprehensive education and outreach including providers, members, family members and MCP staff Questions Plan Contact Information Managed Care Plan Website Buckeye Community Health Plan 1-866-246-4358 TTY: 1-800-750-0750 www.bchpohio.com CareSource 1-800-488-0134 TTY: 1-800-750-0750 www.caresource.com Molina Healthcare 1-800-642-4168 TTY: 1-800-750-0750 www.molinahealthcare.com Paramount 1-800-462-3589 TTY: 1-888-740-5670 www.paramounthealthcare.com UnitedHealthcare Community Plan 1-800-895-2017 TTY: 711 www.uhccommunityplan.com