John Arnold OCVIC Project Director jarnolduhcanohioorg 6144560060 x237 Making a difference Together Ohio Chapter of GAPNAs 7th Annual Continuing Education day Why Your Voice Matters ID: 271488
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Making Our Health Care System Work for Older Adults and People With Disabilities
John ArnoldOCVIC, Project Directorjarnold@uhcanohio.org614-456-0060 x237
Making a difference Together
Ohio Chapter of GAPNA's 7th Annual Continuing Education day
“Why Your Voice Matters”
March 14, 2015Slide2
The ProblemLimited care coordination
Fragmented CareCurrent system is confusing and difficult to navigateMultiple health care needs and high costThe health care and long-term care systems are not connected very well, even though people use both. 2Slide3
The Need
People with both Medicare and Medicaid are among Ohio’s highest need patientsThey are shuttled between multiple doctors who do not communicate with each other or recognize the whole person they are supposed to serve. As a result, these consumers often suffer from unnecessary tests, contradictory therapies and ineffective treatment.3Slide4
Dually Eligible in Ohio
4Currently Enrolled: 182,000 Ohioans9%
91%
40%
60%Slide5
Dual eligible beneficiaries are a
diverse population5Slide6
6
Cognitively or Mentally Impaired
3+ Chronic Conditions
In Fair or Poor Health
Dual Eligible Consumers are sicker than
other
Medicare Consumers
Functionally ImpairedSlide7
Answer7
A coordinated, managed care system that brings together all consumer needs and services under one umbrella called MyCare Ohio Healthcare doctor & Hospital
Long term Care (Passport,
Assisted Living, nursing home care)
Behavioral health/mental healthSlide8
MyCare Ohio
Demonstration to test integrated care and financing model for individuals with Medicare and Medicaid May 2014 to December 2017Federal and State partnership How it will work: Approved ICDS Plans will provide integrated benefits to Medicare and Medicaid enrollees in seven targeted geographic areasPlans must provide all necessary Medicare and Medicaid-covered services, including Medicaid waiver services Single identification card to access services 8Slide9
MyCare Ohio
Three-way contract (Health plan, CMS, State)Rolling start in mid-2014; passive enrollment in Medicare delayed until January 1, 2015Capitated rates adjusted for State and CMS upfront savings; also quality withholdComprehensive care plans required incorporating client and family goals9Slide10
Medicare Passive Enrollment (I)
Beneficiaries must participate in MyCare Medicaid; but Medicare is optionalOn 1-1-2015, individuals who have not indicated a choice, was passively enrolled in MyCare Medicare with the same health plan as their MyCare Medicaid (integrated benefits and funding)10Slide11
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 anytimeThis is all very confusing to consumers and public education has been poor 11Slide12
MyCare Ohio Demonstration
12Slide13
Health Plans by Region13
Northwest: Aetna and BuckeyeSouthwest: Aetna and MolinaWest Central: Molina and BuckeyeCentral: Aetna and MolinaNortheast Central: CareSource and UnitedEast Central: CareSource and UnitedNortheast: Buckeye, CareSource, UnitedSlide14
Who's Eligible?Age 18 and older at the time of enrollment
Eligible for full Medicare Parts, A, B, and D and full Medicaid, andReside in an ICDS Demonstration countyOhio Home Care or Transitions Carve-Out WaiversReceive AoD and/or Mental Health ServicesPassport or Choices WaiverAssisted Living Medicaid Waiver receiving Medicare and Medicaid14Slide15
You're Not Eligible if You're:
Under the age of 18On a delayed Medicaid spend down – (Delayed)If other third party creditable health care coverage is availableA person with Intellectual Disabilities (ID)or Developmental Disabilities (DD) served through an IDD 1915(c) HCBS waiver or an ICF-IDDEnrolled in PACEParticipating in the CMS Independence at Home (IAH) demonstration15Slide16
The Promise
16Single Point of ContactSingle ID Card for all Medicare and Medicaid ServicesNurse Advice Live – 24 hours a day, 7 days a weekCare Team – (Family, doctor(s), Care Coordinator, MyCare Ohio health plan, anyone else chosen) Better Care Coordination = Better Health outcomesProviders submit claims to 1 place Focus on Prevention and WellnessSlide17
The Promise (II)
17Slide18
Benefits for Primary Care ProvidersIdentifiable care manager – phone and email contact
Access to all benefits and servicesOpportunity to enhance home and community-based servicesWEB portal to access patient’s care planAssistance for your most complex patientsOpportunity to participate as part of Integrated Care TeamPotential to shift hospital dollars to community-based services18Slide19
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. 19Slide20
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 Requirements20Slide21
Cost of Inaction21Slide22
Crisis in Quality22Slide23
Implementation Issues
Consumers losing Independent Providers (Homecare and Nurses)Non-medical Long-term Services and Support –under 60Transportation issuesPrimary Care Providers – turning away patientsDurable Medical Equipment –not authorized 23Slide24
Ohio Consumer Voice for Integrated Care“What we do”
24
Consumer
Advisory
Council
Regional
Networks
SWOC, NEOC
Central
State –ODM
Federal - CMS
PlansSlide25
Critical Role of Provider and Consumer Engagement
Dual eligible patients will benefit from your participation in planning and direct care provision in MyCare OhioIf MyCare Ohio is not successful, the alternatives may be less desirable for patients and providersPrimary care and Geriatrics providers’ clinical leadership, when combined with consumer advocacy efforts, is more likely to have an impact25Slide26
How can Providers Get Involved?
Learn about MyCare OhioDiscuss good and bad observations with your health system, Area Agency on Aging, health plan medical directors, and State Medicaid office leadershipJoin advocacy organization list-servesHere’s the sign up link: http://uhcanohio.org/ocvic/primarycareproviders26Slide27
What You Can Do?“Vision”
Be part of the solution Help recruit consumer spoke persons to share their storyIdentify and help recruit others to join Consumer Advocate Conference call – (last Friday of every month) The call in number (free call) and participant code is: (877) 366-0711Participant code - 53257144#Provide a feedback loop to the Plan, Regional and State Coalitions.
27Slide28
Thank you
John Arnoldjarnold@uhcanohio.org614-456-0060 x23728
UHCAN Ohio
Ohio Consumers for Health
@
UHCANOhio
@
KathleenOCHC
Visit
www.uhcanohio.com/OCVIC