Medicare Medicaid

Alignment Initiative (MMAI)

November 14, 2014

MMW work is supported by

grants from:

• The Chicago Community Trust

• Michael Reese Health Trust

• The Retirement Research

Foundation

Who We Are: Leadership • AgeOptions

–Area Agency on Aging (AAA) for suburban

Cook County

• Health & Disability Advocates

–Policy and advocacy group

• Progress Center for Independent Living

–Cross-disability, non-residential – suburban Cook County

What We Do

• Gather and create practical, accessible information and materials

• Educate Medicare consumers, service providers and policymakers

• Problem solving – individual and systemic

• Provide training and technical support for professionals and volunteers

• Advocate for consumer focused laws and policies

• Target underserved groups

What We Will Cover Today

• Background of Illinois Managed Care

Transitions

• Medicare Medicaid Alignment Initiative

(MMAI)

– Who does MMAI Affect?

– How Does MMAI Work?

– MMAI Enrollment

– Tips for Assisting Consumers with MMAI

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Background of

Illinois Managed

Care

Background - Illinois Managed

Care Transitions • State Initiatives

– Public Act 96-1501, January 2011: Illinois must move 50% of all Medicaid recipients into “risk-based care coordination” by 2015

– Save Medicaid Access and Resources Together Act (SMART Act), May 2012: Save $16.1 million by integrating care for most complex Medicaid beneficiaries (acute, primary, behavioral, and long-term services and supports)

“Care Coordination” vs. “Managed Care”

Care coordination: Using a primary point of contact

to establish communication and collaboration

among a patient’s health care providers to ensure

that:

• Individuals receive appropriate care and information

about his/her care

• services are not duplicated or conflicting

• patient receives appropriate follow-up to ensure

improvement of condition(s)

(http://www.wisegeek.com/what-is-carecoordination.htm)

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“Care Coordination” vs. “Managed Care”

• Managed care: a system of financing and delivering health care, involves the use of a “managed care organization” (MCO) that is responsible for implementing techniques generally designed to reduce cost of care and improve quality. Techniques may include care coordination and/or integrated delivery systems (provider networks), utilization review, emphasis on preventive care, or financial incentives to encourage members to use care efficiently

(http://en.wikipedia.org/wiki/Managed_care)

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Illinois – Multiple Entities Involved

• Managed Care Organizations (MCO’s)

• Managed Care Community Networks (MCCN’s)

• Accountable Care Entities (ACE’s)

• Care Coordination Entities (CCE’s)

– Serve specific populations – some for older adults and/or people with specific disabilities, some for children with complex medical needs

Provider

Based

Entities

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Illinois – Multiple Entities Involved

ACE’s

CCE’s

State Pays Care

Coordination rate to entity,

medical services still paid

for separately by state

(fee-for-service).

Entity takes on “full risk”

– state pays a capitated

rate to entity; entity pays

providers for services.

MCO’s

MCCN’s (MCCN’s may start

at full risk or may

progress to full risk

over time)

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Illinois – Multiple Entities Involved

• See Department of Healthcare and Family

Services (HFS) Rollout Chart and Map here:

– Fact Sheet: http://www2.illinois.gov/hfs/SiteCollectionDocuments/CCRollOutFactSheet.pd

f

– Chart: http://www2.illinois.gov/hfs/SiteCollectionDocuments/CC_rolloutchart.pdf

– Map: http://www2.illinois.gov/hfs/SiteCollectionDocuments/CCExpansionMap.pdf

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Illinois Managed Care Initiatives Affecting

Older Adults & People with Disabilities

(AABD/SPD Medicaid)

• Integrated Care Program

• Medicare/Medicaid Alignment Initiative

(MMAI)

• Innovations Project

– Care Coordination Entities (CCE’s)

– Managed Care Community Networks (MCCN’s)

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Illinois Managed Care Initiatives Affecting

Children, Families, and ACA adults

• “Mandatory Managed Care Program”

– Children, families, and the new Medicaid

category known as “ACA adults” are also being

rolled into managed care initiatives in certain

areas of the state

• Managed care organizations (MCO’s)

• Managed Care Community Networks (MCCN’s)

• Provider-based Care Coordination Projects (CCE’s,

ACE’s)

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Medicare Medicaid

Alignment Initiative

(MMAI)

Background - MMAI • Centers for Medicare and Medicaid Services (CMS)

issued demonstration project to increase care

coordination for dual eligibles (people with

Medicare and Medicaid)

• Illinois application approved February 22, 2013

• Memorandum of Understanding between CMS and

state of Illinois available here:

http://www.cms.gov/apps/media/press/factsheet.as

p?Counter=4547

Who Will MMAI Affect?

• Full benefit dual eligible beneficiaries (people with

Medicare and full Medicaid benefits – not

“spenddown”) who are:

– Over the age of 21 and in the “Seniors and Persons with

Disabilities (SPD)” Medicaid category (also known as AABD)

– Do not have high level third-party (private) insurance

– Are not receiving Developmental Disability Waiver services

– Living in Chicago area or Central Illinois:

• Chicago: Cook, Lake, Kane, DuPage, Will, and Kankakee counties

• Central IL: Knox, Peoria, Tazewell, McLean, Logan, DeWitt,

Sangamon, Macon, Christian, Piatt, Champaign, Vermilion, Ford,

Menard, and Stark counties

How Does MMAI Work?

• HFS contracts with managed care companies to

coordinate all medical, pharmaceutical, behavioral

health, and long term services and supports (like

Phase 1 and 2 of the ICP combined).

– One plan will cover all services (Medicare Parts A, B, D,

and Medicaid) - members will no longer need to find

providers who accept Medicare and Medicaid (will need

to use plan’s network instead)

How Does MMAI Work?

• Plans may not charge higher cost-sharing than

traditional fee-for-service Medicaid

• Consumers must use plan network providers

• 180 day transition period

• Must cover out of network emergency care

• Plans will have some flexibility to provide

services that are not currently covered by

Medicare and Medicaid (if they choose)

How Does MMAI Work? • Care Management Services will be offered to all

enrollees to help coordinate medical services

and long term services and supports (LTSS)

– All enrollees will be assigned a Care Coordinator and

have access to an Interdisciplinary Care Team (ICT)

within their MMAI plan.

• Care Coordinator standards/training, caseloads, and contact

requirements are based on the individual’s “risk” level

(health risk screening conducted in first 60 days of

enrollment) and specific Home and Community Based

Service (HCBS) Waiver requirements

– “High risk” enrollees must be contacted by the ICT at least every 90

days

MMAI Enrollment

• Enrollment is conducted through the Client

Enrollment Broker

• Call Client Enrollment Broker at

1-877-912-8880 to

– Enroll, opt out, or disenroll from program

– Compare provider networks

– Find plan’s drug formularies

MMAI Enrollment

• Client Enrollment Broker is an objective third

party entity – no relationship to any plan

• Before calling the Client Enrollment Broker,

client should have

– Social Security Number

– Name(s) of preferred primary care provider, hospitals and

clinics

– Medication list

– Be able to say name and language needed in English (if

needing to use teleinterpreter services)

• Can also use an authorized representative

Visit enrollhfs.illinois.gov/choose/compare-plans to

compare benefits. Client Enrollment Broker will also

assist with comparing plans and provider networks.

Scroll down

to compare

overview of

plan

benefits

Go to plan website to view more detailed benefit information and find in network

providers. Must call Client Enrollment Broker or fill out paper application to enroll.

MMAI Enrollment:

For individuals who are not receiving

Long Term Care Supports and Services

(LTSS)

MMAI and LTSS

Long Term Services and Supports (LTSS)

– Help individuals perform activities of daily living

(eating, cooking, bathing, getting dress, cleaning,

etc)

– May be provided in a long term care facility or

through home and community based services

• 5 home and community based Medicaid waiver

programs included in ICP (Aging – Community Care Program, Disability, AIDS, Traumatic Brain Injury, Supportive

Living Facility)

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Voluntary Enrollment-

Individuals not receiving LTSS

• Began March 2014

• Letters were sent to individuals about 30 days

before voluntary enrollment began explaining the

program and their options

• Clients responded to letter by:

1) Choosing to voluntarily enroll in an MCO of their

choice, OR

2) opting out of the program entirely

Passive Enrollment-

Individuals not receiving LTSS

• Began June 2014

• Individuals automatically enrolled into an MCO after

June 2014 if they did not make a choice during

Voluntary Enrollment

• Passive enrollment conducted in phases

-maximum enrollment of 5,000 beneficiaries/month in the

Chicago area, and a maximum of 3,000 beneficiaries/month in

Central Illinois

Passive Enrollment-

Individuals not receiving LTSS

• Clients received a notice about 60 days before they were

passively enrolled into a plan. Clients had the option to

1) Not respond to the letter and be automatically enrolled

in the MCO listed on the notice

2) Respond to the letters by choosing an MCO of their

choice

3) Opt out of the program entirely to continue to receive

regular Medicare and fee-for-service Medicaid

Once Enrolled-

Individuals not receiving LTSS

• Once a client is enrolled into an MCO, they can

change plans on a monthly basis throughout

year

– will not be “locked” into a plan

• Can disenroll from the program at any time of

the year to receive regular Medicare and fee-

for-service Medicaid (unless receiving LTSS)

• Can change PCP at any time (changes will

occur within 30 days)

MMAI Enrollment:

Individuals receiving LTSS

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Passive Enrollment:

Individuals receiving LTSS

• First letters mailed in September 2014

• Same options as individuals not receiving LTSS:

– Choose an MMAI plan and enroll

– Opt out of the program to continue receiving medical services

through regular Medicare and fee-for-service Medicaid

– Accept passive enrollment into MMAI plan

• Clients have about 60 days from receiving the notice to

make their coverage decision or they will be passively

enrolled into the plan listed on their letter

BUT…

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Managed LTSS Program

• Individuals who opt out of MMAI will be put into

“Managed LTSS” (MLTSS)

– Through MLTSS program, they will need to choose an

MCO to cover their LTSS services (same plans as MMAI).

Medical services will be covered by regular Medicare and

fee-for-service Medicaid. Prescriptions will be covered

under Medicare Part D.

– Will be locked in to MLTSS plan choice for one year from

date of enrollment.

• Individuals can still choose to opt back into the MMAI

program to receive ALL of their services through one plan

at any time of the year

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Options for Individuals with LTSS

MMAI • Medical and LTSS services

covered by MCO

• Can change plan or opt out at any time

MLTSS

• LTSS services covered by MCO

• Medical services through FFS Medicare/Medicaid

• Locked in for 1 year

Opt out of MMAI…

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MMAI Plans • Illinois Department of Healthcare and Family Services

has chosen 8 plans to provide MMAI services:

• Chicago area (Chicago and surrounding suburbs)*: – Aetna Better Health – IlliniCare (Centene) – Meridian Health Plan of Illinois – HealthSpring – Humana – Blue Cross/Blue Shield of Illinois

• Central Illinois: – Molina Healthcare – Health Alliance

* Note: Not all of these plans will be available in every county – visit

http://enrollhfs.illinois.gov to see which plans are available in a specific county

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MMAI Tips for Assisting Clients -

Letters

• Clients are receiving multiple letters from multiple sources about coverage transitions – can be very confusing – MMAI Enrollment Packet from Client Enrollment Broker

– Letters from Medicare Part D plans

– Letters from MMAI plans (that client will be auto-enrolled into if they do not make a voluntary choice)

• If a client gets the wrong letter (e.g., Integrated Care Program letter instead of MMAI letter), DHS system information may be incorrect!

(Contact DHS caseworker to correct immediately.)

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MMAI Tips for Assisting Clients -

Navigating Plan Network, Services

• If client’s providers are not in the plan’s network, client can communicate with them to encourage network participation – 180 day transition period

• Each client should be assigned a Care Coordinator – make sure clients have contact with that person

• Utilize MMW Desktop Guide for Navigating MMAI Insurance Plans (in Managed Care Toolkit here: http://www.ageoptions.org/services-and-

programs_MMW-MedicaidandManagedCare.html)

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MMAI Tips for Assisting Clients -

Navigating Plan Network, Services

• MMAI Ombudsman

– Unbiased advocate who can assist clients who are experiencing issues with their MMAI plan

– Contact the Illinois Department on Aging Senior Helpline at 1-800-252-8966 to be referred to a client’s local MMAI ombudsman program

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MMAI Tips for Assisting Clients -

Opting Out of MMAI and

Medicare Part D

• If an individual opts out of MMAI after being enrolled (either voluntarily or through auto-enrollment), s/he will need to re-enroll in a Medicare Part D plan (this will NOT happen automatically!)

• If the person does not re-enroll in a Part D plan, s/he can use the LINET program to get prescriptions at the pharmacy and be auto-enrolled into a Part D plan. For more information about LINET, see our MMW LINET fact sheet here: http://www.ageoptions.org/documents/LimitedIncomeNetProgram-LOCKED.docx

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For More

Information…

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Resources on Illinois Managed

Care and Care Coordination • HFS website on Care Coordination:

http://www2.illinois.gov/hfs/PublicInvolvement/cc/Pages/default.aspx

(MMAI proposal and information, information about Innovations Initiative)

• Client Enrollment Broker Materials page:

http://enrollhfs.illinois.gov/program-materials

(informational materials about each program – child/families/ACA adults program

is called “Mandatory Managed Care Program”)

• Make Medicare Work Coalition Managed Care Toolkit

http://www.ageoptions.org/services-and-programs_MMW-

MedicaidandManagedCare.html

(Includes ICP & MMAI fact sheets, recorded webinars, enrollment timelines, and

other resources)

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MMW Website

• Please visit our website at

http://www.ageoptions.org/services-and-

programs_makemedicarework.html to...

– Access our materials on Medicare, Medicaid, and

the Affordable Care Act

– Sign up for our e-mail list to receive registration

information for our webinars, trainings, and

meetings and to receive our alerts, bulletins, and

other healthcare related materials

– View our Calendar of Events

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Thank you!

If you have questions, contact:

AgeOptions

(800)699-9043

This presentation was supported in part by grants from the

Chicago Community Trust, the Retirement Research

Foundation, the Michael Reese Health Trust, and an

anonymous donor.