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Overview: Expansion of Special Needs Basic Care NAMI Minnesota November 5, 2011

Overview: Expansion of Special Needs Basic Care NAMI Minnesota November 5, 2011. Pam. Parker @state.mn.us Richard.Seurer@state.mn.us. Outline of Session. Minnesota Health Care Managed Care Programs Special Needs Basic Care (SNBC) Coordination with Medicare and Medicare Part D

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Overview: Expansion of Special Needs Basic Care NAMI Minnesota November 5, 2011

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  1. Overview: Expansion of Special Needs Basic CareNAMI Minnesota November 5, 2011 Pam.Parker@state.mn.us Richard.Seurer@state.mn.us

  2. Outline of Session • Minnesota Health Care Managed Care Programs • Special Needs Basic Care (SNBC) • Coordination with Medicare and Medicare Part D • New legislation about enrollment changes in Special Needs Basic Care • SNBC Enrollment phase in and opt out process • Rights of Enrollees • Where to get assistance with enrollment • Things to consider when enrolling in SNBC • How to help people with enrollment decisions • Stakeholder process and involvement

  3. Overview Minnesota’s Managed Care Public Programs

  4. What Do We Get From Health Plans? • Health plans provide additional customer services, interpreter services, 24/7 nurse lines, navigation assistance, care management, transportation, and oversight not included in current FFS systems • Since Medicare Part D is now delivered through managed care, to coordinate drug coverage we need to work with Medicare plans • Working with health plans also participating in Medicare provides a mechanism for improving coordination between Medicare and Medicaid service delivery and financing • Health plans help leverage network access for people who have difficulty accessing providers on their own (such as dental care) • Health plans help direct/manage providers to encourage preventive care, best practices, care protocols, and work to measure improved health outcomes across populations • Health plans conduct quality assurance and performance improvement programs, disease management programs, pay for performance programs and other incentives for improving and overseeing care • Health plans have flexibility to pay providers and arrange care differently to address access issues where State cannot • Administrative costs in MN health plan public programs are among the lowest in the US, and are reasonable (about 8%) • All plans working with DHS are non profit

  5. Minnesota Public Programs Contracted Managed Care Organizations (MCOs) Health Maintenance Organizations (HMO) County-Based Purchasing (CBP) Entities Itasca Medical Care (IMC) PrimeWest Health System (PW) South Country Health Alliance (SCHA) • Blue Plus • HealthPartners • Medica • Metropolitan Health Plan (MHP) • UCare Minnesota

  6. Enrollment Numbers • Managed Care Enrollment Summary By Benefit October 2011 • MA Under 65……………………………………..404,200 • SNBC………………………………..…..5,681 • PINS ………………….................. ..........391 • MSC+……………… ……………… …11,849 • MSHO………………………………..…36,762 • MinnesotaCare-MA……………….…124,239 TOTAL MANAGED CARE 583,122 • http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_141529

  7. What is Special Needs BasicCare? (SNBC) • SNBC is a managed care program designed with stakeholders especially for people with disabilities who have Medical Assistance (Medicaid). • The goal of SNBC is to assure access to primary and preventive care for members • SNBC can also assist in coordination of physical and mental health needs. • Enrollment in SNBC is voluntary. • SNBC started in 2008 and has about 6,000 enrollees in 78 counties. • The State contracts with 5 health plans to provide SNBC. • SNBC enrollees have access to a care coordinator, care guide or navigator to help them get physical health care, mental health services, and support services.

  8. Services for SNBC Members • People enrolled in SNBC have access to all of the same basic care services provided under Medical Assistance. • All Medicaid mental health benefits including Mental Health Targeted Case Management are also included in SNBC. • Up to 100 days of Medicare or Medicaid nursing facility coverage and home health aide and skilled RN visits are covered under SNBC by the health plan. • SNBC DOES NOT INCLUDE personal care, ICF-MR, home and community based services, private duty nursing and county case management for people with developmental disabilities • These and other long term care services continue to be available through Medical Assistance fee-for-service for SNBC members.

  9. Adult Mental Health Rehab Services: Crisis Services, Assertive Community Treatment (ACT), Adult Rehabilitative Services (ARMHS), Intensive Residential Treatment Services (IRTS) Advanced Practice Nurse Services Cancer Clinical Trials Care Management Services - (Acute Medical) Chemical Dependency Treatment Services Child and Teen Checkups Children’s Residential Mental Health Treatment Chiropractic Services Clinic Services Dental Services Disease Management Family Planning Services Home Care Services - Specified: Home Health Aid (HHA), Skilled Nurse Visit (SNV), Home Care Therapies (PT, OT, RT, ST) Hospice Services Inpatient Hospital Services Interpreter Services Laboratory, Diagnostic and Radiological Services Medical Emergency, Post-Stabilization Care, and Urgent Care Services Mental Health Targeted Case Management Medical Supplies and Equipment Medical Transportation Services Mental Health Services including: diagnostic assessment and testing, crisis assessment and intervention, day treatment/partial hospitalization, individual and family group therapy, inpatient and outpatient treatment, neuropsycnologicai assessment and rehab, medication management Nursing Home services (100 days for people admitted from the community) OBRA Level 1 (NF) Obstetrics and Gynecological Services Outpatient Hospital Services Physician Services Podiatric Services Prescription and Over-the-Counter Drugs Not Otherwise Covered by Part B or D Prosthetic and Orthotic Devices Public Health Services Reconstructive Surgery Regional Treatment Centers (under certain circumstances) Rehabilitation and Therapeutic Services (PT, OT, RT.ST) Transplants Tuberculosis-Related Services Vaccines and Immunizations Vision Care Services Special Needs BasicCare (SNBC) SNBC COVERED SERVICES

  10. BASIC CARE SERVICES Abortion Services, as specified by State and Federal law Child Welfare Targeted Case Management Circumcision for Newborns, as specified by State law Individual Education Plan (IEP) and Individual Family Service Plan (IFSP) Services ICF-MR Services Long Term Nursing Home services (post 100 days) OBRA Level 2 assessments Personal Care Assistance Services (PCA) Private Duty Nursing (PDN) Vulnerable Adult - Developmental Disability (VADD) Targeted Case Management HOME AND COMMUNITY BASED SERVICES WAIVER SERVICES Community Alternative for Disabled Individuals (CADI) Community Alternative Care (CAC) Traumatic Brain injury (TBI-NF, TBI-NB) Developmental Disabilities (DD) Waiver Case Management Long Term Care Coordination (LTCC) OBRA assessments, Level 1 and 2 (waivers) Relocation Service Coordination (RSC) SERVICES COVERED ELSEWHERE Group Residential Housing (GRH) Medicare SSI SSDI IV-E Section 8 Housing Food Stamps Special Needs BasicCare (SNBC) SERVICES CONTINUED UNDER FEE-FOR-SERVICE Minnesota Department of Human Services

  11. How Does SNBC Work? • There are no premiums or additional costs for enrolling in SNBC. • People enroll by signing an enrollment form or having their guardians or authorized representatives sign it. • Members can disenroll (or enroll) in any month by sending a written request to the State or the MCO (effective the 1st of the next month). • SNBC health plans provide additional navigation assistance and care coordination to members to help them use the health care system. • SNBC plans are required to assist members to receive primary and preventive care physician visits. • SNBC health plans must also assist with coordination of Medicare benefits. • Some SNBC plans offer an integrated Medicare plan that includes Part D drugs.

  12. Key SNBC Contract Requirements • Health Risk screening within 30 days of enrollment • Medical home/Primary Care Clinic • Facilitation of annual physician visits • Broad availability and access to specialists, transportation and specialty DME suppliers • Extended health related case management • 24/7 RN call lines • Disability competent member services • Provide information to enrollees about clinic accessibility • Disease management programs specific to people with disabilities • Health plans will cover most Medicaid co-pays for both duals and non duals. • Communication protocols for working with counties and providers who are highly involved (eg residential, home health)

  13. Medicare and Special Needs Basic Care • SNBC health plans either directly manage or coordinate with Medicare Parts A, B, D coverage for people who are eligible for both Medicare and Medical Assistance (often called “Dually Eligible”). • Three of the SNBC plans also offer a Medicare Special Needs Plan (SNP) for people with disabilities that provides all Medicare services including Part D prescription drugs under one card. • SNBC members can choose to enroll in these “integrated” Medicare and Medicaid SNP plans. • For those who don’t enroll in a SNP Medicare remains fee-for-service including Part D drugs. • Some parts of the State do not have SNP options.

  14. SNBC and Medicare Part D Drugs • Medicare Part D is now responsible for most drugs for people who are dually eligible for Medicare and Medicaid. • Medicare eligible people must choose a Part D Plan. • Enrollment in SNBC will not change a person’s enrollment in a Medicare Part D Drug Plan. • SNBC plans must coordinate with Medicare Part D Plan coverage. • However, if a Medicare eligible SNBC enrollee chooses to also enroll in their SNBC plan’s Medicare SNP, their Part D coverage will change to that SNP plan. This allows coordination of all Medicare and Medicaid prescription drugs under one health plan. • Dual eligibles are charged copays for Part D drugs • Institutional enrollees are exempt from Part D co-pays • Health Plans MCOs are NOT ALLOWED to waive Part D Medicare drug co-pays per federal Center for Medicaid and Medicare Services (CMS) rules.

  15. How is SNBC Going for Enrollees • SNBC has low voluntary disenrollment rates (about 3%) • High satisfaction (60% rate health plan a 9 or 10 on scale 1-10) • 89% report they are satisfied with their involvement in planning and care • Low complaint and appeals rates • Over 30% of current SNBC enrollees have a serious mental health condition with over 80% having some mental health diagnosis • SNBC enrollees have more health and mental health need (about 15-20% higher) than average fee-for-service enrollees (Risk Scores) • Mental Health Targeted Case Management access rates in SNBC are also about 20% higher • DHS is working with the Institute of Community Integration at the U of M on a large evaluation related to SNBC • SNBC also is the platform for the Preferred Integrated Network (PIN) project, a partnership between Medica and Dakota County to integrate physical and mental health needs of enrollees • Case studies illustrate how SNBC can be beneficial for enrollees

  16. SNBC Payments • Medicaid payments to the health plans are “risk adjusted” based on the diagnoses and costs of each individual enrollee through the Chronic Disability Payment System • Payments have been specially adjusted to include additional provisions for mental health services and needs • This system will provide higher payments to health plans who enroll high cost enrollees, and lower payments for those who enroll more low cost enrollees • Payments are designed to be budget neutral to current fee for service costs for enrollees • Medicare also provides a separate risk adjusted payment for dual eligible enrollees for people enrolled in SNPs.

  17. Enrollee Rights • Enrollees of SNBC have access to the same rights to appeal Medicaid Assistance coverage issues as they do under fee for service. • Members receive explanations of these appeal rights upon enrollment and DHS also sends additional information during the year to all members. • Enrollees are encouraged to call the health plan to let them know of problems and can also make oral or written grievances/appeals to the health plan. • Enrollees can also appeal directly to DHS through the State fair hearing process or appeal both to DHS and the health plan. • For Medicare services, enrollees also have the right to appeal by contacting the health plan. • Enrollees can also call the Ombudsman for State Managed Health Care Programs for assistance: • 1-800-657-3729 or 651-431-2660

  18. When SNBC Enrollees have a question or a problem with access, services or billing, they may contact: • Health Plan Member Services. • The County Advocate. • The Ombudsman for State Managed Care Health Care Programs (651) 431-2660. • Care Navigator, Care Guide or Care Coordinator • DHS Appeals Office.

  19. Stakeholder Involvement • DHS developed SNBC with the assistance of a broad group of stakeholders, including disability advocates, consumers, counties, providers and health plan representatives. • This Statewide group will continue to meet to provide input to DHS in monitoring and oversight of SNBC. The group meets quarterly and meetings are open to the public. • Contact Cindy Czech 651-431-2514 to be added to the mailing list. • Each health plan participating in SNBC is required to have a similar local stakeholder’s group. • This is an opportunity for consumers and health plans to work together to improve SNBC on an ongoing basis.

  20. What are the Special Needs BasicCare Health Plan Options?

  21. SNBC EXPANSION

  22. SNBC Expansion Beginning Jan. 1, 2012, people with disabilities under age 65 (including children) who have Medical Assistance fee-for-service coverage will be asked to enroll in an SNBC health plan for their health care. Some people may be excluded. Anyone can choose not to enroll and “opt out” to stay in fee-for-service. Those who do not opt out will be enrolled. This expansion of SNBC was mandated by the 2011 Minnesota Legislature (256B.69, subd. 28)

  23. SNBC Expansion Legislation • New legislation requires that adults and children with disabilities receiving Medical Assistance (MA) be assigned to a Special Needs BasicCare (SNBC) health plan unless individuals choose to opt out of enrollment • Beginning Jan. 1, 2012, people with disabilities who have MA must be asked to join a health plan participating in SNBC. • People may choose to opt out of enrollment or to disenroll at any time and return to MA fee-for-service (FFS).   • Estimated 78,216 adults and 11,544 children with disabilities could be affected by the new law. • Preliminary analysis indicates about 19,600 (25%) of these adults have a serious mental illness. • Enrollment will be phased in between January and July 2012. The legislation projected that 50 percent would choose to opt out. • SNBC is still considered a “voluntary” program under federal regulations due to the opt out provision. • People enrolling under the new legislation for Medicaid would not be required to enroll in the Medicare SNP portion of SNBC but could do so at any time.

  24. New SNBC Enrollment Process • SNBC enrollment expansion will be phased in between January and July 1, 2012. • All potential enrollees will receive letters informing them of the new enrollment process. • The mailing will include information on SNBC, the health plan available in their county, their rights, the opt out process and how to contact the Disability Linkage Line for assistance. • An opt out form will be included . People who want to opt out can return the form by the deadline and they will not be enrolled. • People will NOT be enrolled before they are given a chance to opt out. • If they do not return the form, they will be enrolled in one of the plan choices in their area by the State. • People who have been enrolled can opt out at any time effective the next month. • People who opted out may also choose to enroll at a later time.

  25. SNBC Revised Implementation Schedule: First Phase: January 1, 2012 Adults (Approx. 8700), not on HCBS waivers, in counties currently served by Medica, SCHA and PrimeWest where there is only one plan choice (Counties with no choice of health plan – the person is enrolled in whatever health plan serves that county). The initial mailing notifying people of the managed care program called Special Needs BasicCare (SNBC) and the legislation enrolling them in a SNBC unless they choose not to join SNBC is expected to be sent the week of November 7th.

  26. Second Phase: February 1, 2012 Adults (Approximately 6300), not on HCBS waivers, in counties served by UCare where there is only one plan choice (UCare is the only health plan choice). The initial mailing notifying people of the managed care program called Special Needs BasicCare (SNBC) and the legislation enrolling them in a SNBC unless they choose not to join SNBC will be sent the week of December 5. Third Phase: March 1, 2012 Enroll adults on HCBS waivers (CAC/CADI/TBI/DD) in all counties (Approximately 20,628 adults) currently served by SNBC MCOs. The initial mailing notifying people of the managed care program called Special Needs BasicCare (SNBC) and the legislation enrolling them in a SNBC unless they choose not to join SNBC will be sent the week of January 2nd.

  27. Fourth Phase: April 1, 2012 Enroll all remaining adults (Approximately 41,000 adults not on waivers) in counties with choice currently served by SNBC MCOs. The initial mailing notifying people of the managed care program called Special Needs BasicCare (SNBC) and the legislation enrolling them in a SNBC unless they choose not to join SNBC will be sent the week of February 1st. Fifth Phase: July 1, 2012 Enroll all eligible children (approximately 11,000) statewide plus adults (Approximately 1900) in the 9 counties currently without SNBC MCO product. The initial mailing notifying people of the managed care program called Special Needs BasicCare (SNBC) and the legislation enrolling them in a SNBC unless they choose not to join SNBC will be sent the week of May 1sth.

  28. Enrollment Exclusions • Some people are excluded from enrollment in SNBC: • People with other cost effective insurance or other HMO coverage (5,488) • People with only Medicare A or only Medicare B • People living in IMD/RTCs • People receiving services through the Consumer Support Grant (CSG) • Other small groups such as people with ESRD, terminally ill individuals, torture victims, and American Indians in certain circumstances may be excluded. • Monthly spenddowns: SNBC will no longer enroll new members with monthly income spenddowns to enroll. • Current members with spenddowns may remain enrolled • Those already enrolled may continue in SNBC if they later incur a spenddown but they agree to pay the spenddown to the State.

  29. Enrollment Information • Phase-in enrollment mailings: • Each enrollment phase in group will be sent a mailing 45 days prior to their specific enrollment date with materials for enrolling in a plan or opting out. • The mailing will specify a date by which they must notify DHS that they want to opt out. • Future mailings • People who have chosen to opt out would receive information annually from DHS about current plan choices and the opportunity to enroll. • New Medical Assistance enrollees will be sent information on SNBC, current plan choices and the opportunity to opt out or enroll. • Tracking of those who opt out will be maintained by DHS • People are encouraged to call the Disability Linkage Line for assistance with enrollment if they have questions or need help with their options. (1-866-333-2466). • DHS will do the enrollments, not the counties.

  30. Medicare Assistance • People enrolling under the new legislation for Medicaid would not be required to enroll in the Medicare SNP portion of SNBC but could do so at any time. • Disability Linkage Line: assists Medicare recipients of all ages with problems with their Medicare coverage and with selecting a Medicare Part D plan (SNBC include Medicare Parts A, B & D benefits). • Disability Linkage Line: 1-800-333-2466 • The Linkage Line can also help with SNBC SNP choices • Medicare: answers questions about Original Medicare coverage. • 1-800-633-4227

  31. Information from the Health Plan • Shortly after enrollment enrollees should get information from the health plan including: • Evidence of Coverage • Explains what is covered and what is not covered by the health plan • How to get the care needed or prescriptions filled • What to do if unhappy with something related to getting covered services or prescriptions filled • Members rights and responsibilities • Health Plan Member Card • Card includes member ID on the front • Health Plan contact numbers are on the back (member services and 24-hour nurse line) • Carry member cards at all times • Provider Directory • A list of the Health Plan’s network providers • All health plan information must be reviewed and approved by the State.

  32. Things to think about when choosing a plan. • Get information about the doctors available to serve you and the hospitals and other health care providers affiliated with the plan. If you want to keep the doctors you are with find out which health plans your provider is associated with. Are your specialists associated with the health plan? • Determine whether the plan’s providers are in a location convenient to you and whether transportation is available for you. • Determine if your prescription drugs are covered by the health plan. • Find out about any additional benefits the health plan offers. • There is a good guide on the SNBC training site • (Go to MCO grid for comparison, and “Guide to Enrollment – on DHS website)

  33. Primary Care Clinic • Primary Care Clinic: the clinic you chose for your routine care. Most of your cares will be provided or approved by this clinic. The name of your clinic appears on your health plan card. • Must select a primary care clinic or one will be selected for you. • Some health plans allow you to choose a specialist as a primary care provider.

  34. Provider/Stakeholder/Family Assistance with Implementation • Providers/stakeholders can help individuals and assist with a smooth transition in the SNBC Expansion by: • Identifying which clients/individuals are likely impacted by the SNBC Expansion • Familiarize yourself and staff with the SNBC expansion implementation schedule, and the draft of the letter eligible people will be receiving in the mail from DHS. • At appointments/contacts, ask the individual if he/she received a letter from DHS about their health care coverage, did the individual open it and read it, review it with him/her, tell him/her that it is important (don’t throw it away), where he/she can get more information and help (DLL, SNBC website, MCO member services, MCO websites). • Encourage individual to discuss this information with their support networks such as family/friends.

  35. Provider/Stakeholder/Family Assistance with Implementation – (continued) • Download the “Guide for Enrollment” and distribute to clients/individuals • Assist in communication with DLL, if needed. DLL is happy to do three-way conversations: • Follow up with him/her at future contacts to see if the person has the needed information for person to make decisions, and take actions/mail response, if needed. • Help the individual transition (if changes in doctors, clinics, providers, to MCO/different MCO) • BE UNBIASED • GOAL: INDIVIDUAL MAKES INFORMED CHOICE/S

  36. What if your prescription is not on your copy of the formulary • Confirm the health plan does not cover the drug • Call your care navigator/care guide • Call member services • If the prescription is not covered • Ask your doctor if you can switch to another drug that is covered by the health plan • You or your doctor can ask to make an exception to cover your drug • If you recently joined the health plan you may be able to get a temporary supply of a drug you were taking when you joined the health plan. Work with member services or your care navigator on the transition.

  37. Transition Services • The health plan is responsible for care when an enrollee is changing from fee-for-service or from one health plan to another. The plan may develop a transition plan special situations. • Contact the plans member services when continuity of care is needed for this type of service, such as; • Services previously authorized • At risk pregnancy • Chemical dependency treatment service • Mental health services • Prescription drugs

  38. SNBC ExpansionInformation for Providers • Identify which and how many of your current and future clients will likely be impacted by the expansion of SNBC. • Identify which MCOs currently and in 2012 will serve eligible individuals residing in your service area. • Determine if your organizations contracts with the MCO/s to provide the services your organization is providing for your clients. Discuss with MCO topics, such as, strategy for “preparing for the expansion”, helping enrollees transition, and impact on referrals. • If your agency is interested in joining the provider network of MCO– Identify your organizations strengths, costs and questions to discuss with MCO/s. Contact MCO for discussion/information about contracting with the MCO/s. • DON’T contact MCO about specific individual client until after the client’s “Group” is enrolled – MCO will not have individual specific information until then.

  39. Provider Questions/Problems????? • Call the MCO first – most questions/problems can be resolved by contacting them directly. • If problem is not resolved, call the DHS Provider HelpDesk 651- 431-2700 who will put you in touch with a contract manager.

  40. Stakeholder Expansion Process • Regional Meetings • Topic Driven Workgroups • E-mail • Stakeholder Meetings • SNBC Web Site • www.dhs.state.mn.us/SNBC

  41. DHS Managed Care Staff Contacts • Pam Parker, Manager, Pam.parker@state.mn.us 651-431-2512 • Sue Kvendru, Senior Programs in Managed Care Program Policy sue.kvendru@state.mn.us 651-431-2517 • Deb Maruska, People with Disabilities Managed Care Program Policy deb.maruska@state.mn.us 651-431-2516 • Susan Kennedy, SNBC Coordinator Susan.kennedy@state.mn.us 651-431-4895 • Cindy Czech, Stakeholders Workgroup Cindy.czech@state.mn.us 651-431-2514 • JoAnn Jones, Lead Worker Service Implementation joann.q.jones@state.mn.us 651-431-2524

  42. Where to Access SNBC on the Web • The SNBC color map: • http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5218-ENG • Managed Care Enrollment Figures: • http://www.dhs.state.mn.us/main/id_018058 • SNBC web site: • http://www.dhs.state.mn.us/SNBC • Model Contract: • http://www.dhs.state.mn.us/main/groups/business_partners/documents/pub/dhs16_139481.pdf

  43. Acronyms • CAC- Community Alternative Care Waiver • CADI – Community Alternatives for Disabled Individuals Waiver • CBP – County Based Purchasing • CMS - Centers for Medicare and Medicaid Services • DD – Developmental Disability Waiver • Dual eligibles – Person eligible for both Medicare and Medicaid • DHS – Department of Human Services • EOC- Evidence of Coverage • EW- Elderly Waiver Program • FFS – Fee For Service • HMO – Health Maintenance Organization • MCO- Managed Care Organization • MHCP- Minnesota Health Care Program • MSC+- Minnesota Senior Care Plus • MSHO - Minnesota Senior Health Option • NF – Nursing Facility • PMAP - Prepaid Medical Assistance Plan • PINs- Preferred Integrated Network • SNBC – Special Needs BasicCare • SNP – Special Needs Plan • TBI- Traumatic Brain Injury • VADD - Vulnerable adult/developmental disability targeted case management services

  44. Thank You!! When Health Care Improves, Everyone Wins! Together, we will make health care work for people. Not to be copied or distributed without DHS permission.

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