What’s Ahead for Ohio Medicaid?: Connecting Medicare and Medicaid Services

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

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

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

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

7. Region-by-Region • 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

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

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

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

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

12. Enrollment Process 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. Benefits • 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

14. ICDS Medical Services • 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 • 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

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

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 • 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. Care Management • 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

18. Care Management 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

19. Care Management 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

20. Care Management 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

21. Care Management 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

22. Quality Measures • 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

23. Provider Contracting • 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

24. Questions