Key Provision of the Ohio Dual Demonstration:

1. WRAAA Annual Luncheon Cleveland, OH April 16, 2013 Key Provision of the Ohio Dual Demonstration: Integrated Care Delivery System (ICDS) • Larke Recchie • recchie@ohioaging.org • (614) 481-3511 Ohio Association of Area Agencies on Aging www.ohioaging.org Facebook: o4aadvocacy Twitter: @o4aadvocacy

2. Enrollment • Voluntary enrollment: September 2013 • Passive enrollment: phased in by region Oct.–Dec. 2013 • Who will assist with enrollment? • Enrollment broker, OSHIIP, ADRN (AAAs, CILS, other human services) Possible $4 million fund • How to roll out information for current dual eligible individuals? (Enrollment work group) • Regional meetings (providers in morning and consumers/advocates in afternoon • “Tiered messages” to consumers • Branding: My Care Ohio • Notices (CMS vs state) Key Provision of the Ohio Dual Demonstration: ICDS

3. Care delivery model Managed Care Plans coordinate services through a person-centered planning process Plans must contract with AAAs to coordinate HCBS waiver services for enrollees over age 60 Financing CMS capitated financial alignment model Benefits Nearly all Medicare and Medicaid services and plan flexibility to add benefits Key Provision of the Ohio Dual Demonstration: ICDS

4. Targeted population Est. 114,00 beneficiaries Excludes those with developmental disabilities Only Full duals are included People with credible 3rd party insurance are excluded Ombudsman Existing State Long-term Care Ombudsman will offer: Individual advocacy Independent systemic oversight Each MCO is required to have consumer advisory panels Key Provision of the Ohio Dual Demonstration: ICDS

5. Rates: Participating plans receive capitation rate reflecting the integrated delivery of Medicare and Medicaid benefits based on: • Baseline spending in both programs. • Anticipated savings resulting from integration & improved care. • Readiness Review: Ongoing process to asses plans’ Medicare and Medicaid experience and Demonstration readiness. • Two-step process that includes an onsite and desk review of participating plans. • Massachusetts first state to begin. Next Steps

6. 7 ICDS Regions

7. Northwest: Aetna and Buckeye Southwest: Aetna and Molina West Central: Molina and Buckeye Central: Aetna and Molina Northeast Central: CareSource and United East Central: CareSource and United Northeast: Buckeye, CareSource, United Health Plans by Region

8. Overall: • Massachusetts, Ohio, and Illinois have approved capitated Demonstrations • Washington State has an approved managed fee-for-service Demonstration • Continuing to work with over 20 states on initiatives to better integrate care. • Approved Demonstrations www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialModelstoSupportStatesEffortsinCareCoordination.html Demonstration status nationally

9. Implementation and Monitoring: • Ongoing milestones that allow CMS and States to monitor demonstration plan as enrollments begin. • CMS and the State have the right to stop enrollment at any time. • Evaluation: • Contracted independent evaluator (RTI); and • State-specific evaluation plans Considerations

10. Illinois got MOU signed February 22, 2013 • 135,825 eligible beneficiaries in 2 regions • Voluntary enrollment Oct through December 2013, May begin passive enrollment in January 2014 • May keep out of network providers 180, special exceptions after • Care team led by care coordinator. Jointly develop care plan, review every 30 days for high risk, 90 days for moderate risk • Ombudsman created outside Medicaid office • Plans must offer contracts to LTSS providers to avoid redundant services Comparison to another state: Illinois

11. Front door role remains the same MCOs must contract with AAAs for waiver service coordination of NF LOC individuals over age 60 Provider rates protected 90 days to 1 year Consumer chooses LTSS specialists (WSC): PASSPORT care managers are default for people over age 60 ICDS will align with other HHS initiatives (CMS care transitions program) ICDS may contract with AAAs to do caregiver support, evidenced based disease management, provider network management ICDS Provisions Affecting AAAs

12. Annually, AAAs: • Answer 300,000 calls • Perform 45,000 assessments • Enroll 9,700 in PASSPORT • Care manage 43,000 frail people • Ohioans 60+ using Medicaid funded NFs down 14.5% in 12 yrs. despite 15% increase in 60+ population • PASSPORT has 99.3% satisfaction rate statewide • 25+ years of care management Successes

13. AAAs as Front Door to LTSS

14. The Ohio ICDS MOU requires ICDS Plans to default to AAAs as the preferred provider of waiver service coordination for individuals over 60 years old. Required Waiver Service Coordination: Delegated component of ICDS Plan care management. AAAs provide face to face services across all care settings of the ICDS Plan member’s choice, including the following: AAA Network Menu of Servicesfor ICDS Plans

15. Waiver Service Coordination/Care Management • Establish personal goals and plans of care • Address provider management issues • Develop disaster preparedness/back-up plans • Medication review • Provide health and safety review and problem resolution • Assist with transitions between care settings • Work collaboratively with other community-based programs to provide a seamless system of care for the Plan members Required Waiver Service Coordination

16. Care and Service Plan Review Face to face, in-home visits to: • Review of physical health systems, medical history, functioning (ADL/IADL), mental and cognitive abilities, social supports, environment, and financial resources (SSI, VA, HEAP, Homestead Exemption) • Provide disease management education • Recommend housing modifications, DME, and service plan updates • Coordinate benefits and confirm eligibility status • Review and revise disaster preparedness plan • Update care plans Required Waiver Service Coordination

17. Crisis Intervention • Psycho-, social, and environmental problem solving (non-medical) • Provide family and care giver education • Report abuse, neglect, exploitation • Resolve and report service delivery incidents Event-based Visits • Address changes in home environment, caregiver, physical/mental functional areas • Update care plans to address health and safety issues or areas of non-compliance Required Waiver Service Coordination

18. Institution-based Visits • Coordinate with payer to identify diagnosis, treatment, and expected length of stay • Advocate for member in discharge planning meetings • Assist with transition home Service Management • Order and adjust services as needed • Resolve service delivery issues and ensure service plans remain member-centered Required Waiver Service Coordination

19. Medicaid Resolution Assist with Medicaid redetermination and food stamp resolution Assessment of LTSS Need Including functional needs assessment, environmental assessment, social needs assessment Managing Member Care Through Independent Providers and Consumer Direction Required Waiver Service Coordination

20. Technical Assistance: Care Transitions Services Evidence-based transition services, such as the Coleman Care Transitions Intervention, are designed to assist MCO members transitioning from any health care facility to home. These services have been proven to significantly reduce hospital readmissions. Provider Management Assistance Potential Add-on AAA Services

21. Evidence-Based Wellness Programs Matter of Balance Chronic Disease Self-Management Program with special versions for individuals managing chronic pain and diabetes Healthy IDEAS Tai Chi Potential Add-on AAA Services

22. Caregiver Support Customized training and education Health and wellness programs Personal consultation Family mediation Caregiver planning Potential Add-on AAA Services

23. Firewall protections between the Front Door and Care Management/waiver service coordination Rates Enrollment process (transition) Interaction with 2 or 3 Plans and continued administration of Medicaid waiver programs for non-duals and those that are presumptively enrolled in Medicaid (before final Medicaid determination) Evaluation Continuing Issues for AAAs in ICDS

24. Budget Advocacy for Aging Issues Keeping the front door open, Restoring funds to rebalance Medicaid

25. Restore the 10% cuts ($3.6 million) for PASSPORT screening and assessment • Increase all PASSPORT provider rates by 3% • Permit individual care plans that fully support nursing home transition and diversion • Ensure all seniors have access to life-enhancing services no matter where they live both inside and outside the Integrated Care Delivery System • Fully fund Adult Protective Services across the state ($11 million) • Fund the Balancing Incentive Payment Program ($10 million Budget Priorities

26. PASSPORT assessors are the front door to link older adults to cost-effective in-home and community programs PASSPORT enrollment has stalled since July 2011 when 10% cuts to front door funding went into effect, forcing AAAs to lay off screeners and assessors HB 59 proposes only fractional increases to front door funding Not only is PASSPORT cost-effective, it also has 99.3% consumer satisfaction rate statewide 1. Restore front door funding

27. While rates for assisted living and adult day care services are increasing, all other PASSPORT providers are flat-funded after sustaining a 3% cut from the last budget Providers who have earned a Medicare-Medicaid certification get a higher Medicaid reimbursement rate than PASSPORT’s and thus many of them choose not to provide the PASSPORT service ALL provider rates need to be restored to ensure that seniors receive quality services without delay 2. Restore provider rates

28. o4a has submitted an amendment to the legislature that would restore front door funding and increase PASSPORT provider rates AAA representatives continue to follow-up with local representatives, especially those of the House Finance & Appropriations Committee Time to move to the Senate finance committee o4a amendment

29. Good News: • ½ of the request for increases in PASSPORT provider rates and PASSPORT front door activities are in the bill ($6 million) • Bad news: • Only ½ of the funding is included… • Funds for the Balancing Incentive payment Program were removed • MEDICAID EXPANSION WAS REMOVED Budget Advocacy: House Substitute Bill

30. Lower care plan ceilings arbitrarily limit access to necessary services The previous budget reduced the amount AAAs can spend on an individual’s care plan, from an average of $1,147 in FY 2012 to $1,060 in FY 2013 Lower care plan ceilings have lowered the quality of life for many older Ohioans Prescribed services are necessary to avoid or delay nursing home placement 3. Fund senior care plans

31. Rural Ohioans should benefit from the same enhanced services being made available in the ICDS counties The Integrated Care Delivery System (ICDS) will offer an array of new home care services, but only seniors living in 29 predominantly urban and suburban counties are included in the ICDS The state is essentially creating two separate but unequal long-term care systems—one for poor communities and a better one for metropolitan areas Level of service shouldn’t be determined by where you live, but by your needs 4. Treat seniors equally

32. 39 counties do not have enough funding to have full-time adult protective workers • Older Ohioans deserve protection from abuse, neglect, and exploitation • o4a has testified in support of the Ohio Elder Justice Act • This bill would expand the definition of “elder abuse” to include financial harm and make permanent the Elder Abuse Commission, among other provisions that strengthen Adult Protective Services Law 5. Fully fund Adult Protective Services

33. Medicaid expansion makes Ohio stronger by improving the health outcomes of more people of all ages o4a estimates that not extending Medicaid eligibility would force $30 million in cuts to PASSPORT and other aging services over two years If such drastic cuts take effect, older Ohioans might have to go to expensive nursing facilities or be left on their own Extend Medicaid Eligibility

34. WRAAA Annual Luncheon Cleveland, OH April 16, 2013 Thank you Stay in touch with Ohio Association of Area Agencies on Aging • Larke Recchie • recchie@ohioaging.org • (614) 481-3511 Ohio Association of Area Agencies on Aging www.ohioaging.org Facebook: o4aadvocacy Twitter: @o4aadvocacy