Mi Health Link / MMAP

Today’s Agenda

• MI Health Link Overview• Eligibility Criteria• Benefits of MI Health Link• Covered Services• Enrollee Protections• What to Consider• Enrollment and Beyond

3

MI Health Link Program Overview

4

MI Health Link

A new program that joins Medicare and Medicaid benefits, rules and payments into one coordinated

delivery system called MI Health Link

MI Health Link

• Three year program beginning no earlier than March 1, 2015

• Three-way contract between Center for Medicare and Medicaid Services (CMS), Michigan Department of Community Health (MDCH) and MI Health Link health plan– The health plan contracts with Pre-paid Inpatient

Health Plan (PIHP) to deliver behavioral health services

• Provided in four regions in the state

6

Four Regions

• Region 1 - Entire Upper Peninsula

• Region 4 - Southwest Michigan (Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph and Van Buren counties)

• Region 7 - Wayne County

• Region 9 - Macomb County

7

Region 1 – Upper Peninsula

• MI Health Link health plan– Upper Peninsula Health Plan

• Pre-Paid Inpatient Health Plan – NorthCare Network

8

Region 4 – Southwest Michigan

• MI Health Link health plan options– Aetna Better Health of Michigan– Meridian Health Plan

• Pre-Paid Inpatient Health Plan – Southwest Michigan Behavioral Health

9

Region 7 – Wayne County

• MI Health Link health plan options– Aetna Better Health of Michigan– AmeriHealth– Fidelis SecureCare– HAP Midwest Health Plan– Molina Healthcare

• Pre-Paid Inpatient Health Plan – Detroit-Wayne Mental Health Authority

10

Region 9 - Macomb County

• MI Health Link health plan options– Aetna Better Health of Michigan– AmeriHealth– Fidelis SecureCare– HAP Midwest Health Plan– Molina Healthcare

• Pre-Paid Inpatient Health Plan – Macomb PIHP

11

Eligibility Criteria

Under 21

12


People may be eligible for MI Health Link if they:• Live in one of the four regions

• Are age 21 or over (CSHCS exluded)

• Are eligible for full benefits under both Medicare and Medicaid and

• Are not enrolled in hospice

13


• People enrolled in PACE and MI Choice are eligible, but must leave their programs before joining MI Health Link

• People with a deductible are not eligible for MI Health Link

• People in a nursing home are eligible and must continue to pay their patient pay amount to the nursing home

14

Benefits of Joining MI Health Link

1 Card4U

15

Benefits of MI Health Link

• No co-payments or deductibles for in-network services, including medications– Note that nursing home Patient Pay Amounts

will still apply

• One health plan to manage all Medicare and Medicaid covered services

• One card to access all services

16


• Person-centered care with a focus on supports for community living, not just doctor-driven medicine

• Access to a 24/7 Nurse Advice Line to answer questions

17


• Each enrollee will have a care coordinator who will–work with the enrollee to create a personal care

plan based on the enrollee’s goals–answer questions and make sure that the

enrollee’s health care issues get the attention they deserve– connect the enrollee to supports and services

needed to be healthy and live where they want

18


• Each enrollee will have access to an Integrated Care Team that will– include the enrollee’s doctors, providers,

and anyone else the enrollee would like to include–work with the enrollee to identify their

goals and preferences for care and services

19

Covered Services

20

Covered Services

• All health care covered by Medicare and Medicaid–Medications–Dental and vision services– Equipment and medical supplies–Physicians and specialists– Emergency and urgent care

21

Covered Services

• All health care covered by Medicare and Medicaid (cont.)–Hospital stays and surgeries–Diagnostic testing and lab services–Nursing home services–Home health services– Transportation for medical emergencies and

medical appointments

22

Covered Services

• Long Term Supports and Services (LTSS)–Personal care– Equipment to help with activities of daily

living–Chore services–Home modifications–Adult day program–Private duty nursing

23

Covered Services

• Long Term Supports and Services (LTSS) (cont.)–Preventive nursing services –Respite–Home delivered meals–Community transition services– Fiscal intermediary services–Personal emergency response system–Nursing home care

24

Covered Services

• Behavioral Health Services–Behavioral health services are those that

are provided to individuals who have a mental illness, intellectual/developmental disability or substance use disorder.

25

Covered Services

• Behavioral Health Services (cont.)–Behavioral Health services are accessed

through the Health plan, PIHP or local Community Mental Health Service Provider (CMHSP)

– If currently receiving services through the CMHSP, services will not change or be interrupted

26

Covered ServicesBehavioral health services are medically necessary services. Examples of behavioral health services may include:

– Individual, group and/or family therapy–Medication review–Supported employment–Community living supports (meal preparation,

laundry, chores, food shopping)

–Substance abuse treatment services (assessment, treatment planning, stage-based interventions, referral and placement)

27

Covered Services

• Additional services offered by the plan–Health plans can offer services not covered

by Medicare and Medicaid–Plans can enhance Medicaid and Medicare

services• May cover supplies or services more often• May cover a higher dollar amount when there

is a dollar limit on a service–Check Plan finder for enhanced services

29

Enrollee Protections

30


• MI Health Link follows the current grievance and appeal processes for Medicare and Medicaid services

• Enrollees will be offered appropriate appeals rights and directed through the notice letters which entity they should contact if they wish to appeal an action

31


• A MI Health Link Ombudsman Program will be available to help enrollees resolve problems and answer questions

• Health plans must offer a choice of providers and care coordinators

• Health plans must honor the continuity of care requirements

32


• Each MI Health Link health plan is required to have a separate Advisory Council specific to the program–1/3 of the Advisory Council must be

enrollees– The majority of members must be

enrollees, family members of enrollees and advocates

33


• The State will form a MI Health Link Advisory Committee for enrollees, allies, and advocates to give input and suggestions to help improve MI Health Link– Organized by MDCH– Provides a way for enrollees and stakeholders to

offer suggestions and feedback– Membership will represent the diverse interests of

stakeholders, especially enrollees

34


• Application forms for the MDCH Advisory Committee can be found here: http://www.Michigan.gov/MIHealthLink– Call 517-241-4293 if you need the form mailed to you

• A completed application form is required for consideration; a letter of reference is optional

• Completed applications can be sent to MDCH by email, fax or regular mail– Email: [email protected]

http://www.michigan.gov/MIHealthLink

http://www.michigan.gov/MIHealthLink

mailto:[email protected]

35

Enrollee ProtectionsContinuity of Care

The health plan must• Allow enrollees to continue to see current doctors and

providers during the transition period

• Pay out-of-network doctors and providers during the transition period at no cost to the enrollee

• Allow choice of personal care service providers including paying family members or friends to provide the service

• Work to bring providers into the health plan’s network

• Cover current medications

36

The health plan must• Honor current authorizations for services– These could be reported to the plan by the

enrollee– Personal Care authorization information is

provided to the plan by MDCH


37

• Those who want to join MI Health Link and are already in nursing homes are not required to move to a different nursing home in the health plan’s network

• The health plan must enter into single-case agreements for enrollees currently residing in out-of-network nursing homes


38

• Enrollees have the right to live in an out-of-network nursing home for the life of the program if the enrollee:– Resides in the nursing home at the time of

enrollment; – Has a family member or spouse that resides in the

nursing home; or – Requires nursing home care and resides in a

retirement community that includes a nursing home.


39

• Timeframes – Scheduled Surgeries• The health plan must honor specified provider and

prior authorizations for surgeries scheduled within one hundred eighty (180) calendar days of enrollment

–Dialysis• The health plan must maintain current level of

service and same provider at the time of enrollment for one hundred eighty (180) calendar days


40

• Timeframes – Chemotherapy and Radiation• Treatment initiated prior to enrollment must be

authorized by the plan through the course of treatment with the specified provider

– Organ, Bone Marrow, Hematopoietic Stem Cell Transplant• The health plan must honor specified provider,

prior authorizations and plans of care


41

• Timeframes –Durable Medical Equipment• The plan must honor prior authorizations when

the item has not been delivered and must review ongoing prior authorizations for medical necessity

–Dental and Vision• The health plan must honor prior authorization

when an item has not been delivered


42

• Timeframes –Home Health, Personal Care and

Physician/Practitioners• For people receiving services from the PIHP

specialty services and supports program or HAB supports waiver, the health plan must maintain current provider and level of services at the time of enrollment for one hundred eighty (180) calendar days


43

• Timeframes –Home Health, Personal Care and

Physician/Practitioners• For all other enrollees, the health plan

must maintain current provider and level of services at the time of enrollment for ninety (90) calendar days


44

• Timeframes – MI Choice (HCBS) Waiver services• For enrollees previously participating in

the MI Choice HCBS waiver, the health plan must maintain the providers and level of services at the time of Enrollment for ninety (90) calendar days


45

What to consider when joining MI Health Link

What to Consider

• Do current doctors and other providers participate in the MI Health Link plan? • If not, would the provider consider joining the

MI Health Link plan?

• Are current medications covered by the MI Health Link plan? • Each plan offers its own list of covered

medications

47

What to Consider

• Participants of PACE or MI Choice have to leave that program to join MI Health Link–People may have to wait for an

opening if they choose to return to MI Choice

48

What to Consider• MI Choice services are different than the MI

Health Link waiver services– Private duty nursing (maximum hours vary)

– Personal care (eligibility differences)

– Personal emergency response system (eligibility differences)

• These are important considerations if you are in an expanded eligibility category and do not need waiver services under MI Health Link

49

What to Consider

• For MI Choice participants living in an adult foster care home or a home for aged – this setting may not be approved under

the new rules for the MI Health Link waiver–discuss this issue with your current

MI Choice supports coordinator

50

What to Consider - PACE

• PACE integrates all Medicare and Medicaid services- Services are primarily provided in the PACE

Center- Participants must use the PACE primary care

physicians in the PACE centers and other providers like hospitals that are contracted with the PACE organization

- PACE provides social interaction for in the PACE Center for its participants

51

What to Consider – Home Help

• Personal care services in MI Health Link will be provided through the health plans and not DHS

• MI Health Link enrollees can have the same providers they had in Home Help

• The same plan of care (time and task) will be provided until a new assessment is performed

52

What to Consider

• People with employer or union sponsored insurance plans who join MI Health Link may not be able to return to those insurance plans– check with your retiree benefits management

system/human resources• letters sent to potential enrollees will warn those in

employer or union sponsored plans not to enroll unless they meet with retiree benefits manager and are prepared to lose plan

53

What to Consider

• Most people eligible for both Medicare and Medicaid who are enrolled in a Medicaid managed care plan and opt-out of MI Health Link will receive Medicaid services through original Medicaid

• Only people with Medicare employer or union sponsored health plans may continue to receive Medicaid services through a Medicaid managed care plan if they don’t participate in MI Health Link

54

Enrollment and Beyond

55

Enrollment Periods

UP and Southwest Michigan• Opt-in enrollment – People can enroll no earlier than February 1, 2015– Services start no earlier than March 1, 2015

• Passive enrollment of eligible individuals if they do not opt-out– People will receive notices 60 days and 30 days

before they are passively enrolled– Services start no earlier than May 1, 2015

Enrollment Periods

Wayne and Macomb counties• Opt-in enrollment– People can enroll no earlier than April 1, 2015– Services start no earlier than May 1, 2015

• Passive enrollment of eligible individuals if they do not opt-out– People will receive notices 60 days and 30 days

before they are passively enrolled– Services start no earlier than July 1, 2015

57

Enrollment

People eligible for MI Health Link will receive a letter explaining:

• How to enroll in a MI Health Link plan

• Whom to contact for help

• How to opt-out if they don’t want to be part of MI Health Link

58

Enrollment

• People may change plans or opt out at any time

• If people opt-out, the state may not automatically enroll them into a plan– These people are still eligible to enroll if

they wish

59

What Happens After Enrollment?

60

What Happens after Enrollment?

• Enrollees receive a member packet from the health plan including–A new MI Health Link card

–Provider directory

– Summary of benefits

–Member handbook

61

What Happens after Enrollment?

• Enrollees will receive an initial screening • Enrollees will receive a Level I Assessment • If needed, enrollees will also receive a Level II

Assessment• Each enrollee will help develop his or her own

Individual Integrated Care and Supports Plan (IICSP)

62

Screening & Assessments

63

Initial Screening

• Nine “yes” or “no” questions to– Identify current services– Identify immediate or unmet needs

• People calling to enroll will be asked these simple questions during the call

• For people choosing not to answer on the phone, the plan will work with the person to complete the questions

64

Level I Assessment

• A broad assessment used to identify and evaluate current health and functional needs

• Completed within 45 days of enrollment start date

• Serves as the basis for further assessment

65

Level II Assessment

• Completed within 15 days of the Level I Assessment for people identified with– Behavioral Health needs

– Intellectual developmental disabilities (I/DD) needs

– Long term supports and services (LTSS) needs

• Health plans will collaborate with PIHPs and LTSS agencies

• Additional supports and services will be coordinated to meet the needs identified

66

Level II Assessment

For people needing nursing home or waiver services• The Nursing Facility Level of Care

Determination tool will be completed to determine if the enrollee meets the requirements for these services

• The health plan will coordinate with long term supports and services providers to meet the enrollee’s needs

67

Level II Assessment

For people identified with a behavioral health need• the health plan will make a referral to the PIHP• the PIHP will complete a telephonic screen to

determine mental health service need and referral to a provider.

68


69


• Each enrollee will help develop their own care and supports plan with his care coordinator and will choose the people to participate in the process– Selected family, friends and providers– Invited integrated care team members

70


• Follows a person-centered planning process

• Is completed within 90 days of enrollment start date

• Is the single plan that coordinates care for all services and providers and includes the PIHP and LTSS service plans

71


• Contains plan for addressing concerns and goals, as well as measures for achieving them

• Identifies specific providers, supports and services including amount, scope and duration

• Lists the person responsible and time lines for specific interventions, monitoring and reassessment

72


The IICSP contains • Enrollee’s preferences for care, support and

services

• Enrollee’s prioritized list of concerns, goals, objectives and strengths

• Screening and assessment results

73

Ongoing Coordination

Care coordinators will maintain ongoing relationships with enrollees to assure• assessments and care plans are revisited and

updated periodically

• questions and concerns are answered and addressed

• health issues get the attention they deserve

• the enrollee is satisfied with MI Health Link

74

Reporting Requirements

75

Reporting requirements

These 9 Special Use Fields to be used by states approved for data collection for Integrated Care in NPR ShipTalk.

76


What is the source of this referral into the Duals Program? (Select One):1. Referred from State Medicaid Office2. Referred from Enrollment Broker (Michigan ENROLLS)3. Referred from 1-800-MEDICARE4. Referred from CMS Federal Coordinated Health Care Office

(FCHCO)5. Referred from the Appeals Process6. Self referred7. Other

Callis, April (DCH)

can we change to MI Health Link? or is this Duals on survey??

77


Was enrollment broker a topic discussed or service provided?

Y = YesN = No

78


Was letter received from State Medicaid Office a topic discussed or service provided?

Y = YesN = No

79


Was managed care options a topic discussed or service provided?

Y = YesN = No

80


Was enrollment assistance a topic discussed or service provided?

Y = YesN = No

81


Was other Medicare issues a topic discussed or service provided?

Y = YesN = No

82


Was given publications and other materials a topic discussed or service provided?

Y = YesN = No

83


Was the duals client referred out and if so, to where?1. Referred to State Medicaid Office2. Referred to enrollment broker3. Referred to 1-800-MEDICARE4. Referred to CMS Federal Coordinated Health

Care Office (FCHCO)

84


5. Referred to the appeals process6. State Ombudsman7. Not referred out8. Other

85


Beneficiary Disposition1. Beneficiary decided to opt out of the duals

program2. Beneficiary enrolled in the program, but

enrolled in a different managed care plan instead of the one to which they were assigned

86


3. Beneficiary actively enrolled in program and managed care plan of their choice

4. Beneficiary chose to remain enrolled in the program and managed care plan to which they were assigned

5. Beneficiary decision in progress

87

Questions or comments?

Mi Health Link / MMAP

Health & Medicine

Transcript of Mi Health Link / MMAP