RHODY HEALTH OPTIONS (RHO) IMPLEMENTATIONSeptember 5, 2013

Agenda1. Neighborhood –Who we are2. Rhody Health Options Overview3. State update information4. Payment for Services5. Case Management6. Wrap up and Next Steps

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Neighborhood- Who we are• Founded by RI’s Community Health Centers to

expand access to care and improve health for at-risk populations

• Incorporated as an HMO in December 1993; began serving members in Spring 1994

• EOHHS partner for proactive Medicaid managed care

• Support Medicaid programs only• 92,000 members currently• Serve 67 percent of all RI Medicaid managed

care participants • Non-profit; offices in Providence

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Our Network• Large network; nearly every

doctor/provider in RI• More than 900 Primary Care

Practitioners– 42% of Neighborhood’s members receive their

primary care at one of the 21 Community Health Centers in the state

• More than 2700 Specialists and robust ancillary and DME networks

• More than 480 Behavioral Health Providers

• All hospitals in the state • Nearly every pharmacy in the state

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Accolades• Rated “Excellent” by NCQA since 2001• Ranked as one of Top 10 Medicaid Health Plans

in America by NCQA since rankings began in 2004 - (#5 in 2012)

• 5th Fastest Growing Private Company in RI - Providence Business News (2011)

• Sample of Community Service Awards – Healthy Moms, Healthy Babies Coalition – Latino Public Radio – Reach Out and Read Rhode Island – The African Alliance of Rhode Island – PARI Independent Living Center– Rhode Island Foster Parent Association

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97% of

Neighborhood members would

recommend us to family or friends

(2012 CAHPS Survey)

Our Membership Growth

Children in RIte Care (1994)

Parents in RIte Care (1998) Children in

foster care (2000)

Children with special health care needs (2003)

Medicaid-only eligible adults

with disabilities (2008)

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Adults eligible for Medicaid/Medicare - Medicaid benefits

(Nov 2013)

Adults in Medicaid Expansion (Jan 2014)

Adults in HealthSource RI – Both Individual (up to

250%) and Small Business (Jan 2014)

Integrated Care Initiative• EOHHS is working with CMS on an

Integrated Care Initiative– It is designed to transform the delivery of

services to elderly and disabled Medicaid only members and Medicaid Medicare Eligible members (duals) to maintain a high quality of life and live independently in the community.

– The goal of the program is to integrate the two government programs to eliminate the fragmentation and inefficiencies that exist today and improve the quality of care for members.

– In June 2013 EOHHS selected Neighborhood to be its managed care organization to implement this program.

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Rhody Health Options• Phase I – Implementation of Medicaid Long Term

Care benefits to managed care beginning November 2013.

– These members will be known as Rhody Health Options members.

• Phase II – Adds the integration of the Medicare

benefit – The full integration, is currently scheduled

for implementation in early 2015.8

Rhody Health OptionsTimeline • Awards announced August 2013 • Readiness Review July – Sept 2013 • Consumer letters Sept 1, 2013 - Feb 1, 2014 will be

sent – EOHHS will be phasing in RHO membership in 4 waves– Approximately 6400 members per wave– Complete Enrollment Schedule available on EOHHS website – Members will be given the choice to opt out of the program– We are currently working with EOHHS to identify all members

in Wave 1 to insure smooth transition.• Effective Enrollment Nov 1, 2013 - April 1, 2014

Dates • Presentations & Trainings - July 2013 and ongoing

Trainings by EOHHS9

State UpdateSchedule a Presentation on the Integrated Care Initiative• The State will begin to set up community

presentations on these two new programs: Rhody Health Options and Connect Care Choice Community Partners. If you would like to schedule a presentation for your agency or organization, please contact Alison Buckser at abuckser@ohhs.ri.gov

• Check the state website www.eohhs.ri.gov (under “Integrated Care”)

• Email your questions at: integratedcare@ohhs.ri.gov

• There will be an Enrollment Help Line starting on Sept 1, 2013. 10

Teams within Medical Management

Medical Management

Utilization/Medical Review

Nursing Home Transition Care Team

Care ManagementCare ManagersSocial Workers

Community Outreach Workers

Housing Specialists

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Neighborhood BenefitsNeighborhood Case Managers can assist with:

• LTSS Waiver application assistance• Develop and monitor individualized Plan of Care• Collaborate to assess for safe discharge plan to

the community when appropriate• Participate in discharge planning meetings with

members and caregivers• Facilitate community services to ensure safe

transition plan

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Facility Requirements

• Provide access for case managers to meet member and review medical record, including MDS

• Provide supportive clinical information for those receiving skilled services

• Collaboration in identification of those with potential discharge plan

• Collaboration in ensuring a safe transition to the community when applicable

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Payment and Billing Process for Rhody Health Options

• Rhody Health Option members will be billed to Neighborhood Health Plan of RI

• Connect Care Members will be billed to the state (as it is done today).

• Claims typically process within 7-14 days

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Payment and Billing Process for Rhody Health OptionsNeighborhood will require a claim submission for payment

• Claim submission can be completed via electronic faxes regular mail or electronically via a clearinghouse

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Contacts at NeighborhoodMedical Management• Michelle Lupoli, Director of Medical

Management, 459-6035• Kathy Ullrich, Manager of Care Management,

Duals 427-6526Claims Production• Meghan Ruane, Director of Operations, 459-6606Provider Engagement and Contracting• Pat Huschle, Director of Provider Engagement

and Contracting,459-6012• Maureen Brousseau, Manager of Ancillary

Network,459-6033 16

Questions?

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NEXT STEPS AND FOLLOW UP

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