Medicare Medicaid Alignment Initiative (MMAI) The next chapter
of HFS Managed Care
Slide 2
What is Managed Care? A health care delivery system designed to
provide coordinated care that will reduce unnecessary utilization
of services, control cost, increase access and maximize
quality
Slide 3
Benefits of Managed Care Better health for the member oChoices
of doctors, specialists and hospitals oAdditional programs and
services to help them live a healthy life Better quality of life
for the member oCoordination of care with a team of people working
with members to help them live an independent and healthy life
Reduction in the cost of the service over time
Slide 4
Managed Care Organizations Have a network of hospitals,
physicians, specialists Are responsible for covering same services
as Medicaid Accept the full-risk capitated payments
Slide 5
Key Terms to Remember Care Coordination o Determining a persons
needs and creating a care plan o Linking the person to a full range
of appropriate services and monitoring the care provided over an
extended period of time Medical Home o The doctors office or clinic
where clients go to first when seeking healthcare services o The
doctors office or clinic where a client goes to see their PCP
Primary Care Provider (PCP) o The family doctor, nurse, or other
healthcare provider at the clients medical home who takes care of
them Integrated Care Team o A team of health and social care staff
working together to offer patients a better quality service and
easier access to that service.
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Medicaid Managed Care Programs Voluntary Managed Care (VMC)
Primary Care Case Management (PCCM) Integrated Care Program (ICP)
Medicaid Long Term Supports and Services(MLTSS) Medicare Medicaid
Alignment Initiative (MMAI)
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VMC at a glance A voluntary program Provides services to All
Kids, Moms and Babies, and Family Care clients Participants choose
a Primary Care Provider (PCP) in an MCO for their medical home
Operates in 28 counties throughout the state
Slide 8
PCCM at a glance A mandatory program Called Illinois Health
Connect (IHC) Provides services to most individuals covered by an
HFS Medical Program (some exclusions) Participants choose a medical
home and PCP while receiving the advantages of care coordination
and case management Eligible enrollees may opt out of IHC if
enrolling with MCO Operates statewide
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ICP at a glance A mandatory program providing services to older
adults and persons with disabilities Enrollees must be eligible for
Medicaid but not eligible for Medicare, and must be age 19 and
older Excluded populations: oChildren under 19 years of age
oParticipants eligible for Medicare Part A or enrolled in Medicare
Part B oAmerican Indians and/or Natives of Alaska (may voluntarily
enroll) oParticipants with Spenddown oAll Presumptive Eligibility
(temporary benefits) Categories oParticipants in the Illinois
Breast and Cervical Cancer Program oParticipants with high-level
private health insurance (Third Party Liability or TPL)
Slide 10
ICP at a glance ICP provides medical, behavioral, and
home/community based services Beneficiaries are locked into their
MCO plan for one year and cannot switch health plans until their
anniversary month Operates in 29 counties in the following 5
regions of IL: Central IL Metro East Greater Chicago Rockford Quad
Cities
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MLTSS at a glance Begins September 1, 2014 Provides services to
those who opt out of MMAI but receive LTSS (more about MMAI is
coming up on our next slide) Mandatory enrollment in a health plan
to receive: LTSS Behavioral Health Transportation Same health plans
as MMAI MLTSS Program individuals are locked in for their LTSS
services for one year and cannot switch health plans until their
anniversary month
Slide 12
MMAI a closer look A voluntary program with passive enrollment
Three-way contract between HFS, CMS, and Health Plans Robust care
coordination Emphasis on quality measurement
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MMAI a closer look Health plans will provide integrated
benefits to full- benefit dual eligible beneficiaries ages 21 and
over: o All Medicare and Medicaid services including long-term care
institutional and community-based services and supports o
Exclusions include individuals receiving institutional
developmental disability services or Adults with Developmental
Disabilities HCBS waiver services
Slide 14
MMAI LTSS LTSS : Long Term Supports and Services Under MMAI,
the LTSS population includes nursing home residents and those
receiving Home and Community Based Services(HCBS) waivers: 1.
Elderly (Community Care Program participants) 2. Traumatic Brain
Injury 3. HIV/AIDS 4. Physically Disabled 5. Supportive Living
Facility
Slide 15
MMAI Geography Greater Chicago Counties: Cook, Lake, Kane,
DuPage, Will, Kankakee Central Illinois Counties: Knox, Peoria,
Tazewell, McLean, Logan, DeWitt, Sangamon, Macon, Christian, Piatt,
Champaign, Vermilion, Ford, Menard, Stark
Slide 16
MMAI Number Eligible Geographic Region Number of Dual
Beneficiaries Eligible for MMAI Greater Chicago128,000 Central
Illinois20,000
Slide 17
MMAI Health Plans Greater Chicago: Aetna Better Health Blue
Cross Blue Shield Cigna HealthSpring Humana IlliniCare Health Plan
Meridian Health Plan
Slide 18
MMAI Health Plans Central Illinois: Health Alliance Molina
HealthCare
Slide 19
MMAI Timeline March 1, 2014: Voluntary Enrollment for Community
population Begins June 1, 2014: Passive Enrollment for Community
population Begins July 1, 2014: Voluntary Enrollment for LTSS
population Begins September 1, 2014: Passive Enrollment for LTSS
population Begins
Slide 20
MMAI Enrollment Announcement Letter o Includes general
information on: Names of health plans participating in their area
Calling the Illinois Client Enrollment Services (ICES) for help in
explaining their choices How to enroll How to opt out Enrollment
Packet o Includes detailed information on: Health plans
participating in their area How to enroll Reminder Notices o Prior
to passive enrollment date, a couple of notices will be mailed to
beneficiary, these notices include: Name of health plan and PCP
Option to change plans or opt-out at any time
Slide 21
MMAI Disenrollment Disenrollments are effective the first day
of the month following request Individuals can disenroll thru ICES
or through 1-800-Medicare Those receiving LTSS and who disenroll
from MMAI will be required to enroll in the MLTSS program.
Slide 22
How Can Clients Contact ICES? Eligible clients can contact IL
Client Enrollment Services (ICES) By Phone: Call Illinois Client
Enrollment Services o 1-877-912-8880 (TTY: 1-866-565-8576)
Slide 23
How does MMAI compare to ICP? ICP Mandatory Enrollment Must be
19 and over Must be Medicaid, but not Medicare enrolled Several
MCOs to choose from Medical, Behavioral Health, & HCBS waiver
services covered (some exclusions) Developmental Disabilities (DD)
waiver/institutional clients included Enroll through client
enrollment broker Operates in 5 regions of the state MMAI Passive
Enrollment with Opt-Out option for medical services Must be 21 and
over Must be Medicaid and Medicare enrolled (duel eligible) Several
MCOs to choose from Medical, Behavioral Health, & HCBS waiver
services covered (some exclusions) Developmental Disabilities (DD)
waiver/institutional clients excluded Enroll through client
enrollment broker Operates in 2 regions of the state
Slide 24
MMAI a review MMAI is latest managed care program offered to IL
Medicaid clients. The program is for those dually eligible
beneficiaries who receive both Medicare and Medicaid. MMAI will
affect 128,000 people in the greater Chicago region, and 20,000
people in the central IL region. The beneficiaries will be enrolled
in waves rather than all at once. This rollout will begin with
those in the community first, followed by the LTSS population,
those enrollees that are in LTC facilities and on HCBS waivers. The
member handbook is a valuable resource for SHIP staff including
these chapters: o Chapter 2 important contact numbers for members o
Chapter 4 covered services o Chapter 9 grievances and appeals
Slide 25
1. Why would someone want to enroll in this program? 10
Questions you might have about MMAI Care coordination consumers
will have a care coordinator to help them navigate the health care
system Receive all health care from one health plan, no longer
fragmented (some from Medicaid and some from Medicare) Some health
plans offer additional services
Slide 26
2. What is the role of the client enrollment broker? 10
Questions you might have about MMAI The role of the client
enrollment broker is to provide education in an unbiased manner and
enroll individuals into a health plan. They can answer questions
about each health plan and help consumers find out which MCO
network their PCP, specialists or hospital has joined.
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10 Questions you might have about MMAI They have the choice to
stay with the MA or DSNP Plan or to join an MMP health plan. The
plans have similar benefits, but MMAI offers the additional benefit
of care coordination and services beyond what Medicaid and Medicare
offer. If they are in Long Term Supports and Services however, they
are required to select a health plan for those specific services.
3. THE CLIENT IS HAPPY WITH THEIR CURRENT HEALTH PLAN (MEDICARE
FFS, MA PLAN OR D-SNP PLAN). DO THEY HAVE TO ENROLL IN MMAI?
Slide 28
4. What is the difference between passive enrollment and
voluntary enrollment? 10 Questions you might have about MMAI
Passive enrollment means consumers will be enrolled in a health
plan UNLESS they call to opt out. Voluntary enrollment means
consumers can voluntarily decide if they would like to enroll in a
health plan.
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5. ARE ALL HEALTH PLANS AVAILABLE IN ALL COUNTIES? 10 Questions
you might have about MMAI No. Please refer to the Care Coordination
Map handout to see which health plans are serving which
counties.
Slide 30
6. When does coverage begin? 10 Questions you might have about
MMAI It depends what day of the month the consumer calls to enroll.
If they call within the first half of the month, coverage will
begin the first day of the next month. For example, if they call on
March 12 th to enroll, the coverage will begin April 1 st. If they
call in the latter part of the month, it will begin the first day
of the following month. For example, if they call on March 25 th to
enroll, their coverage will begin May 1 st.
Slide 31
7. Can consumers switch from one plan to another? 10 Questions
you might have about MMAI Consumers can switch health plans under
MMAI. It is best to stay with one health plan as that health plans
care coordinator will get to know and understand their needs.
Slide 32
8. What services are provided under this new health plan? 10
Questions you might have about MMAI Consumers get all the services
they currently receive plus care coordination under an integrated
health care delivery system. In addition, all of the health plans
offer additional services at no cost to consumer.
Slide 33
9. What if the consumer thinks they have been unfairly treated
or denied a service BY THEIR MMAI PLAN? 10 Questions you might have
about MMAI They should call their health plan. They can grieve or
file an appeal with the health plan for things such as a denial of
a service or for failure to provide a service in a timely manner.
The health plan can help explain how to file an appeal. The
information is also in the health plans member handbook.
Slide 34
10. If a consumer disenrolls, where do they get services? 10
Questions you might have about MMAI Consumers would return to
services as they had prior to enrolling in MMAI - such as their
Medicare Advantage (MA) Plan, Dual Eligible Special Needs Plans
(D-SNPs) or Medicare Fee-For-Service.