aipam Fall Conference Presented by: Lisa Fox & Maggie Goncerzewicz

Transcription

1 aipam Fall Conference Presented by: Lisa Fox & Maggie Goncerzewicz

2 Today s Agenda Affordable Care Act Health Insurance Marketplace(Exchange) Risk Adjustment ICD-10 MMAI

3 Affordable Care Act We Are Part Of The Largest Health Care Changes IN US HISTORY

4 Affordable Care Act Almost 50 million Americans without health insurance. The Affordable Care Act (ACA) will extend coverage to the uninsured Americans.

5 Internet Resources Stay Informed: BCBS website Sign up for alerts Look for local seminars and events

6 Health Insurance Marketplace 6

7 Marketplace An online tool enabling a member to shop The statewide Marketplace Health Insurance Cost of Product

8 Marketplace Inform consumers about individual mandate exemptions Perform Risk Adjustment Provide toll-free hotline for assistance Public Exchanges Help eligible individuals get federal tax credits & subsidies Screen for Medicaid/CHIP eligibility and enroll if eligible Run state websites that allow consumers to shop for qualified health plans Help consumers and employers choose & enroll in coverage This presentation is a high-level summary and for general informational purposes only. The information in this presentation is not comprehensive and does not constitute legal, tax, compliance or other advice or guidance. 8

9 Marketplace New online sites launch October 2013 Individual Small Group 2-50

10 Marketplace Who is Exempt? Individuals who cannot afford coverage Taxpayers with income below the filing threshold Members of Indian tribes Hardship Religious conscience Members of a health care sharing ministry Incarcerated individuals Individuals who are not lawfully present Individuals who experience short coverage gaps

11 Marketplace The key difference between the metallic plans is the expected percentage of medical expenses shared between the health plan and the member. Platinum 90% (AV) Gold 80% (AV) Silver 70% (AV) Bronze 60% (AV) Expected Percentage of Medical Expenses Covered by the Health Plan Expected Percentage of Medical Expenses Covered by the Member

12 Marketplace Actuarial Thresholds (Metallic Levels) Individual and insured small group plans, sold on and off the exchange, will have to meet one of four metallic levels that correspond to plan actuarial value. Bronze Silver Gold Platinum 60% Actuarial Value (AV) 70% Actuarial Value (AV) 80% Actuarial Value (AV) 90% Actuarial Value (AV) Catastrophic coverage will be available on an exchange, for individuals under age 30 or individuals who received certification for lack of affordable coverage or financial hardship. 12

13 Essential Health Benefits Hospitalization Emergency services Laboratory services Maternity and newborn care Mental health and substance abuse services Prescription drugs Habilitative and rehabilitative services and devices Preventive and wellness services, disease management Ambulatory patient services Pediatric care including oral and vision care

14 Marketplace Internet resources

15 Risk Adjustment 15

16 What is Risk Adjustment? Risk Adjustment is an ACA program designed to identify the differences in health care risk among specific patients, which results in the ability to compare care and cost performance fairly by, analyzing different types of health care data with a variety of statistical models to explain an outcome, adjusting for the differences in such factors as member age, gender and diagnoses

17 Risk Adjustment Risk Score Demographics Age 29 male female Age 38 Age 72 Health status Anxiety Hypertension Diabetes Emphysema Eczema Asthma

18 Risk Adjustment Risk Marker Risk Weight Risk Marker Risk Weight Male, Age Male, Age Total Risk Score 0.22 Diabetes with significant co-morbidities 1.32 Asthma/COPD 0.96 Low cost dermatology 0.30 Total Risk Score 2.80

19 Risk Adjustment Risk Adjustment Risk Score Cost of care 2.2 $$$

20 Risk Adjustment Currently used for Medicare Advantage and Medicaid Transfer of money from health plans with low risk scores to those with high risk scores, to provide plans additional funding for the treatment of the highest risk scored members 20

21 Risk Adjustment Physician s Role and Risk Score Drivers : CLINICAL DOCUMENTATION Ensure the medical records show conditions that are being monitored, evaluated, assessed or treated (MEAT) for each condition relating to a diagnosis code on the date of service. Documentation should be clear, concise, consistent, complete and legible.

22 ICD

23 Introducing ICD ,000 new codes. October Will you be ready?

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25 W56.42XA Struck by shark, initial encounter

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27 V95.40XD Unspecified spacecraft accident injuring occupant

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29 V91.07XA Burn due to water-skis on fire

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31 T63.122A Toxic effect of venom of other venomous lizard, intentional self-harm

32 ICD-10 Yeah, there s a code for that!

33 THE END Or is it just the beginning?

34 Get to know ICD-10 It changes everything! Visit for more information and resources.

35 What You Need to Know ICD-9-CM 3-5 characters Approximately 14,000 codes 1 st character may be alpha (E or V) or numeric Limited room for new codes Lacks detail Lacks laterality Non-specific codification issues Not interoperable with other countries (WHO has adopted ICD-10) ICD-10-CM 3-7 characters Approximately 140,000 codes 1 st character alpha; characters 2-3 are numeric; 4-7 are alphanumeric Flexibility to add new codes Very specific Includes laterality Improved accuracy and richness of codification Interoperable with global community (adopted in 99 countries) X99.99 X99.XXX February 2011: ANSI v5010 / ICD-10 35

36 What You Need to Know ICD-10-CM Structure (Diagnosis Volumes 1 & 2): 3 to 6 position code with leading alpha (+ extension) X X X X X X X. Category Etiology, anatomic site, severity Extension Note: ICD-9-CM diagnosis was 3 to 5 position numeric except V and E February 2011: ANSI v5010 / ICD-10 36

37 What Does This Mean?

38 Medicare Medicaid Alignment Initiative 38

39 MMAI Initiative Medicare Medicaid Alignment Initiative (MMAI) is effective January 1, 2014 and administers Medicare and Medicaid benefits jointly so duals experience health coverage as a single integrated program. MMAI establishes a single point of accountability for the delivery and coordination of primary, acute, behavioral health and long term care supports and services.

40 Targeted Counties 1. Cook 2. DuPage Kane 4. Kankakee 5. Lake 6. Will

41 Potential Enrollment Cook 93,574 DuPage 7, Kane Kankakee 1,889 Lake 5,565 Will 4,781

42 Contracted Providers Hospitals Ambulatory Surgery Centers (ASC s) Federally Qualified Health Centers (FQHC s) Community Mental Health Centers (CMHC s) Ancillary Providers (SNF, Home Health, Hospice, DME) Independent Physicians IPA s Long Term Services & Support (LTSS)

43 Training The Centers for Medicaid and Medicare Services (CMS) and the State of Illinois require that the Blue Cross and Blue Shield of Illinois Plan train MMAI contracted providers, prior to the program implementation date of January 1, 2014, on the following topics: Patient Centered Practice Care Coordination Cultural Competency Disability Literacy Compliance with the Americans with Disability Act Independent Living and Recovery Health Safety and Welfare (Abuse, Neglect and Financial Exploitation Recognition and Prevention) Wellness Principles

44 Training Detail October - December Held at contracted hospital facilities Providers are required to attend a session Providers can choose the seminar location they prefer to attend per their contract LTSS training will be conducted at neighborhood locations/community centers 44

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