Integrated Care Program and Dual Eligible Transition. Rebecca Thompson Benefits Advocacy Coordinator Progress Center for Independent Living

Transcription

1 Integrated Care Program and Dual Eligible Transition Rebecca Thompson Benefits Advocacy Coordinator Progress Center for Independent Living

2 Basics Managed Care Program through the Illinois Department of Healthcare and Family Services Began May 2011 Target Population: Seniors and Adults with Disabilities on Medicaid Only Pilot Counties Affected: - Suburban Cook - DuPage - Kane - Lake - Kankakee - Will

3 Definitions Managed Care is a healthcare system in which an organization, network, or individual provider has administrative control over an individual s primary healthcare services. The goal of the Integrated Care Program is to provide better care coordination by linking primary, specialty, institutional and community services, focused on improving health outcomes for beneficiaries. Capitation Model

4 Advocacy Advocates want Managed Care to be based on: Individual Choice Person-Centered Planning Consumer Self-Direction

5 Plan Phases Mandatory Program No opt-out provision - Service Package 1 covers all medical, pharmacy, dental, and behavioral health services. - Service Package 2 covers nursing facility services and services provided through the HCBS waivers, except those waivers serving individuals with developmental disabilities. - Service Package 3 covers HCBS waiver services for individuals with developmental disabilities.

6 Process Medicaid recipient receives a letter from HFS confirming eligibility status of ICP. Potential enrollee has 60 days to choose a plan, hospital, and PCP. Plans: Aetna Better Health Illini Care If enrollee is not satisfied: 90 days to switch plans Another 90 day window opens to switch back After that, enrollee must stay in plan for one year.

7 Process If potential enrollee does not choose health plan: Auto-Assignment Option of 90 days to switch plans, then switch back Enrollees can go to any PCP or hospital under their plan. Approximately 40,000 people are enrolled.

8 Service Package 2 Start Date: December 1 Aetna Better Health and Illini Care Long Term Supports and Services can be anything from nursing home services, home and community based serves, adult day care, and transportation. Long-term support programs have been created that offer access to community based options. MCO s have signed contracts with numerous nursing homes and will conduct assessments.

9 Integrated Care Program Assistance Illinois Client Enrollment Broker: Automated Health Systems Phone: Online: Aetna Better Health Illini Care

10 Medicare/Medicaid Alignment Initiative This program will place Full Duals into a Managed Care Plan. MCO s will provide care coordination, medical services, and long term supports and services. Collar Counties and Central Illinois April 2013 Illinois and 9 Managed Care Organizations submitted bids to Federal CMS. Passive Enrollments The State is seeking a waiver to make enrollments mandatory, if receiving LTSS. For more information visit:

11 Contact Information Rebecca Thompson Benefits Advocacy Coordinator Progress Center for Independent Living

12 Medicare Open Enrollment

13 Medicare Open Enrollment October 15th -December 7 th People with Medicare can enroll, disenroll or switch to any Part D plan of their choice, including Medicare Advantage plans Any Changes during this time will take effect January,

14 What to Consider During Open Enrollment Cost: What is the plan s cost of premiums, deductibles, and prescription co-payments in 2012, and how does the cost change in 2013? Coverage: Has the plan s formulary changed in 2013? Restrictions: Does the plan have drug restrictions such as prior authorization, step therapy, or quantity limits? Does the plan have a preferred or network pharmacy? Is mail order available? Plan Rating: What is the plan s rating on the Medicare Plan Finder?

15 What to Consider During Open Enrollment If considering a Medicare Advantage plan: What type of plan (HMO, PPO,PFFS) works best for the beneficiaries needs? Are the beneficiaries' preferred doctors in the plan s network? What extra health benefits (such as vision or dental) does the plan offer, and what is the plan s Monthly Health Premium? Note: Remember, you may also drop your MA plan and return back to Original Medicare during open enrollment.

16 What to Consider During Open Enrollment If you a beneficiary would like to stay in their current 2012 plan after reviewing the possible changes that may occur in 2013, they do not need to do anything. They will automatically be re-enrolled into the same plan for 2013.

17 Plan Finder Updates

18 Preferred and Network Pharmacies Network: Pharmacies that have agreed to provide members of certain plans with services and supplies at a discounted price. If a member uses a pharmacy that is not in the plan s network, then their drugs may not be covered. Preferred: A pharmacy that is in the plan s network, and has agreed to work with the plan to provide additional savings to the members. Prescription drug costs at a preferred pharmacy will be cheaper than a network pharmacy.

19 Preferred and Network Pharmacies You can look up the preferred pharmacies in a the beneficiaries area through the Medicare Plan Finder. Use the link below to view a step by step guide created by the MMW Coalition on how to view a list of preferred pharmacies. preferredpharmaciesonmedicare.gov.doc

20 Medication Therapy Management (MTM) MTM is a patient-centered and comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication adherence. MTM Indicators: 1. Have a minimum of 2-3 chronic diseases 2. Taking a minimum of 2-8 Part D drugs AND 3. Are likely to incur annual costs for Part D drugs of at least $3144

21 MTM Services Designed to ensure that covered Part D drugs are appropriately used to optimize therapeutic results through improved medication use Designed to reduce the risk of adverse events such as adverse drug interactions Sponsors must offer a minimum level of services including interventions for beneficiaries and prescribers, an annual comprehensive medication review, and quarterly targeted medication reviews

22 Plan Finder Ratings Medicare reviews the plan s performances and releases the plan s star ratings each fall. (Range of 1-5, 5 being the highest) 5 star Plans- Beneficiaries receive a SEP to enroll in a 5 star plan once per calendar year. (Illinois does not have any 5 star plans in 2013) Low Performing Plans- -Received less than 3 stars for 3 years -You cannot enroll in these plans using the Plan Finder. You must call the plan directly to enroll. -Letters are being mailed out to beneficiaries in low performing plans informing them of the plan s low rating. Beneficiaries in low performing plans will receive a one time SEP to switch to a higherrated plan if they choose.

23 Trends in Medicare Advantage

24 Trends in Medicare Advantage The MA program is growing as a percentage of coverage for beneficiaries MA premiums dropped $5 from 2010 to 2011 to an average of $39. Dropped a further 7% in 2012, while enrollment increased 10% Enrollment predicted to increase 11% in 2013 with an average premium increase of $ % of MA-PD s have no premium beyond the Part B premium.

25 Trends in Medicare Advantage Consolidation, especially along Medicare-Medicaid continuum Reduction in PFFS beneficiaries and growth in PPO s yet nearly 70% are enrolled in HMO s Growth in EGHP s of 12%

26 Affordable Care Act Updates Erin Weir AgeOptions November 1,

27 Changes Currently in Place Changes to Medicare New Annual Enrollment Period (October 15-December 7) Elimination of the donut hole New free preventive services Changes in payments to Medicare Advantage plans Demonstration Projects Fraud Prevention Dependent Coverage (children can stay on their parents plans up to age 26) Coverage for children with pre-existing conditions Free preventive services No lifetime caps on benefits No policy rescissions for reasons other than fraud Medical loss ratio (plans must spend 80-85% of premiums on health benefits) Illinois Pre-Existing Condition Insurance Plan (IPXP) Tax credits for small businesses to provide health insurance 2

28 Changes to come in 2014 No discrimination due to pre-existing conditions or gender The only factors that may be considered in determining premium rates are geography, age, and tobacco use. No annual limits on coverage Increased tax credits for small businesses Expanded Medicaid eligibility (anyone with income below 138% Federal Poverty Level) Affordable Health Insurance Exchanges Individual Responsibility (Most individuals will be required to maintain insurance coverage. Some groups exempt from this requirement.) 3

29 Health Insurance Exchange Marketplace that allows consumers to compare all available plans at once Standardized plans (easier to compare) similar to Medigap All plans must cover 10 essential benefit categories. Subsidies for people with income less than 400% FPL to help purchase coverage. Cost-sharing assistance for people with incomes less than 250% FPL. Exchanges will exist in every state. If a state chooses not to operate their own Exchange, the federal government will establish one in that state. States can also choose to operate a state-federal partnership Exchange. 4

30 Health Insurance Exchange Website compare plans, enroll, check eligibility for benefits (Medicaid, premium subsidies) Similar to Part D Plan Finder Real-time eligibility determinations for assistance programs Electronic calculator will help people determine actual cost of coverage after application of premium tax credits, costsharing reductions Navigators Counselors who will help people understand options and enroll in appropriate plans (like SHIP counselors) 5

31 Essential Health Benefits All plans must cover benefits in these 10 categories: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care 6

32 Essential Health Benefits Mental health parity Equal coverage for mental health/substance abuse (MH/SUD) services and other hospital/medical coverage Illinois: Plans cannot impose financial requirements or treatment limitations that are more restrictive than those applied to most other hospital/medical benefits under the plan (e.g., if the plan requires a $25 co-payment for all other outpatient services, then it may not require more than a $25 co-payment for outpatient MH/SUD services). Service limits determined by dollar amount, not by number of visits (e.g., if plan has a limit of 20 doctor visits a year, does not mean must allow 20 MH/SUD visits. If 20 outpatient visits are worth $10,000, then plan must cover $10,000 worth of MH/SUD services, as well). 7

33 Essential Health Benefits Illinois benchmark: Blue Cross Blue Shield BlueAdvantage (largest small group plan in the state) Federal Employee pediatric vision insurance plan AllKids pediatric dental plan minimum standard (All plans offered in 2014 must have benefits that are actuarially equivalent to the benefits in this plan.) Plans can have different coverage/modified coverage, as long as they do not reduce the value of coverage in each of the 10 benefit categories Covers all state mandates Among plans least likely to impact premium rates 8

34 Exchange Design in Illinois State-federal partnership Exchange in 2014, with the intention of moving to a state Exchange in Governor s letter: linois_exchange%20declaration%20letter.pdf Federal government will oversee Exchange, Navigators. State Department of Insurance will oversee Plan Management functions and some Consumer Assistance functions. 9

35 Financing for Exchange Financing Establishment grants from federal government (Illinois has received $38 million) Exchange must be self-sustaining beginning January 1, 2015 (through charging assessment to participating health insurance companies or otherwise generating funding) Financing for Medicaid Expansion Federal government pays 100% of benefits for newly eligible population until 2016, then gradually decreases to 90% in 2020 (and stays at 90% after that). 10

36 Legislation What Comes Next? Exchange Establishment Participation in Medicaid Expansion Education/Outreach Navigators, In-Person Assistance State and federal campaigns Open Enrollment October

37 For More Information Federal health care reform (ACA) website: Illinois Department of Insurance: Illinois Health Matters: Illinois-specific ACA information for individuals, families, small businesses, community organizations, media, policymakers ACA Timeline, blogs, Q&A, data on uninsured populations in various regions of the state 12

38 The Future of Illinois Cares Rx

39 Background: Illinois Cares Rx Elimination

40 SB2840 Senate Budget Bill for FY2013 (begins July 1, 2012) Passed House and Senate 5/24/2012 Governor signed 6/14/2012 Included many cuts and changes to Medicaid and other programs

41 ICRx Elimination Illinois Cares Rx program ended for everyone July 1, 2012 People with ICRx coverage received a letter in June from the Department of Healthcare and Family Services (HFS) People on Medicare and ICRx had a Special Enrollment Period (SEP) to change their Medicare Part D plan. This SEP will run from June 1, 2012 to August 31, 2012.

42 Options for Clients Losing Illinois Cares Rx Coverage

43 Options for Clients Losing ICRx Change Plans for cheaper prices during this open enrollment Screen for Extra Help Eligibility Charities, Co-Pay Assistance Programs, Drug Discount Cards, Patient Assistance Programs, and $4 Generic Programs Individuals with HIV can go back to the AIDS Drug Assistance Program Medicaid Spenddown

44 The Return of Illinois Cares Rx?

45 HB 6178/ SB 3923 Titled Senior Pharmaceutical Assistance Relief Program HFS shall establish and administer a pharmacy assistance program. Bi-Partisan House Bill: Jakobsson (D), Flowers (D), Brown (R), Beiser (D), Verschoore (D), Cassidy (D), and Mayfield (D). Support in Senate: Freriches (D), McGuire (D), Haine (D), Martinez (D)

46 65 or older Domiciled in state Eligibility for Program At or below 200% FPL Apply for federal extra help Asset limit of $13,070 single and $26,120 couple (updated annually to match limitations under federal extra help)

47 Program Discretion On applications How income is counted Type of prescription drugs covered No mention of Part D, wrapping around, copayments and cost sharing, etc.

48 Veto Session General Assembly will be back in a two week session at the end of November called the veto session Here, they consider overriding any governor vetoes and other urgent legislation. If the bill is not heard during the veto session, it will need to be re-introduced in the Spring.

49 Next Steps Media chatter about elimination of Illinois Cares Rx---start some more! Continue to send stories to AARP Illinois Facebook page Participate in community meetings, candidate forums, etc. Inform legislators of the impact of the elimination o f this program.

50 Thank You!