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Making Our Health Care System Work for Older Adults and People With Disabilities
John ArnoldOCVIC, Project Directorjarnold@uhcanohio.org
614-456-0060 x237
Making a difference TogetherOhio Chapter of GAPNA's 7th Annual Continuing
Education day“Why Your Voice Matters”
March 14, 2015
2Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
The Problem
• Limited care coordination• Fragmented Care• Current system is confusing and difficult to
navigate• Multiple health care needs and high cost• The health care and long-term care
systems are not connected very well, even though people use both.
3Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
The Need
People with both Medicare and Medicaid are among Ohio’s highest need patients
They are shuttled between multiple doctors who do not communicate with each other or recognize the whole person they are supposed to serve.
As a result, these consumers often suffer from unnecessary tests, contradictory therapies and ineffective treatment.
4Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Dually Eligible in Ohio
Currently Enrolled: 182,000 Ohioans
Total Medicaid En-rollment for State of
Ohio
Dually ElligibleMedicaid Only
9%
91%
Medicaid Spend-ing in Ohio
Dually El-igibleMedicaid Only40
%60%
5Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Dual eligible beneficiaries are a diverse population
Under Age 65
39%Facility
13%
Mental Impairment
49%0 or 1
Chronic Conditions
25%
Age 65-74
26%2 Chronic
Conditions
20%
Age 75-84
21%
Community
87%
No Mental Impairments
51%3 Chronic
Conditions
20%
Age 85+
14% 4 or more Chronic
Conditions
35%
Age Type ofResidence
MentalImpairments
Number of Chronic
Conditions
6Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
26%
22%
44%
25%
44%
50%
55%
58%
Dual eligiblebeneficiaries
All other Medicarebeneficiaries
Cognitively or Mentally Impaired
3+ Chronic Conditions
In Fair or Poor Health
Dual Eligible Consumers are sicker than other
Medicare Consumers
Functionally Impaired
7Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Answer
A coordinated, managed care system that brings together all consumer needs and services under
one umbrella called MyCare Ohio
Healthcare doctor & Hospital
Long term Care (Passport,Assisted Living, nursing home care)Behavioral health/mental health
8Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
MyCare Ohio
• Demonstration to test integrated care and financing model for individuals with Medicare and Medicaid
• May 2014 to December 2017• Federal and State partnership • How it will work:
– Approved ICDS Plans will provide integrated benefits to Medicare and Medicaid enrollees in seven targeted geographic areas
– Plans must provide all necessary Medicare and Medicaid-covered services, including Medicaid waiver services
– Single identification card to access services
9Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
MyCare Ohio
• Three-way contract (Health plan, CMS, State)
• Rolling start in mid-2014; passive enrollment in Medicare delayed until January 1, 2015
• Capitated rates adjusted for State and CMS upfront savings; also quality withhold
• Comprehensive care plans required incorporating client and family goals
10Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Medicare Passive Enrollment (I)
–Beneficiaries must participate in MyCare Medicaid; but Medicare is optional–On 1-1-2015, individuals who have
not indicated a choice, was passively enrolled in MyCare Medicare with the same health plan as their MyCare Medicaid (integrated benefits and funding)
11Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Medicare Passive Enrollment (II)
• Individuals can choose to stay with traditional Medicare or another Medicare Advantage plan
• Beneficiaries can switch from MyCare Medicare to traditional Medicare, or vice versa at anytime
• This is all very confusing to consumers and public education has been poor
12Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
MyCare Ohio Demonstration
13Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Health Plans by Region
• Northwest: Aetna and Buckeye• Southwest: Aetna and Molina• West Central: Molina and Buckeye• Central: Aetna and Molina• Northeast Central: CareSource and
United• East Central: CareSource and United• Northeast: Buckeye, CareSource,
United
14Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Who's Eligible?
• Age 18 and older at the time of enrollment• Eligible for full Medicare Parts, A, B, and D
and full Medicaid, and• Reside in an ICDS Demonstration county• Ohio Home Care or Transitions Carve-Out
Waivers• Receive AoD and/or Mental Health Services• Passport or Choices Waiver• Assisted Living Medicaid Waiver receiving
Medicare and Medicaid
15Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
You're Not Eligible if You're:
• Under the age of 18• On a delayed Medicaid spend down – (Delayed)• If other third party creditable health care
coverage is available• A person with Intellectual Disabilities (ID)or
Developmental Disabilities (DD) served through an IDD 1915(c) HCBS waiver or an ICF-IDD
• Enrolled in PACE• Participating in the CMS Independence at Home
(IAH) demonstration
16Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
The Promise
• Single Point of Contact• Single ID Card for all Medicare and Medicaid
Services• Nurse Advice Live – 24 hours a day, 7 days a
week• Care Team – (Family, doctor(s), Care Coordinator,
MyCare Ohio health plan, anyone else chosen) • Better Care Coordination = Better Health
outcomes• Providers submit claims to 1 place • Focus on Prevention and Wellness
17Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
The Promise (II)
18Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Benefits for Primary Care Providers
– Identifiable care manager – phone and email contact• Access to all benefits and services• Opportunity to enhance home and community-
based services
– WEB portal to access patient’s care plan– Assistance for your most complex patients– Opportunity to participate as part of
Integrated Care Team– Potential to shift hospital dollars to
community-based services
19Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Continuity of Care and Transition Requirements
• Health plans must ensure individuals have access to current providers and service levels at the time of enrollment.– Length of transition period differs by service.
• For prescription drugs, Medicare Part D transition requirements apply.– Health Plans must provide a one-time fill- 30 day
supply- of an ongoing medication within the first 90 days of plan membership.
– Residents in long term care facilities can receive multiple fills.
20Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Continuity of Care Requirements (Continued)
• During the transition, Health Plans will advise enrollees and providers that they have received care that would otherwise not have been covered.
• Ongoing basis, Health Plans must contact providers not part of their network with information on being credentialed as in-network providers.
• Health Plans must always reimburse an out-of-network provider of emergent or urgent care.
Details: Plan Payment Requirements
21Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Cost of Inaction
22Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Crisis in Quality
Multiple VisitsMultiple Docs
Multiple Rx Fills
Duplicate Tests &
Procedures
Too Frequently
Hospitalized
Too Frequently Readmitted to Hospital
Little or No Info upon Discharge
Inappropriate Rx
23Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Implementation Issues
• Consumers losing Independent Providers (Homecare and Nurses)
• Non-medical Long-term Services and Support –under 60
• Transportation issues• Primary Care Providers – turning away
patients• Durable Medical Equipment –not authorized
24Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Ohio Consumer Voice for Integrated Care“What we do”
ConsumerAdvisoryCouncil
RegionalNetworks
SWOC, NEOC Central
State –ODMFederal - CMS
Plans
25Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
Critical Role of Provider and Consumer Engagement
• Dual eligible patients will benefit from your participation in planning and direct care provision in MyCare Ohio
• If MyCare Ohio is not successful, the alternatives may be less desirable for patients and providers
• Primary care and Geriatrics providers’ clinical leadership, when combined with consumer advocacy efforts, is more likely to have an impact
26Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
How can Providers Get Involved?
• Learn about MyCare Ohio• Discuss good and bad observations
with your health system, Area Agency on Aging, health plan medical directors, and State Medicaid office leadership
• Join advocacy organization list-serves• Here’s the sign up link:
http://uhcanohio.org/ocvic/primarycareproviders
27Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – jarnold@uhcanohio.org
What You Can Do?“Vision”
• Be part of the solution • Help recruit consumer spoke persons to share
their story• Identify and help recruit others to join Consumer
Advocate Conference call – (last Friday of every month) The call in number (free call) and participant code is:
• (877) 366-0711• Participant code - 53257144#• Provide a feedback loop to the Plan, Regional and
State Coalitions.
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