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Texas Dual-Eligibles Integrated CareDemonstration Project: Nursing FacilityProgram ManagementMedicaid and CHIP DivisionHealth and Human Services Commission

What is Managed Care? Healthcare provided through a network of doctors,hospitals and other healthcare providersresponsible for managing and delivering quality,cost-effective care. The state pays a managed care organization(MCO) a capitated rate for each member enrolled,rather than paying for each unit of serviceprovided.Page 3

Dual Demonstration The Centers for Medicare & Medicaid Services(CMS) and the Texas Health and Human ServicesCommission (HHSC) established a federal-statepartnership to better serve individuals eligible forboth Medicare and Medicaid (dual eligibles). HHSC entered into a formal agreement with CMS andthe STAR PLUS Medicare-Medicaid Plans (MMP). Test new payment methodology designed to minimizecost shifting, align incentives and support the bestpossible health and functional outcomes for enrollees.Page 4

Dual Demonstration Fully integrated managed care model for adultswho are enrolled in Medicare and Medicaid.MMP must provide the full array of Medicare andMedicaid benefits. AmerigroupCigna-HealthspringMolinaSuperiorUnited Healthcare Members started enrolling March 1, 2015 Demonstration runs through December 2018Page 5

Dual Demonstration Goals The goals are to: Integrate the fragmented model of care for dualeligibles by creating a single point of accountability forthe delivery, coordination, and management ofMedicare and Medicaid services Require one MMP to be responsible for the full-arrayof services Streamline process for providers Improve quality of care, reduce health disparities, andmeet both health and functional needs of enrollee Reduce avoidable hospitalizations and potentiallypreventable events Promote independence in the community and improvetransition between care settingsPage 6

LegendDual Demonstration County .The Demonstration will beimplemented in the following 6counties: Bexar Dallas El Paso Harris Hidalgo Deaf n RobertsSwisherDual DemonstrationCountiesOchiltree LipscombGrayGeographic AreaHemphillWheelerTarrant (16,986)Donley CollingsworthBriscoeHallAmerigroup, otleyFloydCottleWilbargerWichitaFoardClayCochran JackHaskell Throckmorton YoungWiseDentonGainesCollinHopkins Franklin ackelford StephensParkerRainsRockwalDallas lTarrantWoodUpshurKaufman Van ndCallahanJohnsonErathMolina, SuperiorCassMidland Glasscock SterlingCokeHendersonColeman BrownBosqueReaganTom lerSan BastropHaysOrangeAustin dallRealPolkBurlesonKerrEdwardsVal rnetSabineHoustonLeonFallsLlanoTerrellPresidioSan BellJeff DavisShelbyFreestoneMcLennanConchoPanolaAnderson unnelsMarionHarrisonSmithEllisMcCulloch San Saba LampasasAmerigroup, MolinaDallas (27,941)BowieTitusCampEl PasoEl Paso (19,645)Red RiverDeltaSomervellHudspethLamarFanninFort BendGalvestonLavacaMedinaWhartonBrazoriaWilsonDe kMatagordaGoliadDimmitCalhounBeeLa SalleMcMullen Live OakRefugioAransasSan PatricioWebbDuvalJim WellsHarris (47,160)Amerigroup, Molina, UnitedNuecesKlebergBexar (26,452)Zapata Jim Hogg BrooksAmerigroup, Molina, SuperiorStarrKenedyWillacyHidalgoCameronHidalgo (27,090)Cigna-Health Spring, Molina, SuperiorHHSC, Project ManagementPage 7

Eligible Population Clients can participate in the project if they meetall of these criteria: Are age 21 and older and have a physical or mentaldisability and qualify for SSI Have Medicare Part A, B and D, and are receiving fullMedicaid benefits Eligible for or enrolled in the Medicaid STAR PLUSprogram, which serves members who have disabilitiesand those who meet a nursing facility level of care andget STAR PLUS home and community based waiverservices Reside in one of the demonstration countiesPage 8

Excluded Population Dual eligible children (age 20 and younger) who havechosen to receive their Medicaid services through theSTAR PLUS managed care program. Dual eligible individuals not eligible for STAR PLUStoday, including those receiving services in a communitybased Intermediate Care Facility for Individuals withIntellectual Disabilities or Related Conditions (ICF-IID) orreceiving services in the following ICF-IID 1915 (c)waivers: Home and Community-based Services (HCS)Community Living and Support Services (CLASS)Texas Home Living (TxHmL)Deaf-Blind Multiple Disabilities (DBMD)Page 9

Voluntary Populations Other eligible individuals may choose toparticipate, or opt to enroll, but will not bepassively enrolled Those in a Medicare Advantage Plan not operated byan MMP participating in the demonstrationThose participating in a Medicare Accountable CareOrganization with fewer than 9,000 membersThose receiving services through the Program of AllInclusive Care for the Elderly (PACE)10

Enrollment Enrollment for most eligible individuals will beconducted using a seamless, passive enrollmentprocess and will include: Welcome letter sent 90 days prior to enrollment date Will be sent to address reflected in Texas Integrated EligibilityRedesign System (TIERS) Notify Social Security Administration to update Notification letters to enroll or opt out will be sent at 60and 30 days prior to enrollment effective date Letters will include the plan the member will be enrolled in ifthey do not call to disenroll or switch plans.Page11

Enrollment Eligible beneficiaries have the opportunity to make avoluntary choice to enroll (opt-in) or disenroll (opt out), orchange plans at any timeRequest to enroll or disenroll can be made throughMedicare (1-800-MEDICARE) or MAXIMUS, the StateEnrollment Broker, at 1-877-782-6440If moving out of a demonstration county, update addressand call to disenroll MAXIMUS may accept disenrollment, but cannot re-enrollindividuals into previously assigned Medicare Advantage Plan. New enrollments will not be accepted within 6 months ofthe end of the Demonstration.12

Enrollment Enrollment requests and plan changes will beaccepted through the 12th of each month foreffective coverage on the first calendar day of thenext month Enrollment requests received after the 12th will beeffective on the 1st of the second month Those opting out after an initial enrollment in anMMP will automatically revert to traditionalMedicare. Effective date will always be on the 1stof the next month.Page 13

Passive Enrollment Those who do not actively enroll or opt out willbe automatically assigned to an MMP Assignment is prioritized based on an algorithm that canbe found /dual-eligible/enrollment-algorithms.pdf Nursing facility passive enrollmentschedule August 1, 2015: Bexar and El Paso counties September 1, 2015: Harris county October 1, 2015: Dallas, Hidalgo and Tarrant counties14

Primary Care Provider Enrollees must choose a Primary Care Provider(PCP), or one will be assigned to them Must be contracted and credentialed with MMP May change their PCP at any time with cut-off onthe 25th of any month for an effective date on the1st of the following month Notify MMP to make a change to PCP15

Loss of Eligibility CMS will notify the State if resident is no longerentitled to both Medicare A or B benefits. CMS will make disenrollment effective the 1st of themonth following the last month of entitlement to either,whichever occurred first If resident loses Medicaid eligibility, they will bedisenrolled on the 1st of the following month MMP must offer the full continuum of benefits throughthe end of the calendar month in which the Statenotified the MMP of the loss of eligibility16

Benefits Election of Medicare Hospice Benefit Will remain enrolled in MMPHospice services billed to Medicare fee for serviceMMP is required to work with hospice providers tocoordinate these services with the rest of residentsservices including Part D and any flexible benefitsoffered by MMP Behavioral health services for NF residentsenrolled in MMP statewide (including the Dallasservice area)are billed to MMP17

Benefits For pharmacy services, both the STAR PLUSand the Medicare formularies will be used Skilled nursing may be provided without apreceding acute care inpatient qualifying stay Must be prior authorized and clinically appropriateCan avert the need for inpatient stay18

Service Coordination MMP must: Assign a Service Coordinator (SC) to each residentNotify NF of change in SC within 10 daysEnsure SC returns calls to NF within 24 hoursCoordinate all aspects of medically necessary acutecare and long term services as well as access specialtyprovidersEnsure SC makes initial face to face visit within 30days of enrollment and quarterly thereafter Must follow up within 14 days upon notification of asignificant change in resident condition or of resident requestto transition to the community19

Service Coordination NF must: Invite SC to care plan, service planning and dischargeplanning meetings, provided the resident does notobjectAllow SC access to all medical records, MDS andPASRR records and other information concerning theirmember while at the facility20

Continuity of Care Medically necessary covered services must beprovided or arranged for during the transition period Current acute care services will be authorized for upto 90 days while contracting efforts are underway. Exception made for enrollee who has been diagnosed withand is receiving treatment for a terminal illness, coveredservices are authorized up to 9 monthsPage 21

Participating Providers Nursing facilities are considered Significant TraditionalProviders. Medicaid rates protected under provisions of state law Separate agreements or contracts must be executedbetween NF and MMP Credentialing process should take no longer than 90 days afterreceiving a completed application Recredentialing must occur at least every three years Skilled services rates will be negotiated Providers must not be under sanction from Medicaid or MedicareprogramsPage 22

Participating Providers NF ancillary service providers must meetcredentialing requirements and have currentMedicare and Medicaid provider numbers. (i.e.,physicians, lab, x-ray, pharmacy, DME) MMP reserve the right to transition their membersto contracted providers after the continuity of careperiods conclude.Page 23

Prior Authorizations For skilled stay admission from hospital or fromlong term care bed: Check your MMP contract for negotiated rate andnotification requirements Submit documentation supporting medical necessityvia phone, fax or MCO portal Emergency turnaround time -1 business dayStandard turnaround time – 3 business daysMMP will provide facility notification of # days approved anddate for recertification24

Prior Authorizations Contact MMP if admission is clinically complex orinvolves high cost drugs to determine any rateenhancements on a case by case basis. Notify MMP immediately upon learning that aresident enrolls in MMP during a traditionalMedicare stay to authorize continued services. CMS will honor skilled admits without 3 dayqualifying stay if member is transitioning totraditional Medicare from MMP, as long as theycontinue to meet criteria for a skilled stay25

Prior Authorizations Information generally required to support medicalnecessity (not all inclusive) Current and historical patient data related to requestedservices (i.e., therapy notes showing need for continuedservices, progress, prior level of function)History and Physical (H&P) AssessmentMedication listPhysician orderNursing and physician progress notesLabs, x-ray information26

Prior Authorizations Services and supplies billed to MMP that werehistorically billed to Medicare Part B require priorauthorizations Turnaround time requirements 1 business day-emergent3 business days-standardTherapies (physical, occupational, speech)Physician ordered supplies traditionally billable to PartB (ostomy, urological, enteral and tracheostomy) Ancillary providers are responsible for their ownprior authorizations and billing directly to MMP27