Medicaid Managed Care Lunch Panel Presentation

Medicaid Managed Care:
Serving Children with Special
Health Care Needs
Dawn McCree, Buckeye Community Health Plan
Toni Bigby, CareSource
Greg Meredith, Molina Health Care
Kim Crandall, United Community Health Plan
Julie Hoskins, Paramount Advantage
Today’s Agenda
• General Overview – Who, What, Where, When, Why Moving Children with Special Health Needs into
managed care
• Enrollment – How ODM worked with Managed Care
Plans to ensure successful enrollment
• Transitioning into Managed Care – Special
considerations employed to ensure success
• Care Coordination – Cornerstone of the Medicaid
Managed Care program and how it will benefit these
• Respite Benefit – NEW!
• Q&A
General Overview
Dawn McCree
Buckeye Community Health Plan
New Medicaid Managed Care Regions
Beginning 2013
Ohio’s Medicaid Managed Care Plans
Medicaid Children w/ Special Health Needs
• State budget included provision to enroll 37,000
children with special health needs into Medicaid
health plans
• Impacts children who are Medicaid eligible due to
disability and receive monthly fee-for-service
medical card
• This does not include:
Children enrolled in a Medicaid waiver; or
Medicaid-eligible children who reside in institutional settings; or
Children who receive both Medicare AND Medicaid benefits
Also, Medicaid-eligible children with cystic fibrosis, cancer or hemophilia are not
obligated to enroll
• Enrollment began on July 1, 2013
Once Enrolled, children now have…
• All of the medically necessary Medicaid benefits plus:
Single Point of Contact
Expansive provider and hospital network
Personal member card
Member Service Center
24-hour nurse advice line
Additional Transportation Benefits
Case management and outreach programs
Disease Management programs
New Managed Care Requirements to Benefit
Children w/ Special Health Needs
• Family Advisory Councils: MCPs are required to convene
Family Advisory Councils (consisting of current members)
at least quarterly. The purpose of the Council is to engage
members and elicit input related to the MCP’s strengths
and opportunity for improvement.
• MCPs are required to participate in Individualized
Education Program (IEP) meetings, when contacted and
invited by the child’s parents or school district.
Toni Bigby
How Does Managed Care Enrollment Work?
• Notification letters sent by Ohio Department of
Medicaid (ODM)
• Letters direct consumers to contact the Medicaid
Consumer Hotline to enroll
1-800-324-8680/TTY 800-292-3572
• Hotline provides unbiased information about providers,
extra benefits, plan contact information and answer
general questions
• Voluntary vs Auto-Assignment:
• Consumers have 90 day to change plans,
if needed
Ohio Medicaid Managed Care Enrollment
Process Timeline of Events
Notice of Mandatory Enrollment
(60 days in advance – 90 days for children with special
health needs)
Reminder Notice w/ date and plan
assignment (30 days in advance)
Final Notice of Enrollment w/ plan
assignment (15 days in advance)
90 days to make a change
State Actions to Ensure Managed Care
Enrollment Success!
• ODM took great strides to ensure impacted families
were aware of 7/1 changes
• Facilitated stakeholder workgroup – met regularly to
determine process
• Crafted “friendly letter” to introduce concept of
managed care
• Allowed plans to provide approved educational
materials and speak to members prior to normal
enrollment timeframes
• Allowed additional time for families to
make plan selection
ODM Communication Tactics
• January 2013 - State Notice to Trade Associations
• March 2013
– “Soft” letter to families advising of the opportunity to enroll their child
into Managed Care
– Enrollment Packets mailed to families
• April 2013 - Families began to choose a MCP
– ODM posted FAQs to
• May 2013 – “Tentative” auto assignment file to health plans
• New! - MCP encouraged to reach out to members before effective
• July 1, 2013 – New membership began!
– Have until November 30th to make plan changes
Children with Special Healthcare Needs
Where they live:
Cuyahoga County-10,374 (20.55%)
Franklin County – 5725 (11.34%)
Hamilton County- 5683 (9.28%)
Lucas County- 3578 (7.09%)
Montgomery – 2539 (5.03%)
Summit – 2446 (4.85%)
White- 51%
Black or African American – 47.91%
American Indian/Alaskan Native- 0.09%
Native Hawaiian/Pacific Islander –
14 – Office of Medical Assistance, March 2013
English – 97.91%
Spanish – 1.30%
Spanish/English bilingual - 0.21%
Somali - 0.21%
Mental Health Services – 27.85%
Medicaid School Program – 19.68%
FQHC – 8.41%
Targeted Case Management – 7.31%
Home Health – 4.84%
Ohio Dept. ALC/Drug Addictive Services
– 1.32%
Transition Requirements
Greg Meredith
Molina Health Care
Children with Special Health Care
(CSHCN) effective 7-1-13 state wide for all
Managed Care Organizations (MCO’s)
Moves children from Fee for Service (FFS)
to a managed care environment
MCO’s develop Transition of Care (TOC)
To ensure continuity of care for members that have chronic or
catastrophic illness and are in an active course of treatment.
To provide care coordination for prescheduled health services, access
to preventive and specialized care, care management, member
services, and education with minimal disruption to members’
established relationships with providers and existing care treatment
Improve service and decrease cost
Who will be covered?
Aged, Blind and Disabled (ABD)
Members under the age of 21
with Supplemental Security
Income (SSI) indicator
What will be covered?
Scheduled health
care appointments
Prescribed drugs
lab/radiology tests
Planned and/or
approved surgeries
(inpatient or
Home health care
Necessary durable
medical equipment
Ancillary or medical
Private duty
nursing (PDN)
Medical Supplies
How will services be covered?
Scheduled Health Care Appointments
ABD under 21 or
SSI – 90 days up
to 180 days if
needed unless in
21years or
older – 90
Management – 90 days
Planned and/or approved surgeries (inpatient or outpatient) –
If prior approved
Ancillary or medical therapies – Ongoing Chemotherapy or
radiation treatment
Prescribed Drugs – No prior Authorization (PA) for 30 days or
one refill
Scheduled lab/radiology tests – If prior approved
Dental and Vision Services – If prior approved
Organ, bone marrow or hematopoietic stem cell transplants,
MCP must receive prior approval from ODM to transfer services
to a par provider.
Management – 90 days continued
Home Health Care Services/Private
Duty Nursing, DME/Medical supplies
• Current level with current provider
• Home visit by RN
• Medical necessity
• The ABD member is in her third (3) trimester of
pregnancy and has an established relationship
with an obstetrician and/or delivery hospital.
Care Coordination
Kim Crandall
United Healthcare Community Plan
Care Management Model
• A member is assessed within
30 days of the point of
identification and a Care Plan
is created.
• MCP reviews the member’s
records and pharmacy
information from ODM’s FeeFor-Service encounter data.
• The Care Manager holds a
minimum of quarterly visits
with the member.
The Field Care Manager
• Licensed Registered Nurse or Social Worker
 Expertise in case management, coordination of care and
community resources
 Intensive classroom orientation plus additional self guided
learning experiences & ongoing in-service/educational
programs on topics related to member needs, Care
Coordination activities, & resources
 Community based RN or SW in field to conduct assessments,
develop care/service plans, & access resource information
 Teams grouped by geography in close proximity to members
 Coordinates plan covered benefits, in collaboration with local
medical and behavioral health providers, along with familiarity
with local community resources
Connected care is all about you.
As our member, you get to decide who is included as part of their care team with
support from the care manager. Your Primary Care Physician is a part of the core
team, along with family, caregivers and other specialists important to your care.
Members Matters
Care Coordination and Follow-up
• Effective care coordination includes the member, the current
treating practitioner or facility, the practitioner or facility at
the next level of care, and, as appropriate, the member’s
family, the Primary Physician, Psychiatrist and relevant
community resources
• Coordinated activities include:
– Ongoing assessment of the member’s clinical needs
– Communication with the member and their family about the treatment
– Coordinating, with the member’s consent and in a timely manner, a discharge
or transfer plan to the treating practitioner or facility at the next level of care
and to the Primary Physician and Psychiatrist
– Identifying the needs of the member following discharge from facility-based
treatment, and, as appropriate, ensuring that the member has the means to
meet those needs;
– Ensuring that the facility has scheduled for the member an outpatient
appointment for follow-up care within 7 days of discharge
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Julie Hoskins
• Effective January 1, 2014
• Offered by Ohio’s five managed care plans, through ODM
• Offered to members and their families who meet the criteria
under the age of 21 who are determined eligible for social security
income for children with disabilities; OR
supplemental security disability income for adults disabled since
• Prior Authorization is required for all Respite Care Services
• Provide short-term, temporary relief to the informal, unpaid
caregiver of an individual in order to support and preserve the
primary caregiving relationship.
• Provided on a planned or emergency basis and shall only be
furnished in the member's home.
• The provider must be awake during the provision of respite
services and the services shall not be provided overnight.
• Member must reside with informal, unpaid primary caregiver
• Member must reside in a home/apartment that is not controlled by any
health-related treatment or support service
• Member must not be in foster care
• Member must be enrolled in the MCP’s care management program
• Member must be determined by the MCP to meet an institutional level of
care as set forth in Administrative Code rules 5160-3-07, 5160-3-08
• Member must require skilled nursing or rehabilitative services at least
• Member must receive at least 14 hours per week of home health aide
For at least six consecutive months preceding the request for respite care
• Services are limited to no more than 24 hours per month/250 hours per
• Services must be provided by enrolled Medicaid providers who meet the
qualifications of the program, including a competency evaluation program
and first-aid training
• Services must not be delivered by the child’s legally responsible family
member or foster caregiver
• MCP staff trained to increase awareness of member’s who may benefit
from this service; to facilitate referrals/requests
• Provider education regarding new benefit
• Allows caregivers the opportunity to “refuel and replenish”
• Few actual requests to date
• Likely have respite services within current home health care
• Recognize the importance of this service
• Opportunities through transition process
• Continued comprehensive education and outreach including providers,
members, family members and MCP staff
Plan Contact Information
Managed Care Plan
Buckeye Community Health Plan
TTY: 1-800-750-0750
TTY: 1-800-750-0750
Molina Healthcare
TTY: 1-800-750-0750
TTY: 1-888-740-5670
UnitedHealthcare Community Plan
TTY: 711