2009 medicare part d update and medicare advantage in minnesota: the other ma kelli jo greiner, mn...

2009 Medicare Part D Update and Medicare Advantage in Minnesota: the Other MA

Kelli Jo Greiner, MN Board on Aging

Jeff Goodmanson, MN DHS

Susan Kennedy, MN DHS

Medicare Part D 2009 Update and Medicare Advantage Overview

Kelli Jo

Greiner

Minnesota

Board on Aging

2009 Medicare Part D Preview

10/1/08: Mailings and Marketing begin

11/15/08: Open Enrollment begins 12/31/08: Open Enrollment ends1/1/09: New Plan enrollment effective

Annual Coordinated Election Period (AEP)

• People can join, drop, or switch – Prescription drug plans– Medicare Advantage plans– Medicare Advantage plans with prescription drug

coverage

Minnesota Amounts for 2009

• National Average Part D Basic Premium: $28.00

• MN Benchmark amount: $33.19• MA capitation rate in MN

– Ranges from $740.82-$874.60 per month per bene

What Color is the Letter?

• GREY: Loss of Extra Help (Sept. 2008) CMS• ORANGE: Change in co-payment level (October 2008) CMS• BLUE version 1: Reassignment due to plan leaving market CMS

– (October 30, 2007) CMS will reassign to new plan• BLUE version 2: Current plan above benchmark in 2008; CMS

– CMS will reassign to new benchmark plan for 2009• TAN: LIS who chose plan on own and will no longer be benchmark plan; CMS

– CMS will not reassign to a new benchmark plan for 2009• PURPLE: Deemed Status for 2009 approved CMS• YELLOW: Auto-enrollment notice (ongoing) CMS• GREEN: Facilitated enrollment (ongoing) CMS

Part 2: Mailings From the Plans

• October 1, 2008: Plans begin marketing to beneficiaries• By October 2, 2008: Plans leaving market in 2008 issue

termination letters to current enrollees.• By October 31, 2008: Plans notify beneficiaries of formulary,

benefit and premium changes for 2009

Medicare Part D Standard Benefit2006 2007 2008 2009

Deductible $250 $265 $275 $295

Initial Coverage Limit $2,250 $2,400 $2,510 $2,700

Out of pocket (OOP) threshold

$3,600 $3,850 $4,050 $4,350

Total Covered Drugs at OOP

$5,100 $5,451.25 $5726.25 $6,153.75

Copays at Catastrophic Level

$2/generic$5/brand

$2.15/generic$5.35/brand

$2.25/generic$5.60/brand

$2.40/generic$6.00/brand

5%95% Catastrophic Benefit

100%

75%25%

$295 Deductible

Monthly Premium

$2,700.01 - $6,153.75

$295.01 - $2,700

$.01 - $295

Over $6,153.75 (copays of $2.40/$6.00)

Drug Costs

Beneficiary CostsPart D Plan

2009Part D Standard Benefit

No Extra Help (LIS)

Catastrophic BenefitCo-Pays $2.40/$6.00

15% 85%

$60 Deductible

Sliding Scale Premiums

$60.01- $6,153.75

$.01 -$60

Over $6,153.75

Drug Costs

Beneficiary Costs

Part D Plan

2009Part D Partial Extra Help (LIS)

•Lower Premiums•Lower Deductible

•Lower Coinsurance•No Doughnut Hole

will vary

Benchmark• A prescription drug plan with a monthly premium at or

below the low income premium subsidy amount.• MN Benchmark amount in 2009 = $33.19• Dual eligible premiums for these plans are completely

covered by Extra Help– Duals can enroll in non-benchmark plans but will

have out of pocket costs for premium

BE AWARE!!

• CMS has notified us that the

number of dually

eligible beneficiaries that will be

affected by changes in

benchmark plans will be higher in

2009 than 2008.

Catastrophic Benefit100% PlanNo co-pays

Co-Pays

Co-Pays

$1.10/$3.20 <100% FPL

$2.40/$6.00 >100% FPL

No premiumsNo deductibles

$.01 - $6,153.75

Over $6,153.75

Beneficiary Costs

Part D Plan

2009 Part D Full Extra Help (LIS)No Premiums if in Benchmark PlanNo DeductibleNo CoinsuranceNo Doughnut HoleNo monthly cap on co-pays

Drug Costs

Full Dual Eligible Co-pays

2006 2007 2008 2009

Copays for institutionalized FBDE (SNF and ICF/MR) does not apply to assisted living

$0 $0 $0 $0

Income < 100% FPG

$1/generic$3/brand

name

$1/generic$3.10/brand

name

$1.05/generic$3.10/brand

name

$1.10/generic$3.20/brand

name

Income > 100% FPG

$2/generic$5/brand

name

$2.15/generic$5.35/brand

name

$2.25/generic$5.60/brand

name

$2.40/generic$6.00/brand

name

REGION 19

Medicare Advantage: Penetration Rates for Region 19

• Minnesota – 28.6% (9th highest penetration rate in U.S.)• Montana – 11.9% • Iowa – 11.1%• Nebraska – 8.4%• North Dakota – 5.9%• South Dakota – 3.8%• Wyoming – 2.7%

• Oregon – 38.7% (highest penetration rate)

• Alaska – 0.1% (lowest penetration rate)

Medicare Advantage in MN

• Coordinated Care Plans (Local HMOs and PPO)• Cost Based Plans with Part D• Regional Preferred Provider Organizations• Private Fee-for-Service• Special Needs Plans• Medicare Medical Savings Accounts

Medicare Advantage Option 1 in Minnesota (Medicare A, B and D benefits)

• These plans provide:

– Medicare A benefits– Medicare B benefits– Medicare Part D benefits

• Option 1 includes:– Medicare Advantage HMO/Point of Service– Cost plans– Medicare Advantage Private-Fee-For- Service– Medicare Advantage Regional Preferred Provider

Organization

Medicare Advantage Option 2 in Minnesota (Medicare A and B benefits)

• These plans provide

– Medicare A

– Medicare B

– No part D• May enroll in a stand alone PDP only under Cost plan and PFFS

• Option 2 includes:

– Medicare Advantage HMO/Point of Service

– Cost plans

– Medicare Advantage Private-Fee-For Service

Medicare Advantage Option 3 in Minnesota (Medicare A, B, D and all Medicaid)

• These plans provide all

– Medicare A benefits– Medicare B benefits– Medicare Part D benefits– Most Medicaid benefits

• Option 3 includes:– Medicare Advantage Special Needs

Plans (MA-SNP: MSHO and MnDHO)

Medicare Advantage Option 4 in Minnesota

• These plans provide all– Medicare A benefits– Medicare B benefits– Medicare Part D benefits– Some Medicaid benefits

• Only available to beneficiaries age 18-64

• Option 4 includes– Medicare Advantage Special Needs Basic

Care Plans (MA-SNBC)

Medicare Advantage Option 5 in Minnesota (Medicare A and B, deductible must be paid first)

• These plans will pay for Medicare A and B services once a high annual deductible is met

– Deductible amount varies from plan– Once deductible is reached , the MSA plan will

cover most costs of Part A and B services– No Part D coverage

• Option 5 includes

– Medicare Advantage Medical Savings Accounts (MA-MSA)

2008 Medicare Advantage Plans in Minnesota

• 4 MA-RPPO

• 11 MA-Cost with Part D

• 5 MA-Cost without Part D

• 5 local MA-HMO with Part D

• 2 local MA-HMO without Part D

• 16 MA-PFFS with Part D

• 17 MA-PFFS without Part D

• 3 MA-MSA Plans

• 9 MA-SNP (MSHO)

• 2 MA-SNP (MnDHO)

• 2 MA-SNP (Medicare only)

• 7 MA-SNBC

Medicare Advantage Enrollment, 1999-2008

0.9 1.70.2

2.1

6.9 6.86.1 5.5 5.3 5.5

6.1

7.6

9.09.7

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Total Medicare Advantage

Private Fee-for-ServiceEnrollment in millions:

NOTE: Includes local HMOs, PSOs, and PPOs, regional PPOs, PFFS plans, Cost contracts, Demonstrations, HCPP, and PACE contracts. SOURCE: Kaiser Family Foundation, based on Mathematica Policy Research, Inc. “Tracking Medicare Health and Prescription Drug Plans Monthly Report” December 1999-2007. CMS Medicare Advantage, Cost, PACE, Demo, and Prescription Drug Plan Contract Report, Monthly Summary Report, March 2008.

Need Assistance with Solving Problems related to Part D?

• Call the Senior LinkAge Line® at 1-800-333-2433• MBA has data sharing agreement with DHS

– Access to CMS monthly return file• SLL is the SHIP for MN

– Plans have designated specific staff for Senior LinkAge Line® to work with to resolve problems

– Designated staff at CMS to work at resolving problems for SHIP

– CMS has designated specific contacts for SHIPs to use at 1-800-333-2433. This is not available to the general public.

• Senior Linkage Line® is here to help you and your clients!

27

Need more Information, Answers or Help?

• Senior LinkAge Line® 1-800-333-2433• Disability Linkage Line ® 1-866-333-2466• Veterans Linkage Line 1-888-546-5838 (LinkVet)• www.cms.hhs.gov• www.Medicare.gov 1-800-MEDICARE• www.socialsecurity.gov 1-800-772-1213• www.MinnesotaHelp.info

CONTACT INFORMATION

• CONTACT INFORMATION– Kelli Jo Greiner– 651-431-2581– Kellijo.greiner@state.mn.us

Minnesota Senior Health Options

Jeff Goodmanson

651-431-2530

jeff.goodmanson@state.mn.us

Common Acronyms

CMS - Centers for Medicare & Medicaid Services CBP - County Based Purchasing Plans MA-PD - Medicare Advantage Prescription Drug plan MA - Medicare Advantage MMA - Medicare Modernization Act MnDHO - Minnesota Disability Health Option MSC - Minnesota Senior Care (formerly PMAP for seniors) MSC+- Minnesota Senior Care Plus MSHO - Minnesota Senior Health Option PMAP - Prepaid Medical Assistance Plan SNP - Special Needs Plan TPA - Third Party Administrator ESRD – End Stage Renal Disease

Managed Care Options For Seniors

MSC - Minnesota Senior Care

MSC+ - Minnesota Senior Care Plus

MSHO – Minnesota Senior Health Options

MSHO, MSC+, MSCMSHO (83 counties)

MSC + (80 counties) MSC (7 county metro area, being phased out in 2009)

Medicare Part A & B

Medicare Special Needs Plan (SNP)

Fee for Service or other non-coordinated plan.

Fee for Service or other non-coordinated plan.

Medicare Part D Drugs

SNP Separate Free standing Medicare PDP

Separate Free standing Medicare PDP

Remaining Medicaid Drugs

SNP Medicaid MCO Medicaid MCO

Medicaid Basic Care

SNP Medicaid MCO Medicaid MCO

Medicaid NF SNP (180 days for new community enrollees) remainder FFS

MCO (180 days for new community enrollees) remainder FFS

MCO (90 days for new community enrollees) remainder FFS)

Medicaid EW SNP Medicaid MCO Medicaid Fee for Service

MSHO Overview

CMS Payment Demonstration since 1997 Combines Medicare and Medicaid services Includes Elderly Waiver Includes 180 days of nursing home care Enrollment is voluntary instead of mandatory enrollment

in MSC or MSC+ Operating statewide (83 of 87 counties) All nine PMAP plans participate 36,000+ enrolled

Overview Continued

Care Coordinator assigned to each enrollee.

Some plans contracting with counties for CC functions while others are using clinics/care systems.

MSHO Key Features

Simpler, seamless care for enrollees Improved management of chronic conditions,

clinical care coordination across primary, acute and long term care and Medicare and Medicaid benefits

Simplifies access to ALL Medicare A,B, D and Medicaid benefits

Integrated Medicare and Medicaid member materials and enrollment, providers bill one place for all services

Care Coordination: Each enrollee assigned a care coordinator or health service coordinator who assists with coordination of primary, acute and LTC services

Typical Dual Eligible Drug Coverage

Dual Goes to Pharmacy for Drugs: Must Present 3 Different Cards

Medicare Part D Drugs Medicare Part B Drugs Medicaid Drugs

Medicaid Card

Medicare Card and Medicaid CardPart D Plan Card

Medicaid pays 20% cost sharing, pharmacy or provider bills DHS separately

Integrated Drug Coverage

MSHO Enrollee Takes 1 Card to Pharmacy

Medicare Part D drugs

Medicare Part B drugs

Medicaid drugs

20% Medicare Cost Sharing covered

How Do I Identify The Care Coordinator?

The Care Coordinator can be found on RMGR in MMIS. PF4 to navigate

If no information is listed on RMGR or no screening document has been entered, please contact the health plan to get the Care Coordinator contact information.

The contacts for identifying Care Coordinators for MSHO and MSC can be found on the DHS website.

RMGR

PF4 TO PSUM

TRANSMIT TO PADD

Communication Form

DHS developed a new communication form that will be used by counties, managed care plans (Care Coordinators), and DHS to help improve communication.

The new communication form was developed in a workgroup that included DHS, Counties, and Managed Care staff.

Please see bulletin 07-21-09 for additional information.

Participating MSHO SNPs and MSC/MSC+ Health Plans for Seniors

Blue Plus First Plan Health Partners Itasca Medical Care ** Medica * Metropolitan Health Plan * Prime West ** South Country Health Alliance ** UCare Minnesota *

* Original MSHO plans** Current MSC+ plans

Who can Enroll into MSHO?

People 65 or over, and Are eligible for Medicare Part A and B or who do not

have Medicare, and Live in a participating MSHO county, and Are eligible for MA without a medical spenddown, or Are Eligible for SIS EW with a waiver obligation. Effective 6/1/05 applicants with a medical

spenddown are not eligible to enroll. People who acquire a medical spenddown after MSHO enrollment are allowed to continue MSHO enrollment if the spenddown is paid directly to DHS.

What Happened 1/06?

On 1/1/06 nine MSHO plans became Medicare Special Needs Plans (SNPs) offering Medicare A, B and D services

1/1/06 CMS passively enrolled 23,000 dually eligible seniors into MSHO SNPs due to new Part D system

Most Medicaid seniors are now enrolled in MSHO instead of MSC/MSC+

What Happened Continued

More services (like SNF stays and Part B) now subject to coverage under Medicare managed care

MSHO plans began new contracting partnerships with counties for care management

Most MSHO plans have $0 premiums for Part D Duals pay co-pays of $1.05-3.10 or $2.25-5.60

depending income level. NF residents pay $0 co-pays

0

2000

4000

6000

8000

10000

12000

14000

BluePlus

FirstPlan

HP Itasca Medica MHP

PW SCHA UCare

MSHO

MSC/+

MSHO 9,788

MSC/+ 31,613

PMAP and MSHO Senior Enrollment by Plan 11/05

0

2000

4000

6000

8000

10000

12000

14000

BluePlus

FirstPlan

HP Itasca Medica MHP

PW SCHA UCare

MSHO

MSC

M

MSHO and MSC Senior Enrollment 1/06

MSHO 33,371

MSC 8,674

84.7%

15.3%

72.6%

27.4%65.6%

34.4%

74.9%25.1%

69.9%

30.1%

53.0%47.0% 67.4%

32.6%

68.7%

31.3%

85.6%

14.4%

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

MSHO and MSC Enrollment September 2008MSHO Total: 36,303 MSC/MSC+ Total: 11,502

MSC 1,833 375 1,415 156 3,698 676 1,032 872 1,445

MSHO 10,162 995 2,704 466 8,600 763 2,133 1,915 8,565

Blue PlusFirst Plan

BlueHealthPa

rtners

Itasca Medical

CareMedica Metro HP

Primewest Health System

South Country Health

UCare Minnesot

a

93

Living Arrangement Impact on Part D Co-Pays

DHS provides NF information to CMS for dual eligibles on a monthly file based on what is listed in MMIS for the living arrangement

It is important that the NF submit the 1503 to the county timely

The county must update the living arrangement immediately so the correct information gets sent to CMS

Once the living arrangement is updated, the NF information is submitted to CMS on the next monthly file

CMS processes the DHS file and then tells the health plan how much to charge for the co-pay

The amount of time it takes for all actions to occur may result in delays in the resident getting charged the correct co-pay.

More About Part D Co-Pays

It is important that all providers bill timely If the enrollee has a spenddown, the enrollee is

not considered a dual eligible until the spenddown has been reached once in the calendar year for Medicare Part D purposes

DHS will not submit the enrollee for dual status until the spenddown has been reached even if the enrollee is a NF resident

Timely billing is a key factor in the enrollee getting changed the correct co-pay level

Medical Spenddowns

People who acquire a medical spenddown after MSHO enrollment has started are allowed to remain enrolled in MSHO only if they pay the full spenddown amount directly to DHS.

DHS (SRU) bills the enrollee each month Enrollees with AMM’s should only remain

enrolled if medical expenses are routinely more then the amount of the spenddown.

Waiver Obligations

Enrollees with waiver obligations are allowed to enroll in MSHO

Waiver obligations are paid directly to the provider similar to fee-for-service

Providers bill the health plan for EW services MSHO health plans pay the provider after

deducting the waiver obligation amount DHS informs the health plan of the waiver

obligation amount monthly

Institutional Spenddown

Institutional spenddowns for people enrolled in MSHO are collected by the provider just like all other Medicaid enrollees

See Bulletin 06-21-05 for more information about institutional spenddowns for people on MSHO

Designated Providers

Designated provider numbers should not be used for waiver obligations and medical spenddowns for MSHO

Exception: People who are in a nursing home and elect hospice should be coded as AMM with the hospice provider as the designated provider. (See MMIS User Manual)

Designated Providers should be used for institutional spenddowns.

Why can’t we use a designated provider for waiver obligations

and medical spenddowns? The health plans do not use our designated

provider data DHS is paying a cap to the health plan to pay

claims DHS bills the client directly for the medical

spenddown amount because claims are being paid by the health plan in full

The health plans can only deduct the waiver obligation amounts based on DHS provided information but they do not use our designated provider data

Why can we have designated providers for Institutional and

Hospice Spenddowns? When the health plan has the NF liability for an

MSHO enrollee, the plan pays the facility the full charges for the 180 days.

DHS will deduct the amount of the AIM spenddown from the provider on the remittance advice DHS pays to the provider

Once the 180 liability ends, the claims are submitted to DHS fee-for-service and the amount is reduced on the submitted claims

Hospice room and board charges are submitted to DHS fee-for-service so DHS can reduce the spenddown amount when the claim is submitted

Enrollment Hassles

MSHO enrollments may come in either through the counties, health plans, or through changes that CMS makes directly with notification to the plan/State

Dual eligibles can change plans or disenroll each month per CMS policy

Signing an enrollment in a freestanding Prescription Drug Plan or another type of Medicare plan (Medicare Private FFS Plan) automatically terminates an MSHO SNP enrollment per CMS policy

Enrollment Hassles

Loss of Medicaid eligibility also may change enrollment

Counties DO NOT control MSHO enrollment The State tracks the MSHO Medicare SNP

enrollments because we coordinate the Medicare and Medicaid enrollment to the best extent possible

SOME enrollment changes MUST be made retroactively due to CMS SNP rules

Minnesota Disability Health Options(MnDHO)

Special Needs BasicCare (SNBC)

Special Needs Purchasing

Susan Kennedy – Project Coordinator

Managed Care Programs for People with Disabilities

People with disabilities in MN are excluded from mandatory managed care programs. Two voluntary programs exist:

MnDHO: 7 county metro, people with disabilities 18-64. Enrollment is voluntary. Includes Medicare, Medicaid, all Medicare and Medicaid drugs, extensive case management, home and community based services and some nursing home care. Operating since 2001. No longer needs CMS waivers. DHS contracts with one SNP for services. Legislation prohibits expansion until after 7/2009.

SNBC: Started 1/2008. Statewide, open to all Medicaid eligible people with disabilities 18-64. Voluntary enrollment. Integrates Medicare and Medicaid primary, acute and drugs. Long term care services covered under FFS, except for some S/NF care. Medicaid co-pays covered by plan. Includes most Medicaid mental health services but not county case management.

Sept `08 MnDHO (1,110 enrollees) SNBC (2,672 enrolles)

Enrollment Voluntary, people with physical disabilities in 7 county metro and with DD in 3 counties with limit of 120 DD

Open to all Medicaid dually eligible and non dually eligible with disabilities potentially statewide. Started 01/08.

Medicare Services All Medicare services including Part D drugs through Medicare Advantage SNP

All Medicare services including Part D drugs through Medicare Advantage SNP

Medicaid Basic Care Services

Most Medicaid services provided through same SNP plan including remaining drugs and PCA services

Most Medicaid services provided through same SNP plan including remaining drugs except PCA and PDN which remain Fee for Service

Medicaid Long Term Care Services

Medicaid CADI/CAC and TBI waiver services though same SNP plan plus 180 days of Medicaid nursing home care

Medicaid HCBS waivers and long term care services remain Fee for Service except for the first 100 days of nursing home care

Disability Managed Care Programs

What Is SNBC? Special Needs Basic Care (SNBC) is a new

managed care option designed especially for people with disabilities ages 18-64 who are on Medical Assistance (Medicaid).

Enrollment in SNBC is totally voluntary, and enrollees can decide to drop out and return to what they had before if they don’t like it.

SNBC does NOT include long term care services such as PCA, ICF-MR, county case management and home and community based waiver services,

Those long term care services remain available under fee for service Medical Assistance to anyone who enrolls.

Purpose of SNBC

To provide additional health care delivery options for people with disabilities by integrating Medicare and Medicaid primary and acute care services

To simplify access to health care services by including all prescription drugs under one health plan

To improve access to primary and preventive care for people with disabilities

To improve care for enrollees with chronic conditions

What is Different from FFS

Health plan member services to help answer your questions on obtaining services

24 hour nurse line to refer you to the best place for health care

Network of providers: doctors, clinics, pharmacies, dentist and specialists.

Coordination of Medicare and Medicaid drug coverage

Covers most medical services

Who is Eligible to Enroll in SNBC?

People can enroll if they: Are 18 through 64 years of age. Are Medical Assistance eligible, with or without Medicare. Are certified disabled by SSA or SMRT or determined

disabled by the county for Developmental Disability waiver services.

Reside in one of the counties where SNBC is available. People can enroll if they are:

Enrolled in Medical Assistance Employed Persons with Disabilities.

Have an institutional or medical spenddown Elected hospice coverage Have waiver services, PCA or PDN services (these

remain fee for service)

Special Needs BasicCare (SNBC) Voluntary Managed Care Adults with Disabilities Age 18-64 BASIC CARE COVERED SERVICES *

Adult Mental Health Rehab Services: Crisis Services, Assertive Community Treatment (ACT), Adult Rehabilitative Services (ARMHS), Intensive Residential Treatment Services (IRTS)

Advanced Practice Nurse Services Cancer Clinical Trials Care Management Services - (Acute Medical) Chemical

Dependency Treatment Services Child and Teen Checkups Children’s Residential Mental Health Treatment Chiropractic Services Clinic Services Dental Services Disease Management Family Planning Services Home Care Services - Specified:

Home Health Aid (HHA), Skilled Nurse Visit (SNV), Home Care Therapies (PT, OT, RT, ST)

Hospice Services Inpatient Hospital Services Interpreter Services Laboratory, Diagnostic and Radiological Services Medical Emergency, Post-Stabilization Care, and Urgent Care

Services

* This is not an all inclusive list of services covered under each category of services.

Medical Supplies and Equipment Medical Transportation Services Mental Health Services including: diagnostic

assessment and testing, crisis assessment and intervention, day treatment/partial hospitalization, individual and family group therapy, inpatient and outpatient treatment, neuropsycnologicai assessment and rehab, medication management

Nursing Home services (100 days for people admitted from the community)

OBRA Level 1 (NF) Obstetrics and Gynecological Services Outpatient Hospital Services Physician Services Podiatric Services Prescription and Over-the-Counter Drugs Not

Otherwise Covered by Part B or D Prosthetic and Orthotic Devices Public Health Services Reconstructive Surgery Regional Treatment Centers (under certain

circumstances) Rehabilitation and Therapeutic Services

(PT, OT, RT.ST) Transplants Tuberculosis-Related Services Vaccines and Immunizations Vision Care Services

Special Needs BasicCare (SNBC) Adults with Disabilities Age 18-64 SERVICES CONTINUED UNDER FEE-FOR-SERVICE BASIC CARE SERVICES Abortion Services, as specified by State

and Federal law Child Welfare Targeted Case Management Circumcision for Newborns, as specified by

State law Individual Education Plan (IEP) and

Individual Family Service Plan (IFSP) Services

ICF-MR Services Mental Health Targeted Case Management Long Term Nursing Home services (post

100 days) OBRA Level 2 assessments Personal Care Assistance Services (PCA) Private Duty Nursing (PDN) Vulnerable Adult - Developmental Disability

(VADD) Targeted Case Management

HOME AND COMMUNITY BASED SERVICES WAIVER SERVICES

Community Alternative for Disabled Individuals (CADI)

Community Alternative Care (CAC) Traumatic Brain injury (TBI-NF, TBI-NB) Developmental Disabilities (DD) Waiver Case Management Long Term Care Coordination (LTCC) OBRA assessments, Level 1 and 2 (waivers) Relocation Service Coordination (RSC)

SERVICES COVERED ELSEWHERE Group Residential Housing (GRH) Medicare SSI SSDI IV-E Section 8 Housing Food Stamps

Medical Spenddowns

People with Medical Spenddowns will be allowed to enroll

PCA/Waiver providers will collect the spend down if they are listed as the designated provider in MMIS

Cost of waivered or PCA services must exceed the spend down amount

If the enrollee has a designated provider listed in MMIS and is not meeting the spenddown. The enrollee will be dis-enrolled from the SNBC health plan and returned to fee-for-service

Medical Spenddown – No Designated Provider If no designated provider is listed in MMIS, the

enrollee will be billed monthly by DHS Special Recovery Unit

Enrollee will be responsible for paying DHS directly each month

Spenddowns are to be paid in advance Enrollees will be dis-enrolled from the SNBC

plan if the medical spenddown is not paid in full for 3 consecutive months

Institutional Spenddowns

Institutional spend downs are collected by the NF provider just like all other Medicaid recipients.

When the health plan has the NF liability for an SNBC enrollee, the plan pays the facility the full charges for 100 days.

DHS will deduct the amount of the AIM spend down from the provider on the remittance advice DHS pays to the provider

Once the 100 day liability ends, the claims are submitted to DHS fee-for-service and the amount is reduced on the submitted claims

NF provider will be listed as the designated provider in MMIS

What happens at age 65?

Enrollee may remain in the SNBC plan when they turn 65, unless; They lose MA eligibility for a period of time and a new enrollment needs to be sent the

CMS to restart the Medicare coverage. They choose to become a participant in the Elder Waiver (EW) program and receive

Home and Community Based Services through EW.

Things to consider: SIS-EW budget allows the recipient to retain more of their income. EW may not have all the services provided through CAC, CADI, DD or TBI waivers. The SNBC service area is not the same as the MSC+ or MSHO service area. The

same health plan may not be available.

Enrollee Rights Enrollee of SNBC have access to the same

rights to appeal as they do under fee for service.

For Medicare covered services, enrollee may file an appeal with the health plan.

For Medicaid covered services, enrollee may appeal directly to DHS for a State Fair Hearing.

Ombudsman Contacts

Assistance is available:

DHS Ombudsman for Managed Care1-800-657-3729

Ombudsman for Mental Health and Developmental Disabilities

1-800-657-3506

The Formulary Can Change

Health Plans can:Add or remove drugs from the formularyAdd prior authorizations, quantity limits,

and/or step-therapy restrictions on a drug.Move a drug to a higher or lower cost-sharing

tier

What if your prescription is not on your copy of the formulary

Confirm the health plan does not cover the drug Call your care coordinator/care guide Call member services

If the prescription is not covered Ask your doctor if you can switch to another drug that is

covered by the health plan You or your doctor ask to make an exception to cover your

drug If you recently joined the health plan you may be able to get

a temporary supply of a drug you were taking when you joined the health plan. Work with member services or your care coordinator on the transition.

Temporary Supply of Prescription Drugs

Health Plan may provide a temporary supply of a drug that isn’t on the health plan formulary or that has coverage restrictions or limits. Health plan may cover a 30 day supply (unless the prescription is written for fewer days). After the health plan covers the temporary [must be a least 30]-day supply, they generally will not pay for these drugs as part of their transition policy again. They will provide you with a written notice after their cover your temporary supply. This notice will explain the steps you can take to request an exception

Exception Process: Contact care coordinator / care navigator Contact member services

Transition Services

The health plan is responsible for care when an enrollee is changing from fee-for-service or from one health plan to another. The plan may develop a transition plan special situations. Contact the plans member services when continuity of care is needed for this type of service, such as;

Services previously authorized At risk pregnancy Chemical dependency treatment service Mental health services

Disability and Senior Linkage Line The Disability Linkage Line® (DLL) and

Senior LinkAge Line® (SLL) are available to assist people with Medicare Part D choices

They have received special training on the new SNBC option

They are also available to assist people with disabilities to make an informed choice about SNBC options

DLL 1-866-333-2466 SLL 1-800-333-2433

Miscellaneous

What happens with Medicare coverage if SNP is closed?

The MSHO, MnDHO, and SNBC contract states that health plans will continue to cover Medicare services for up to 3 months when Medicaid eligibility ends.

The up to 3 months only applies to enrollees who lose eligibility with a disenrollment reason of “EE” on RPPH. (Closed for review)

People who close for voluntary disenrollment “VL” or because they move “MV” DO NOT get the 3 months. Same for closure for non-payment of medical spenddown

The up to 3 months of additional Medicare coverage was negotiated to allow the recipient an opportunity to choose another Part D plan if MA (MSHO, MnDHO, and SNBC) is not reopened.

Retro enrollment into SNP

If MSHO, MnDHO, or SNBC closes due to loss of MA, once MA is reopened, the client will be retro enrolled into the health plan with no gap in enrollment as long as the gap in MA is less than three months and the enrollee did not enroll into a different Part D plan.

This policy only applies to dual eligibles in MSHO, MnDHO, and SNBC. Non duals are enrolled the next available month.

Product ID Description

MA/NM01 Minnesota Senior Care

MA02 Minnesota Senior Health Options

MA/NM30 Minnesota Senior Care Plus without EW

MA/NM35 Minnesota Senior Care Plus with EW

MA15 Minnesota Disability Health Options (Physical Disabilities)

MA16 Minnesota Disability Health Options (Developmental Disabilities)

MA17 Special Needs Basic Care

Health Plan Provider Contacts

Blue Plus 651-662-5200 or 1-800-262-0820 First Plan Blue 218-740-2336 or 1-800-584-9488 HealthPartners 952-883-7699 or 1-888-663-6464 Itasca Medical Care 218-327-5527 Medica 1-800-458-5512 Metropolitan Health Plan 1-877-620-9090 PrimeWest Health System 320-335-5359 or 1-866-431-0802 South Country Health Alliance 1-800-262-0820 UCare 612-676-3300 or 1-866-280-7202

General Q and A?

Kelli Jo Greiner Jeff Goodmanson Susan Kennedy

THANK YOU!