Seniors and Persons with DisabilitiesService Package II: Long Term Services & Supports

Revised November 2013

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Company Overview

• Parent Company • Established in 1995• Serving TANF Population• Over 85,000 enrollees• Not-for-Profit

• Wholly Owned Subsidiary of FHN

• ICP Expansion Plan under Medicaid

• Medicare Advantage and D-SNP

• Serving Chicago and Rockford

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FHN Company OverviewNot-for-profit created in 1995 by five safety-net hospitals

Mt. Sinai HospitalNorwegian American HospitalPresence Health (Originally: St. Mary of Nazareth)St. Anthony HospitalSt. Bernard Hospital

• FHN is the only not-for-profit Managed Care Community Network in the State of Illinois• Illinois company with locally dedicated resources• History of successful provider-incentive programs

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FHN Program OverviewMedicaid TANF Population• Over 88,000 members • Targeted Patient-Centered Care Management• Disease Management Programs to coordinate care and provide education, support

and monitoring, as well as appropriate medical home • Pay for Quality for Providers and Healthy Incentives for Enrollees to improve HEDIS

scores and to encourage preventive care, early diagnosis and healthy behaviors

Value-Added Benefits• No copayments for physician visits and hospital services• Free Adult Dental, Weight Watchers membership, Transportation, Pregnancy Tests

and Jewel-Osco Coupons• Health Education Programs and Children’s Book Club• Drug co-pay reimbursement for prescription copays ($2-$5)

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CCAI History and PartnersSeeking a better alternative for Medicaid health care and financing, Family Health Network took a grassroots approach and joined with the following allies to develop CCAI

• Access Living of Metropolitan Chicago, a nationally recognized advocacy group for people with disabilities

• Health & Medicine Policy Research Group, an independent policy center that conducts research, educates and collaborates with other groups to advocate policies and impact health systems to improve the health status of all people

• Sinai Health System and Schwab Rehabilitation Hospital recognized as national models for urban health care delivery

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CCAI OverviewMissionThe Community Care Alliance of Illinois is a health plan dedicated to consumer-directed, community-based innovative health services specializing in the care of Seniors & Persons with Disabilities.

VisionTo be the leader in Choice, Access, and Quality of Health Services for the people we serve.

CCAI Philosophy• Empowerment of the consumer voice and

use of community peer resources• Prevention of complications through our

Care Coordination Model• Incorporation of Long Term Services and

Supports • Decreased Emergency Department Visits

and Hospitalizations

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CCAI Program Overview

Integrated Care Program– Rockford Roll-Out

• July 2013• 5,100 eligible in Boone, McHenry, and Winnebago Counties

– Chicago Roll-Out • December 2013 voluntary enrollment• February 2014 mandatory enrollment• 60,000 eligible in Cook County

Medicare Advantage – new!– Medicare-only (HMO and Part D)– Medicare-Medicaid (Dual-Eligible Special Needs Plan)

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Program Exclusions

SPD Populations Excluded from ICP• Children under the age of 19• Those eligible for Medicare Part A or enrolled in Medicare part B• American Indians/Alaskan Natives may voluntarily enroll• Enrollees currently in a spend-down status• Individuals aligned with presumptive eligibility• Individuals in the Breast/Cervical Cancer Program• Participants with comprehensive third-party coverage

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SPD Initial Enrollment Process• Eligibility determined by the State; enrollment managed by Client

Enrollment Broker (CEB)• CEB responsible for initial PCP assignment• Population is required to select a MCO/MCCN (mandatory enrollment)

within 60 days

• Enrollees who do not choose are auto-assigned by the state

• Enrollees are given an additional 90 days to switch plans

• If Enrollees make no changes, they remain with the assigned health plan until the next Open Enrollment period

• Open Enrollment occurs two months prior to the Enrollee’s anniversary date

• Enrollees may switch PCPs within their health plan at any time

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Added Value for CCAI Enrollees

• Integrated Care Team to assist with the coordination of services, including access to both nurse and long-term services and supports (LTSS) care coordinators

• No copayments for office visits or prescriptions• Practice visits for Dental and OB-GYN services • Dental and Vision benefits• Weight Watchers• Financial incentives for healthy behaviors

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Transportation

• Enrollees are eligible for transportation to receive covered medical services

• Transportation arrangements can be made by contacting Enrollee Services at (866)871-2305 at least 48 hours prior to the appointment

• Enrollee Services will arrange transportation and provide an authorization number

• There is no cost associated with this benefit

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Person Centered with Six Domains

• Medical • Functional• Environmental• Financial • Social Support• Psychological/Behavioral Health

Focus on the Whole Person

CCAI Model of Care

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CCAI Model of Care (continued)

• Person-centered care plan• Wraparound “all-in” care, integrating medical,

psychosocial, and long-term supports and services• Focus on prevention, health, and wellness• Disability-competent primary care services with Integrated

Care Teams• Integral role for disability-trained primary care nurse

practitioners• Flexible sites of service, including more home care and

fully accessible sites of care (Anchor Health Homes)

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Interdisciplinary Care Team

Disability Competent Primary Care• Primary Care Provider (PCP): MD/DO or Nurse Practioner (NP)

specializing in family medicine or internal medicine• Nurse Care Coordinators• Long Term Services and Supports (LTSS) Coordinator: social worker

Specialty Care• Rehabilitation professionals• Behavioral/mental health providers• Specialists

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Anchor Health Homes: Gold Star DesignationFully accessible and user-friendly environment for people with disabilities and complex needs, Anchor Health Homes will provide the following:• CCAI-Dedicated Nurse Practitioners on-site• CCAI Nurse Care Coordinator on-site• CCAI LTSS Coordinator on-site• Physical access (parking, entrance, clinic space, bathrooms)• Communication access including interpreting services available • Accessible medical equipment including exam tables, wheelchair accessible

scales, transfer equipment and staff training • Knowledgeable staff regarding disability care and accommodations• Commitment to incorporating health information technologies and

enhancements  • Team meetings, case reviews, etc.

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Anchor Health Homes

Rockford• Rockford Health System• Crusaders Community Health Center

Chicago• Mercy Diagnostic • Prime Care• Schwab Rehabilitation • Sinai Health System• St. Bernard Hospital• Swedish Covenant Hospital

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Mental Health & Substance Abuse All mental health and substance abuse (MHSA) services are sub-contracted to PsycHealth. PsycHealth manages both inpatient and outpatient services, as well as all UM processes related to MHSA.

CCAI nurse and LTSS care coordinators work closely with PsycHealth care coordinators to ensure that the Enrollee’s MHSA treatment is coordinated with their medical and LTSS care.

• No referral or prior authorization is required for an Enrollee to seek MHSA. However, if any provider feels the Enrollee needs such services, they can refer them to PsycHealth at (800)753-5456.

• Mental Health Claims should be submitted to:

PsycHealth, LTD.1121 Florence Ave., 2nd Floor

Evanston, Illinois 60202

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PharmacyCCAI has chosen CVS Caremark as its Pharmacy Benefits Manager.Enrollees may contact the Customer Care Line at (855)248-3446 or visit the CCAI website and click the CVS Caremark button on our Home Page to find a participating pharmacy nearby.

Mail Order OptionPrescriptions will be filled for up to a 30-day supply in the pharmacy. Enrollees who need long-term medication can send their prescriptions to CVS Caremark’s mail-order pharmacy at

CVS CaremarkPO Box 94467

Palatine, IL 60094-4467

Formulary, Prior Authorization and Step TherapyCCAI utilizes a Preferred Drug List, which can be found on the CCAI website. There are medications that require Prior Authorization or are only accessible through Step Therapy. These, along with instructions for obtaining authorization, can be found by calling the CVS Caremark Customer Care Line at (855)248-3446.

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Long-Term Services & Supports (LTSS)

Home & Community-Based Services (Waiver Programs) serving the following populations:• Elderly • HIV/AIDS• Physical Disability• Supportive Living Facilities• Traumatic Brain Injury

Long Term Care Facilities– Nursing Facilities

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LTSS in Home/Community Setting

The State completes Determination of Eligibility (DOE) for home/community ‘waiver’ services; eligibility shared with CCAI• Dept. of Human Services/Division of Rehab Services (DHS/DRS) =

Brain Injury, HIV/AIDS, Disability waivers• Care Coordination Units (CCUs) = Elderly and Supportive Living

Program waivers

CCAI develops and implements a Waiver Service Plan for Enrollees who are LTSS waiver-eligible. The Waiver Services Plan• Addresses the Enrollee’s LTSS needs in the home or community-based

setting• Is incorporated into the Enrollee’s Care Plan

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Working with Existing LTSS Entities

CCAI contracts with CCUs and Centers for Independent Living (CILs) to ensure that Enrollees’ LTSS needs are met in the home/community setting• CCAI buildings from the expertise in the community in

order to best serve Enrollees• CCU and CIL case managers work directly with CCAI care

coordinators to ensure integration of LTSS home/community services with medical and MHSA care

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Prior Authorizations for LTSSAll Long Term & Support Services require Prior Authorization.

Authorizations may be obtained any of the following ways• The web portal www.ccaillinois.com (must be a participating/contracted

provider)

• Telephone (866)871-2305• Fax (312)491-9856

Services Requiring Authorization• LTC/SNF admissions (Patient face sheet is acceptable and may be faxed in)

• Home and Community Based Services under the following waivers– Elderly– HIV/AIDS– Physical Disability– Supportive Living Facilities – Traumatic Brain Injury

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Home & Community Based Waiver ServicesElderly Waiver• Adult Day Service• Adult Day Transportation• Homemaker• Personal Emergency Response System

People with HIV or AIDS Waiver• Adult Day Care• Adult Day Transportation• Home Modifications• Home Delivered Meals• Home Health Aide• Homemaker• Nursing: Skilled & Intermittent• Personal Assistant• Personal Emergency Response System• Occupational/Physical/Speech Therapies• Respite• Specialized Medical Equipment Supplies

Persons with Disabilities Waiver• Adult Day Service• Adult Day Transportation• Home Modifications• Home Delivered Meals• Home Health Aide• Homemaker• Nursing: Skilled & Intermittent• Personal Assistant• Personal Emergency Response System• Occupational/Physical/Speech Therapies• Respite• Specialized Medical Equipment & Supplies

Supportive Living Program Waiver• Nursing Services• Personal Care• Medication Assistance• Laundry• Housekeeping• Maintenance• Social and Recreational Programming• Personal emergency Response System• Management of Resident Funds

Persons with Brain Injury Waiver• Adult Day Service• Adult Day Transportation • Home Modifications• Home delivered Meals• Home Health Aide• Homemaker• Nursing: Skilled & Intermittent• Personal Assistant• Personal Emergency Response System• Occupational/Physical/Speech Therapies• Respite• Specialized Medical Equipment & Supplies• Supported Employment• Prevocational Services• Day Habilitation• Behavioral Services

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CCAI Sample ID Card

The Enrollee’s ID number is the same as their Medicaid Recipient ID number

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Verifying Eligibility

Providers are able to verify Enrollee eligibility via

• HFS MEDI system

• CCAI secure web portal

• Enrollee & Provider Services (866)871-2305

• Monthly Eligibility List

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Claims

Timely Filing Guidelines• Best efforts to submit claims within 60 days from the date of service• No later than 180 days from the date of service

CCAI follows CMS guidelines for clean claims• Complete all data fields accurately• Complete CMS 1500 for Professional Services• Complete UB for Institutional Services• Include NDC numbers for J and Q codes

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Claims (continued)Electronic Submissions• Claims may be submitted online via the CCAI web portal (www.ccaillinois.com)• Individual or batch claim submissions in 837P/837I format are accepted• Submit through Availity using Payor ID “CCAI”

Submission of Corrected Claims• May be submitted via the secure portal• May be dropped to paper and mailed to claims address• Must be clearly marked to avoid duplicate denial

Claim Appeals or Disputes• CCAI will consider claims-payment disputes received within 90 days of the date on the EOP• Disputes may be submitted through the Provider Portal or by mail at the address below• Include original CCAI claim number and supporting documentation • CCAI will process Claims Payment Disputes within 45 days of receipt. After consideration by CCAI, the

resubmitted claim will be processed as a new claim. The resolution will be reflected in the EOP. The EOP may be accompanied by a letter, if further explanation is warranted.

Community Care AllianceC/0 Appeals Dept.

322 S. Green St., Suite 400Chicago, Illinois 60607

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Claim Forms

CMS 1500 UB-04

Professional Services Institutional Services

These forms are available on the website at www.cccaillinois.com

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Common Claim Rejection ReasonsThe following items will cause a claim to be rejected prior to processing• Enrollee unknown to CCAI • Illogical dates of service (i.e., future service dates, etc.) • Incorrect claim form • Missing Enrollee information, such as name, date of birth, ID number• Missing Provider information, such as name, tax ID or NPI number (for Medical

Providers) • Missing any of the following fields

– Valid diagnosis – Admission type – Patient status – Occurrence code or date – Valid revenue or CPT code

Rejected claims will be returned to the provider along with an applicable explanation

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Claim Submissions and Inquires

Mail claims toCommunity Care Alliance of Illinois

4044 N. Lincoln, #294Chicago, IL 60618

Contact Enrollee and Provider Services at (866)871-2305 with claim inquiries.

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Value for Providers

Timely and accurate claims payment• 99.96 % of claims are paid within 30 days• Average clean claim paid within 14 days

Online Resources on CCAI Website• Provider Manual• Provider Directory• Authorization List• Online Forms

Access to the CCAI Secure Web Portal for Contracted Providers• Electronic Eligibility• Electronic Submission of Outpatient Authorization Requests• Electronic Claims Submissions (837 batch submission capability)• Electronic Funds Transfers• Electronic EOBs

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Secure Web Portal

Please visit us at www.ccaillinois.com and register today!

Cultural Competency

CCAI works to

• Value diversity

• Assess ourselves and our processes

• Manage the dynamics of difference, through compassion and human-rights

framework, as well as legal compliance

• Acquire and institutionalize cultural knowledge through ongoing education,

diverse staff and learning from our Enrollees

• Adapt to diversity and the cultural contexts of individuals and communities

served via quality processes: ongoing review, grievances, provider network,

and other resources available to support our interfaces

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Cultural Diversity in Health Care

• We must be aware that some cultures are not comfortable going to see a health care provider

• Some cultures prefer to see a health care provider of the same gender

• Some cultures are not comfortable with self examinations• Some cultures have sensitivity around Mental Health issues

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CCAI Resources Available

• Bilingual written materials

• Language Line

• Multi-Faceted Provider Network

– PCPs – 45% Female and 55% Male

– Specialists – 35% Female and 65% Male

– PCP 43 different languages spoken

– Specialists 38 different languages spoken

– TTY (teletypewriter) is available through Enrollee & Provider

Services at (888)461-2378

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Abuse, Neglect, Exploitation & Critical Incidents

What is Abuse?• Abuse is any negligent act by a caregiver or other adult that causes harm or

serious risk of harm to a vulnerable adult. • Abuse can include

-Physical -Sexual -Emotional or Mental Abuse -Confinement-Neglect-Financial Exploitation

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Abuse, Neglect, Exploitation & Critical Incidents (continued)What are the Reporting Requirements?• An allegation of Abuse, Neglect or Exploitation must be reported to Adult

Protective Services minimally within 4 hours of its initial discovery

(866)800-1409, (800)544-5304 (TTY)

• CCAI should also be notified of Critical Incidents or Abuse, Neglect or Exploitation of Enrollees by calling Enrollee Services at:

(866)871-2305

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Abuse, Neglect, Exploitation & Critical Incidents (continued)

When Should You Report to the Hotline Number?Whenever you believe that an individual with disabilities or an older adult has been abused or neglected. Some examples of abuse or neglect are

• if you see someone hitting or otherwise injuring a person with disabilities in a domestic setting or in a facility

• if you see an injury on the body of a person with disabilities that does not appear to have been caused by an accident

• if a person with disabilities tells you that he or she has been harmed by a care giver

• if a person with disabilities appears or seems to be neglected, emotionally abused, or financially exploited

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Abuse, Neglect, Exploitation & Critical Incidents (continued)

Where should you report Abuse or Neglect?

Adult Protective Services Hotline at 1-866-800-1409, 1-888-206-1327 (TTY)Adults 18 years and older with Disabilities and Adults 60 years of age and older Illinois Department of Public Health Hotline at 1-800-252-4343Abuse, neglect, exploitation of an adult 60 years of age older in a Nursing Home Supportive Living Facility (SLF): 1-800-226-0768Enrollees residing in SLFs Community Care Alliance of Illinois at 1-866-871-2305Enrollee Services

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Questions?