What Really Happens After Enrolling in Medicaid Managed Care?

 

Health & Disability Advocates (HDA) is monitoring the rollout of the Medicare-Medicaid Alignment Initiative (MMAI) and has heard from frustrated case managers working with consumers who are confused about the enrollment process and their rights. In response, HDA developed an enrollment timeline that explains what new enrollees can expect from Managed Care Organizations (MCOs) and plan representatives upon enrollment. To produce the timeline, HDA researched the MMAI demonstration contract developed by the State of Illinois and approved by the Center for Medicare and Medicaid Services (CMS)  HDA also solicited input from health plans on whether their on-the-ground practices were accurately reflected in the timeline.

The finished product outlines important points for case managers and their clients to consider.

One Day Changes Everything

Consumers who are enrolled in a managed care plan after the 12th day of the month will not see their coverage start until the month after next. This is relevant for consumers choosing a specific managed care plan in order to see a particular provider or specialist in that plan’s network. Submitting paperwork after the cut-off date means consumers would have to wait longer than expected for necessary treatment. Helping consumers submit required documents in a timely manner can guarantee they are connected to the medical treatment they need, which promotes continuity of care.

Stratification Sets Up Future Contact Standards

Once enrolled in a plan, all enrollees can expect to complete a Health Risk Screening within 60 days. The screen collects information on the enrollee’s physical and mental health conditions and identifies their current medical providers. This is what IlliniCare’s Health Screen looks like. Health plans use the screen to establish intensity of services and frequency of contact with Care Coordinators by stratifying the enrollee as low, moderate or high risk.

Enrollees stratified as low risk will receive annual follow-ups from their Care Coordinators while those stratified as moderate or high risk will have quarterly follow-ups. Moderate and high risk enrollees will also complete a Health Risk Assessment and create an Individualized Care Plan within 90 days. These enrollees will help form their own Interdisciplinary Care Team of healthcare providers that meets quarterly to review the Individualized Care Plan.

The Care Coordinators’ Role

Care Coordinators focus on enrollees’ healthcare needs by connecting them to necessary tests, doctors and treatment. They also facilitate information sharing among providers by leading the Interdisciplinary Care Team. Addressing enrollees’ medical needs is their priority. Care Coordinators direct less attention to linking enrollees to social supports, like housing and public benefits.

It’s also important for case managers to know that Care Coordinators must manage a substantial caseload of up to 600 enrollees. Caseloads include a blend of low, moderate and high risk enrollees, with each risk level weighted differently.

Understanding what a care coordinator can—and cannot—be expected to do is advantageous to case managers. When roles are clearly recognized, case managers know how care coordinators can be used as a resource. And in what instances an alternative referral would be more appropriate. This establishes a stronger professional relationship between case managers and care coordinators, which ultimately benefits the enrollee.

Case managers and Care Coordinators are on the front lines of healthcare reform and fostering solid working relationships between these two players will be a critical component of the success or failure of these efforts. Knowing what case managers and their clients can expect from managed care plans can lay the foundation for a strong relationship that supports the health of individuals while also furthering the goals of healthcare reform.

Bryce Marable MSW

Health Policy Analyst

Health & Disability Advocates

Medicaid: The Long-Term Costs of Short-Term Savings

The Rauner Administration’s decision to cut $1.5 billion in Medicaid spending to balance the state budget is like the proverbial cutting off the nose to spite the face. Central to the Rauner “plan” is to tighten eligibility for people with disabilities and older adults to access long-term care services and supports (LTSS). The Administration is proposing to increase the minimum eligible level of something called the “Determination of Need” score. 

The DON eligibility process determines how many hours of assistance an older adult or person with a disability can get in order to stay in their own home.While the Administration views this as an appropriate cost-cutting measure, in reality such a move will ultimately reduce needed community-based services for people with significant disabilities, and will spread those costs to other parts of the healthcare delivery system.
Where the costs go

What happens to those costs? They get passed on to hospitals and urgent care providers, taxpayers (in the form of other social programs), and family members who are either under-employed or unemployed in order to help a loved one.Persons who are aging or living with a disability require access to long-term care to live independently, and do not have other options to find support for their medical needs. Reducing access to home and community-based services means individuals who are at risk of living in more costly nursing facilities become desperate to find any help with activities of daily living, through friends or family members who may be able to assist with financial or personal healthcare needs.This is easier said than done, however, as family members or friends who can volunteer to assist are often being forced to choose between their own employment and assisting their family member or a loved one. 

Creating a further burden is Rauner’s proposed elimination of funding for developmental disabilities respite care, a program that provides assistance for people who care for persons with disabilities,Medicaid is not only the payer of last resort, but the program of last resort, for persons with significant medical needs – paying for as much as 49% of the country’s long-term care services.
How to save the state money

Keeping people out of emergency rooms and nursing homes ultimately saves the state money. Progress Center for Independent Living released data showing that home services remove pressure from Medicaid spending on nursing homes, saving the state more than $17,500 per person, per year in the Home Services Program for people with disabilities.The cost savings for seniors in the Community Care Program are even greater, at more than $24,150 per person, per year. Consider the fact that the Home Services Program serves 30,000 people with disabilities, and the Community Care Program serves more than 80,000 people year round (based on the FY 2014 Public Accounting Report for both HSP and CCP from the Illinois Office of the Comptroller), and you have staggering numbers for cost savings. According to the Service Employees International Union, more than a third of people with disabilities now in the Home Service Program – some 10,000 people – will lose access to care in their homes, thereby creating a dependence on hospitals and institutions to address their long-term care needs. 

The Community Care Program will be losing more than 38,700 seniors.Debate surrounding the state budget should be aimed at taking concrete strategic actions, rather than cutting low-cost and money-saving programs. Governor Rauner appears bent on forging ahead despite opposition from the Illinois house and senate.The facts are clear. The cuts to the Medicaid budget are not cost-effective, and they isolate vulnerable populations. The notion that diminishing social safety nets is a good way to control state budget deficit is at best misguided, and we need to move on from this policy.

Illinois Must Continue to Provide Vital Benefits, Regardless of Failure to Pass State Budget

The following originally appeared on The Shriver Brief from the Sargent Shriver National Center on Poverty Law.

As Illinois’s budget impasse continues, the failure of Governor Rauner and the state legislature to pass a fair, adequate, and fully funded budget is beginning to have an impact. Late last week, Illinois Attorney General Lisa Madigan filed a lawsuit seeking to clarify what payments the state can and cannot make in the absence of a state budget. At issue, among other things, is the state comptroller’s authority to continue to pay state workers.

Importantly, the state also has an obligation to millions of low-income Illinoisans who are recipients of public benefits or beneficiaries of health care coverage. Earlier in June, the Shriver Center formally reminded state officials of their obligations under existing consent decrees to continue to provide these important services. The agreed order entered yesterday by the court in People v. Munger authorizes and requires the comptroller to continue to provide cash assistance through the Temporary Assistance for Needy Families and Aid to the Aged, Blind and Disabled programs, medical assistance, and child care assistance regardless of the lack of a state budget.

Millions of Illinois residents who would suffer needlessly by losing their income and health care coverage due to the lack of an operational state budget can feel secure tonight that their benefits will continue uninterrupted. Now it’s time for the governor and the state legislature to work together toward a budget that serves all of Illinois and includes the sustainable revenue needed to fund the programs that families need.

Dan Lesser
Director, Economic Justice
Sargent Shriver National Center on Poverty Law

ObamaCare Is Here – But Is It Working for People with HIV?

Read AFC's CountyCare report and press release.

On January 1, 2014, national health care reform will kick into high gear, providing new health insurance options for millions of people across the country. And thanks to visionary leadership from Cook County Board President Toni Preckwinkle, Cook County Health and Hospitals System Board CEO Dr. Ram Raju, and the Obama administration, the Affordable Care Act (ACA) is already being implemented in Cook County in the form of CountyCare.

This new program implements a provision of national health care reform that allows states to expand Medicaid programs to cover most low-income adults. The federal Center for Medicare and Medicaid Services (CMS) granted Cook County permission to implement the program in October 2012. Previously, as many as 250,000 Cook County residents were excluded from Medicaid because they did not meet the program’s restrictive eligibility requirements, such as being totally disabled. The AIDS Foundation of Chicago (AFC) estimates that 1,800 or more Cook County residents with HIV could benefit from CountyCare.

While CountyCare is a sign of great things to come, it also provides some critical lessons that can be applied later this year when health care reform rolls out statewide. AFC recently released a new report, CountyCare & the Ryan White Program: Working Together to Optimize Health Outcomes for People with HIV, that details the importance of CountyCare and the role it can play in improving access to health care for HIV-affected individuals. It also contains a number of policy recommendations for the city and state departments of public health, Cook County, and the federal government that aim to improve the program for people with HIV and avoid problems in the future.

The most significant issue with CountyCare for people with HIV is that nine HIV clinics  in Chicago are excluded from the primary care network. As a result, 500 or more patients with HIV could be forced to switch doctors to receive care at a clinic that’s already enrolled.

Many low-income people with HIV have connections to the health care system that are tenuous at best. They are facing not just HIV and its paralyzing stigmas, but also homelessness, mental illness, substance use, and chronic physical health conditions, such as diabetes and heart disease. Large numbers live in violence-plagued communities in Chicago, where a trip to the corner store can mean getting caught in turf-war crossfire. In such contexts, HIV care is the last thing on a person’s mind, and something as simple as having to find a new doctor can cause them to drop out of medical care entirely.

Delayed or disrupted health care harms people with HIV and also worsens the health of our communities.  People who are not taking HIV medications face a far greater risk of transmitting HIV to their partners. In fact,research shows that people whose HIV is controlled with medications have a 96 percent lower risk of transmitting HIV to their partners.

If those nine clinics are unable to join the CountyCare network, their HIV-positive clients will be forced to switch to new health care providers. The federal Ryan White Program, which subsidizes medical care for low-income uninsured patients with HIV, is mandated by law to be the payer of last resort, tapped only when people have exhausted all other sources of coverage. In fact, federal law prohibits clinics from serving patients with Ryan White dollars if their insurance could be used. Thus, people with HIV are caught in a bind: They are required to apply for all insurance for which they are eligible, but if they enroll, they might be forced to leave their current health care provider of choice.

The Ryan White Program’s payer-of-last-resort provision is a double-edged sword. Despite being a resource for people without coverage, it has the potential to disrupt existing doctor/patient relationships, something all of us – and especially people with chronic, complex health conditions like HIV and other co-occurring diagnoses – want to avoid.

Such potential disruptions occur because different federal government entities routinely drop the ball in coordinating and communicating their strategies. One of the lessons we have learned as we prepare to implement health care reform nationwide is to closely monitor the interactions and implications of various programs.  We cannot rely on the federal government to communicate across or even within agencies. Sustained advocacy and vigilance will be needed as health reform kicks off.

So what are other lessons we are learning from the CountyCare rollout, and what can we do to avoid situations like this in the future?

It’s clear that the transition to new health care reform programs will be slower than we want. Case managers and other staff at community clinics are already overwhelmed by the flood of clients they see every day; it will be challenging to help thousands more people apply for new ACA programs, connect them important resources, and ensure they’re receiving optimal HIV care. New federal funding for ACA enrollment staff will hopefully help with this task.

Moreover, the HIV community needs to better prepare itself for health reform programs. Most importantly, clinics should aggressively reach out to new Medicaid and private insurance programs to make sure they are part of these new programs, and the insurance companies must do their part and enroll HIV clinics in their networks.  Clients can’t be stripped of medical options because their doctor doesn’t accept their insurance.

Establishing the right enrollment and service systems under CountyCare is paramount for people living with HIV. We have a unique opportunity to improve health care access and services for individuals with this disease. Getting this right is imperative, so we can learn from this rollout and help tens of thousands of other Illinoisans affected by HIV, who will have new insurance options in 2014 when the ACA goes into full swing.

The new report from AFC also details recommendations for service organizations, case managers, government officials, and people with HIV, so that all can take full advantage of CountyCare. It’s available at www.aidschicago.org/countycare.


David Ernesto Munar
AIDS Foundation of Chicago
(This post was originally published on the AIDS Foundation of Chicago blog).

Connecting Navigators to Jobs so They Can Continue Connecting Consumers to Coverage

 

Navigators are key to health care outreach and enrollment across the country, but in Cook County the number of working Navigators is on the decline as grant funding slows. This is not only bad for individual Navigators unable to find work, but compromises the success of future enrollment cycles. In-person assisters of all stripes — including Navigators, Certified Application Counselors, agents, and brokers — play a crucial role in helping people apply for coverage. An Enroll America study found that people who got in-person help were nearly 60 percent likelier to enroll. To help keep assisters in the community, through the Health Insurance Workforce Pipeline Initiative, Health & Disability Advocates and the Chicago Cook County Workforce Partnership are connecting unemployed Navigators with jobs in the health insurance field — specifically as brokers.

Health & Disability Advocates is leveraging its connections in the health insurance community to bring employees and employers to the table. Meanwhile the Chicago Cook Workforce Partnership contributes Workforce Investment Opportunity Act (WIOA) dollars that pay for job-readiness training, workshops, and on-the-job training that new hires may need once they start their jobs as brokers. Since its formation in early May 2015, the Health Insurance Workforce Pipeline Initiative has hosted Rapid Response Workshops that describe the resources available for unemployed or soon-to-be unemployed enrollment assisters. HDA and CCWP also organized an exclusive job fair where Navigators could meet and interview with employers looking to hire.

Former Navigators are already transitioning into new jobs thanks to this initiative. A group of eight new hires who had previously collaborated as enrollment assisters to connect 51,000 people with Medicaid and marketplace coverage will now be working together as brokers, drawing on their experiences as Navigators. According to Tearalla, a new hire, “As a broker, my Navigator skills are transferable and aligned with my current responsibilities. I will continue to provide outreach, education, and enrollment assistance to newly enrolled consumers and consumers seeking to re-enroll in the Marketplace.”

These transitioning Navigators will be doing outreach and drawing on their strong connections — including with Navigators — in the communities where they worked for the first two enrollment cycles where they already have strong connections. Said Tearalla, “Networking with existing community stakeholders is ongoing.”

Everyone wins — employers and Navigators alike — when these Navigators transition into new roles as brokers. According to one hiring manager, they were able to hire more former Navigators because money spent for training was covered by WIOA dollars. The hiring manager was also excited that the new hires have great working relationships with groups and community leaders.

New hires are eager to continue enrollment work. They are already reaching out to previous community contacts to spread the word about their new role and the ongoing opportunity to get health insurance. Said one former enrollment assister, Olivia, “I’m excited about the opportunity to continue to enroll folks in the ACA.” It’s a wonderful opportunity for the overall enrollment push in Illinois, too. Having seasoned pros with strong community connections on the front lines of Affordable Care Act outreach like Olivia and Tearalla can help set up a strong foundation for the upcoming enrollment cycle and get even more people connected to health insurance.

This post originally appeared on Enroll America's blog.

Bryce Marable
Health Policy Analyst
Health & Disability Advocates