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

Redoing Redes: Strengthening Communication Procedures in the Illinois Medicaid Redetermination Project

The Illinois Medicaid Redetermination Project (IMRP) is erroneously suspending vital medical care for people who remain eligible. Since the rollout of the IMRP in early 2013, the program has been plagued by inadequate communication from the state that leaves consumers confused and ultimately without healthcare. Consumers report that they are not receiving the required notices by mail and when they call with questions, frontline state staff cannot provide answers. Because of the state’s ineffective communication protocols and inadequate employee training, rightful Medicaid beneficiaries are in the precarious situation of being unable to fill their prescriptions, go to the doctor or receive treatment. The purpose of the IMRP is to save state dollars by trimming the Medicaid program of those who are no longer eligible, not cut people who still deserve services.

Letters Lost in the Mail

Medicaid beneficiaries are cut simply because they never received their redetermination notices in the mail. For example, Health & Disability Advocates worked with a mother whose child had been dropped from Medicaid because IMRP sent the notice to a non-existent address. The fact that IRMP sent the letter to an incorrect address on the same street where the family lived suggests that it was a clerical error. In this situation, a young adult dealing with serious mental illness could not access medication and treatment, because the state, not the individual made an error. Sudden lapses in care can pose serious consequences for people who rely on these supports for their physical and mental health.

This is not an isolated instance. A survey of case managers working with older adults and people with disabilities found that the IMRP fails to adequately notify people of their redetermination responsibilities and inform them when they are bounced from the program. Many get the bad news when they attempt to fill prescription or go to the doctor and are told that they are no longer covered. People deserve clear communication from the state telling them they are no longer covered and the steps to get reinstated.

Confused and Not Covered

Even in cases where Medicaid recipients do receive notices, many consumers find the letters are hard to understand and filled with jargon. Given that the intended audience has never before been required to submit to annual redeterminations and may also have lower literacy levels, the letters must be crystal clear. Reports from case managers suggest the letters are confusing.  One case manager surveyed noted “clients do not understand what documents they need to submit with the form and whether they need to submit anything.” With the potential for people to lose their health coverage, the consequences of this confusion are severe.

IMRP’s own data reveal their communication shortcomings. According to May’s Medicaid redetermination numbers, 81% of cancellations are due to a lack of response. Being cancelled doesn’t mean a person is ineligible. In fact, a substantial portion of these clients should still be receiving services.  Of those dropped, 1/3 were reinstated within three months.  In FY 2015 alone, this translates into 238,025 people being incorrectly cut from Medicaid, and this number could be even higher. People who are less frequent healthcare users may learn of their cancellation when they attempt to schedule a doctor’s appointment. With people who deserve Medicaid cut from the program, the IMRP is not achieving its main objective of reducing state expenditures by eliminating those who no longer qualify. Cutting eligible people will actually result in higher costs. Without access to primary medical treatment, people will resort to more costly emergency room care for conditions that could have been managed or even prevented.

Matters get worse when consumers call state workers for clarification, because frontline staff members are often not fully informed themselves. In the above-mentioned case of the mother fighting for her son’s coverage to be reinstated, her interaction with the IMRP hotline was unhelpful and hurtful. The representative said there was nothing more she could do and blamed the family. Stateline workers should be fully trained to provide answers; anything less only increases confusion and frustration.

The Path Forward

The state must develop plain-language notices that explain redeterminations and their importance while outlining the specific steps to keeping coverage. This would not be a new undertaking. State officials have previously brainstormed ways to create simple, more consumer friendly forms. Unfortunately, the furor around budget deficits and service cut threats has drowned out the push for clear communication standards. Even worse, continuing to deemphasize this issue will leave many rightful Medicaid recipients suddenly without coverage. Communication protocols and state staff should support individuals in maintaining their vital connection to healthcare, not create hurdles that effectively jeopardize emotional and physical health. State officials must restart the discussions on clear notices and broaden the conversation to include improved training for frontline staff. These reforms will go a long way towards supporting the IMRP’s original objective of eliminating wasteful spending while also keeping those who still deserve coverage connected to care.

Reducing Obesity: Not Simple But Doable

Photo via k lachshand
Eating these is one way to reduce obesity.

James R. Knickman President & CEO at the New York StateHealth Foundation  asked the million dollar question in his Huffington Post piece, “What's Workingto Reduce Obesity?” In his post Mr. Knickman reveals that researchers from Drexel University studied a range of experiments aimed at reducing obesity, assessing how effective those strategies were. Researchers concluded that measures such as improving sidewalks and banning trans fats had strong impact but other approaches such as restaurants posting nutrition information had very little, to no impact.

So what does work to reduce obesity?

Mr. Knickman believes reducing obesity comes down to the following points:

- Better and more research will provide a better sense of the impact of various strategies reducing obesity in communities

- Different populations require different strategies so research can determine which approaches are most effective for high risk populations

- Seek out the economic and social benefits of interventions

- Success happens when communities and neighborhoods make it easy and affordable to be physically active and eat healthy foods, rather than one method such as banning trans fats

- All these healthy components add up to create “a neighborhood value, a point of pride” and becomes a part of the culture.

Mr. Knickman asks, “What is the best bang for your buck?” Here at the Bronx Health REACH Coalition we have launched the Towards A Healthier Bronx initiative using policy, systems and environmental improvements that increase access to healthy food, healthy beverages and opportunities for physical activity for over 75% of 675,215 residents residing in 12 high need South Bronx zip codes. Many public health campaigns rely heavily on clinical evidence, but fail to research the motivating factors relevant to that audience. To avoid this our campaign emphasizes actionable health behaviors.

Led by the Institute for Family Health, Bronx Health REACH was formed in 1999 to eliminate racial and ethnic disparities in health outcomes in diabetes and heart disease in African American and Latino communities in the southwest Bronx. Since then the Bronx Health REACH coalition has grown to include over 70 community-based organizations, 47 faith-based organizations, and health care providers. Bronx Health REACH serves as a national model of community empowerment demonstrating ways to build healthier communities by promoting healthy life-style behaviors.

The plan behind Towards A Healthier Bronx is:

- Increasing the number of bodegas and restaurants involved in incentive programs offering and promoting affordable healthy foods

- Increasing the number of farm stands making healthy food more affordable and available to the community

- Increasing the number of public and charter elementary schools emphasizing nutrition education and supporting related school policies

Partnering with bodega, deli and restaurant owners by providing them with training and education makes these initiatives not only a healthy benefit for their customers, but an economic benefit for the business owner. Encouraging chefs to attend monthly trainings on healthy food preparation results in offering patrons 2 to 3 healthier menu options. As New York City neighborhood demographics change, the restaurants and bodegas can now more easily adapt to the healthy choices their new customers are seeking resulting in those restaurant and bodega owners seeing more customers come into their stores and restaurants and gaining more revenue.

Mr. Knickman also states, “So if menu labeling isn't working for the target population--as the Drexel research and other studies suggest--we need to find and test other ways to make the healthy choice the easy choice.” Euny C. Lee, Evaluator and Policy Analyst at Bronx Health REACH agrees with Mr. Knickman citing a New York University study, “Calorie Labeling Has Barely Any Effecton Teenagers' or Parents' Food Purchases” which revealed that posting calories for food items at fast food restaurants had no impact on what consumer purchased.

Euny has moderated several focus groups with our faith-based coalition members to determine which types of messages encourage healthy behavior such as healthy eating and physical activity. Findings reveal educating the community about daily calorie intake to be important as most were not aware that you should consume no more than 2000 calories a day to maintain a healthy lifestyle.

Messaging matters as well. Signs and posters promoting a health benefit rather than a scare tactic elicit more positive behavior changes. Interventions have to be customized to a specific demographic/ethnic group so that it is culturally and linguistically understandable and appropriate. Other results include social support such as having a friend or family member who you are accountable to for your actions to reach the desired health goals.

Focus group members felt this ad was not accurate saying the soda bottle should be bigger and would be more effective if other ailments such as diabetes and heart disease that causes stroke were listed.

Focus group members felt the above ad was actually a real advertisement selling juice boxes and a better message would have been the child drinking from a water bottle.

But the question still remains. “What is doable in the fight to reduce obesity?” Bronx Health REACH can point to a few projects. A city wide campaign was created to serve only low-fat and fat-free milk rather than whole milk at New York City public schools. Bronx Health REACH educated policy makers, Coalition members and residents from the community about obesity and the benefits of reduced fat milk. This led to the New York City Public school system adopting the policy and impacting over 1.1 million children in 1,579 schools as well as a model for public schools in 15 other states.

I don't know if the day will ever arrive where the only thing one needs to do is take a miracle pill that sheds those excess pounds without any physical effort while drinking a large vanilla milkshake every day. What I do know is these healthy initiatives together will begin slowing the overweight/obesity epidemic we now face.

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

The Budget Crisis Impact on Centers for Independent Living

Like many other human services providers, the Illinois Network of Centers for Independent Living

(INCIL) is being hit hard by the Illinois budget crisis. Access Living is one of the 22 Centers for Independent Living (CILs) in Illinois. The CILs serve 95 of the 102 counties in Illinois. INCIL’s Executive Director, Ann Ford, shared the following, based on reports from 19 of the 22 CILs, which employ between 450-500 people:

•39 CIL staff have been laid off state wide since July 1, 2015
•93 CIL staff are working reduced hours because of furlough days, experiencing pay cuts ranging from 20% to 40%
•21 vacant CIL positions remain unfilled throughout the state (delaying hires is one way to save money)
•Two CILs are in the process of closing satellite offices
•All CILs are restricting travel, including in some areas travel to consumers’ homes
•At least four CILs are developing contingency plans to close in the event funding doesn’t come within the next six months
•It is difficult to determine how many consumers have gone without services. A reasonable estimate would be 800 to 1,000 people statewide
•The impact includes the enormous emotional toll this issue is taking on staff at all CILs, as they take on increased workloads while losing a portion of their income.

The CILs are doing the very best they can to continue to provide services to empower people with disabilities to live as independently as possible in the community. Quite often they are a real lifeline for many people with disabilities. During this difficult state budget crisis, know that your local CILs have been doing everything they can to show whLike many other human services providers, the Illinois Network of Centers for Independent Living

(INCIL) is being hit hard by the Illinois budget crisis. Access Living is one of the 22 Centers for Independent Living (CILs) in Illinois. The CILs serve 95 of the 102 counties in Illinois. INCIL’s Executive Director, Ann Ford, shared the following, based on reports from 19 of the 22 CILs, which employ between 450-500 people:

•39 CIL staff have been laid off state wide since July 1, 2015
•93 CIL staff are working reduced hours because of furlough days, experiencing pay cuts ranging from 20% to 40%
•21 vacant CIL positions remain unfilled throughout the state (delaying hires is one way to save money)
•Two CILs are in the process of closing satellite offices
•All CILs are restricting travel, including in some areas travel to consumers’ homes
•At least four CILs are developing contingency plans to close in the event funding doesn’t come within the next six months
•It is difficult to determine how many consumers have gone without services. A reasonable estimate would be 800 to 1,000 people statewide
•The impact includes the enormous emotional toll this issue is taking on staff at all CILs, as they take on increased workloads while losing a portion of their income.

The CILs are doing the very best they can to continue to provide services to empower people with disabilities to live as independently as possible in the community. Quite often they are a real lifeline for many people with disabilities. During this difficult state budget crisis, know that your local CILs have been doing everything they can to show why their programs matter to the local community. The CILs are still waiting for just over $4 million in FY 16 budget money for CILs from the state of Illinois, as well as other funds specific to certain disability programs they run.

While Access Living has been holding on, we are very concerned about our fellow CILs at risk of closing. Please contact Ann Ford at annford@incil.org if you have questions about the network; you can also check www.incil.org to see what CILs serve your area. We also urge you to contact your Governor, state senators and representatives to urge them to work on a budget solution ASAP so that disability services are not further impacted.

Ann Ford
Executive Director
Illinois Network of Centers for Independent Living

This was originally shared as an Advocacy Alert from Access Living.Like many other human services providers, the Illinois Network of Centers for Independent Living