WHAT DO I NEED TO KNOW ABOUT MSHO?

Jeff Goodmanson

website: www.dhs.state.mn.us/healthcare/MSHO-MNDHO

651-431-2530 jeff.goodmanson@state.mn.us

Common Acronyms

CMS - Centers for Medicare and 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+, MSC

MSHO (83 counties)

MSC + (25 counties) Expanding in 2008

MSC (58 counties)

Medicare Part A & B

Medicare Special Needs Plan (SNP)

Fee for Service Fee for Service (FFS)

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 35,000+ 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

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

The new communication form is being developed in a workgroup that includes DHS, counties, and managed care staff.

A bulletin will be issued once the form is finalized.

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

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?

Medicare Part D started 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 $1-3.10 or $2.15-5.35

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

Standard Part D Benefits

2006 2007 2008

Deductible $250 $265 $275

Initial Coverage Limit

$2,250 $2,400 $2,510

Out of pocket (OOP) threshold

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

Total Covered Drugs at OOP

$5,100 $5,451.25 $5726.25

Copays at Catastrophic Level

$2/generic$5/brand

$2.15/generic$5.35/brand

$2.25/generic$5.60/brand

Copays for Full Benefit Dual Eligibles

2006 2007 2008

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

$0 $0 $0

Income < 100% FPG

$1/generic$3/brand

name

$1/generic$3.10/brand

name

$1.05/generic$3.10/brand

name

Income > 100% FPG

$2/generic$5/brand

name

$2.15/generic$5.35/brand

name

$2.25/generic$5.60/brand

name

What Was Passive Enrollment

Was a one time option for SNPs that also have Medicaid managed care contracts.

Allowed SNPs to transfer their Medicaid dual eligibles into their Medicare SNP plan to facilitate Part D coverage.

CMS approved passive enrollment for all MSHO SNPs.

Passive Enrollment-Continued

MSHO eligible seniors enrolled in PMAP as of 8/05 were offered opportunity to be passively enrolled.

9/05 enrollees were sent letters by current PMAP plans explaining the benefits and the “opt-out” option.

Enrollees had the option to “opt-out” by contacting DHS by 10/31/05.

About 23,000 people passively enrolled.

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

86.9%

13.1%

71.3%

28.7%61.1%

38.9%

74.0%26.0%

68.1%

31.9%

55.7%44.3% 94.3%

5.7%

71.5%

28.5%

85.0%

15.0%

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

MSHO and MSC Enrollment September 2007MSHO Total: 35,930 MSC Total: 10,840

MSC 1,525 378 1,673 163 4,072 671 124 798 1,436

MSHO 10,147 937 2,632 465 8,673 844 2,057 2,006 8,169

Blue Plus

First Plan Blue

HealthPartners

Itasca Medical

CareMedica

Metro HP

Primewest Health System

South Country Health

Alliance

UCare Minneso

ta

93

What happens with Medicare coverage if MSHO is closed?

MSHO contract states that health plans will continue to cover Medicare services for up to 3 months when MSHO 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.

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 is not reopened.

Retro enrollment into MSHO

If MSHO closes due to loss of MA, once MA is reopened, the client will be retro enrolled into MSHO 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 does NOT apply to MSC/MSC+

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

2007 Changes

MSHO enrollments are allowed until the last day of the month for Medicare and Medicaid dual eligibles only

This change is needed to match up with CMS enrollment for Part D that allow enrollment up to the end of the month

Non-duals who want to enroll into MSHO will continue to follow current enrollment dates (on or before cut-off).

It is important that enrollment forms get sent to DHS timely to make sure proper enrollment dates are applied

2007 Changes

People who are ESRD will not be allowed to enroll in MSHO

This change matches CMS policy for ESRD

People who are already enrolled in MSHO and are ESRD will be allowed to maintain MSHO enrollment

ESRD information can often be found on the RSVL screen in MMIS

2008 Changes – MSC+

MSC + will be expanding in 2008 statewide except in the 7 county metro area.

People in affected counties that are currently enrolled into MSC will be automatically transitioned to MSC+.

The managed care exclusions for MSC still apply for MSC+.

MSC+ includes EW and 180 days of NF liability.

MSC+ Continued

Designated providers should not be used for AWM waiver obligations for people on MSC+.

The waiver obligation will be deducted on the claims paid by the health plans similar to fee-for-service claims.

Questions?