STATES MUST BECOME SMARTER PURCHASERS

1
WHAT DO I NEED TO KNOW ABOUT MSHO? Jeff
Goodmanson website www.dhs.state.mn.us/healthcar
e/MSHO-MNDHO 651-431-2530 jeff.goodmanson_at_state.m
n.us
2
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

3
Managed Care Options For Seniors

• MSC - Minnesota Senior Care
• MSC - Minnesota Senior Care Plus
• MSHO Minnesota Senior Health Options

4
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
5
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

6
Overview Continued

• Care Coordinator assigned to each enrollee.
• Some plans contracting with counties for CC
  functions while others are using clinics/care
  systems.

7
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

8
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.
  

9
RMGR
10
PF4 TO PSUM
11
TRANSMIT TO PADD
12
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.

13
Typical Dual Eligible Drug Coverage
14
Integrated Drug Coverage
15
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

16
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.

17
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

18
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

19
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
20
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 lt 100 FPG 1/generic 3/brand name 1/generic 3.10/brand name 1.05/generic 3.10/brand name
Income gt 100 FPG 2/generic 5/brand name 2.15/generic 5.35/brand name 2.25/generic 5.60/brand name
21
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.

22
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.

23
PMAP and MSHO Senior Enrollment by Plan 11/05
24
MSHO and MSC Senior Enrollment 1/06
MSHO 33,371 MSC 8,674
25
(No Transcript)
26
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.

27
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

28
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.

29
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

30
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 AMMs should only remain enrolled
  if medical expenses are routinely more then the
  amount of the spenddown.

31
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

32
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

33
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.

34
Why cant 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

35
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

36
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

37
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

38
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

39
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

40
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.

41
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.

42
Questions?