1 commonwealth coordinated care bpro may 2015. 2 what is commonwealth coordinated care? blending of...
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Commonwealth Coordinated Care
BPRO May 2015
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What is Commonwealth Coordinated Care?• Blending of Medicare and
Medicaid • MMP’s (Medicare-Medicaid
Plans)• Anthem Healthkeepers• Humana• Virginia Premier
• CCC is an enhancement over regular Medicare/Medicaid
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Full Benefit Medicare (A,B,D) & Medicaid
Who is eligible for CCC?
EDCD &
Nursing
Home
Residents
21 and Older
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Who is not eligible? Other Medicaid
Long-Term Care Waivers
HospiceOther
Comprehensive Insurance
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31One system
to coordinate
care
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5Person-
centered care
coordination
6Unified appeals process
One ID card for all care
24/7 local call center with
access to beneficiary
records
Expanded Benefits
Benefits for Signing Up
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Care Coordination• Unique to CCC• No extra cost• Help with arranging
appointments and services
• Care Manager gets to know member and helps to develop the care plan
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COSTS • No deductibles, premiums or co-
pays for doctor or specialist visits• Some co-pays for prescriptions• No co-pays or premiums for
extra benefits• Continue to pay long-term care
patient pays• No balance billing patients
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Do I Have to Change Providers?• Keep Providers that
are In-Network • Care continues with
current providers for up to 180 days
• Afterwards, will need to choose In-Network providers
• During transition providers bill the MMP, not Medicare & Medicaid
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Frequently Asked Questions1. My clients ask me questions about CCC, but I don’t feel
comfortable answering their CCC questions. Who should I refer them to?
2. What notifications do beneficiaries receive?3. My client didn’t realize they got enrolled, how did this happen?4. A client came to me to complain about an issue obtaining
medications and they are in CCC, where should they turn?5. I suspect someone has opted my client out of CCC without their
knowledge, who can I inform?6. My client didn’t opt out of CCC but they were dropped, why?7. What if I’m in CCC and my ID/DD waiver slot comes available?8. How can I identify the MMP in VaMMIS?
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For CCC Questions, refer beneficiaries to VICAP
1-800-552-3402Assist VICAP Coordinators
& Counselors
Information, education, and guidance, to CCC-eligible individuals. Helping to increase the confidence of beneficiaries and their families in their Medicare and Medicaid supports
Enhancing educational opportunities at venues serving Virginia’s five service regions
Serving as a liaison between the AAA’s, VICAP Coordinators and DMAS
Collaborates with
DMAS
Serves as Liaison
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VICAP Coordinators have three options when individuals call requesting assistance with CCC enrollment
1Refer & connect Individual with MAXIMUS
2Refer Individual to VICAP Educator for personalized assistance
3Review MMPs in Plan Finder with Individual
VICAP Educator connects Individual with MAXIMUS
Connect Individual with MAXIMUS
Individuals call their trusted source for insurance information-VICAP!
All Roads Lead to MAXIMUS
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Eligible Individuals Receive Notification by Mail1. A 60 day letter informing the individual he/she
will be signed up by a specific date unless he/she opts out
2. A 30 day letter informing the individual he/she will be signed up by a specific date unless he/she opts out
3. A welcome package from the health plan providing coverage for the individual
Eligibility is determined by a joint process in DMAS and CMS information systems
What notifications do beneficiaries receive?
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For Access to Care issues, refer to LTC OMBUDSMAN 1-800-552-3402
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Assistance understanding enrollee rights, responsibilities and benefits; investigate complaints and resolve beneficiary problems with their CCC health plan or services
Assist individuals in nursing facilities and assisted living facilities as well as persons receiving community-based services at home. Coordinated Care Advocates assist individuals in the community.
Enrollment and disenrollment, continuity of care, accessibility and information, timeliness of plan responses to beneficiary inquiries, covered services and appeals and grievances
Assistance Resolving CCC Issues
Resource for
members & their
Advocates
Beneficiary Rights & Problem
Solving
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Beneficiary EnrollmentChoice
• Opt-out decision rests with the beneficiary and their authorized designee (POA or family member)
• Opt-outs accepted by telephone through MAXIMUS (written opt-outs not accepted)
• To opt-out or change health plans, the member calls MAXIMUS 1-855-889-5243
Maintaining Eligibility
• Access to care issues may result from a break in eligibility.
• No retroactive enrollment • Contact the CCC team with
any suggestions for preventing coverage breaks
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If a beneficiary receives an ID/DD waiver slot and is in CCC:– They will enroll with the waiver and their
waiver services will begin right away. Use the existing process for waiver enrollment and service authorization.
– They will stay in the CCC program through the end of the month and then transition back to regular (often called Fee-for-Service) Medicaid.
– Medical services, pharmacy, etc will be covered by CCC until disenrollment.
Waiting for ID/DD Waivers
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Identifying MMPs in MMISYou can identify which MMP a beneficiary is in by locating the Provider ID on the Eligibility or Managed Care screens in MMIS.• Anthem Healthkeepers Medicare-Medicaid Plan– 0173025666
• Humana Gold Integrated Plus– 0173030070
• Virginia Premier Complete Care– 0173024859
