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aIPAM Fall Conference
Presented by: Lisa Fox & Maggie Goncerzewicz
Today’s Agenda
• Affordable Care Act
• Health Insurance
Marketplace(Exchange)
• Risk Adjustment
• ICD-10
• MMAI
Affordable Care Act
We Are Part Of The Largest Health Care Changes IN US HISTORY
Almost 50 million Americans without health insurance. The Affordable Care Act (ACA) will extend coverage to the uninsured Americans.
Affordable Care Act
• BCBS website • Sign up for email alerts
• Look for local seminars and
events
Stay Informed:
Internet Resources
6
Health Insurance Marketplace
Marketplace
An online tool enabling a member to shop The statewide Marketplace
Cost of Product Health Insurance
Marketplace
8
Provide toll-free hotline for assistance Help eligible
individuals get federal tax credits
& subsidies
Inform consumers about
individual mandate exemptions
Screen for Medicaid/CHIP eligibility and
enroll if eligible
Public Exchanges
Perform Risk Adjustment
Run state websites that allow consumers to shop for qualified
health plans
Help consumers and employers choose &
enroll in coverage
This presentation is a high-level summary and for general informational purposes only. The information in this presentation is not comprehensive and does not constitute legal, tax, compliance or other advice or guidance.
Marketplace
New online sites launch October 2013
Individual Small Group 2-50
Marketplace
Individuals who cannot afford
coverage
Taxpayers with income below the
filing threshold
Members of Indian tribes
Hardship
Individuals who experience short
coverage gaps
Who is Exempt?
Religious conscience
Members of a health care
sharing ministry
Incarcerated individuals
Individuals who are not lawfully
present
Marketplace
Platinum
Gold
Silver
Bronze
Expected Percentage of Medical Expenses Covered by the Health Plan
Expected Percentage of Medical Expenses Covered by the Member
90% (AV)
80% (AV)
70% (AV)
60% (AV)
The key difference between the “metallic” plans is the expected percentage of medical expenses shared between the health plan and the member.
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• 90% Actuarial Value (AV)
• 80% Actuarial Value (AV)
• 70% Actuarial Value (AV)
• 60% Actuarial Value (AV)
Platinum Gold Silver Bronze
Individual and insured small group plans, sold on and off the exchange, will have to meet one of four metallic levels that correspond to plan actuarial value.
Catastrophic coverage will be available on an exchange, for individuals under age 30 or individuals who received certification for lack of affordable coverage or financial hardship.
Actuarial Thresholds (Metallic Levels)
Marketplace
Essential Health Benefits
Ambulatory patient services
Emergency services
Hospitalization Maternity and newborn care
Mental health and substance
abuse services
Prescription drugs Habilitative and rehabilitative services and
devices
Laboratory services
Preventive and wellness services,
disease management
Pediatric care including oral and
vision care
Marketplace
www.bcbsil.com/reformandyou
www.becoveredillinois.org
Internet resources
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Risk Adjustment
What is Risk Adjustment?
Risk Adjustment is an ACA program designed to identify the differences in health care risk among specific patients, which results in the ability to compare care and cost performance fairly by,
analyzing different types of health care data with a variety of statistical models to explain an outcome, adjusting for the differences in such factors as member age, gender and diagnoses
Risk Score
Demographics Health status
female
Age 72
male
Age 38
Age 29 Anxiety
Diabetes Emphysema
Asthma
Hypertension
Eczema
Risk Adjustment
Risk Adjustment
Risk Marker Risk
Weight
Male, Age 32 0.22
Total Risk Score 0.22
Risk Marker Risk
Weight
Male, Age 32 0.22
Diabetes with significant co-morbidities
1.32
Asthma/COPD 0.96
Low cost dermatology 0.30
Total Risk Score 2.80
Risk Adjustment
Risk Score Cost of care
2.2 $$$
Risk Adjustment
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Currently used for Medicare Advantage and Medicaid
Transfer of money from health plans with low risk scores to those with high risk scores, to provide plans additional funding for the treatment of the highest risk scored members
Risk Adjustment
Risk Adjustment
Physician’s Role and Risk Score Drivers :
Ensure the medical records show conditions that are being monitored, evaluated, assessed or treated (MEAT) for each condition relating to a diagnosis code on the date of service.
Documentation should be clear, concise, consistent, complete and legible.
CLINICAL DOCUMENTATION
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ICD -10
Introducing ICD-10 141,000 new codes.
October 2014.
Will you be ready?
W56.42XA Struck by shark, initial encounter
V95.40XD Unspecified spacecraft accident
injuring occupant
V91.07XA Burn due to water-skis on fire
T63.122A Toxic effect of venom of other venomous lizard, intentional self-harm
ICD-10 Yeah, there’s a code for that!
THE END Or is it just the beginning?
Visit www.bcbsil.com/provider for more information and resources.
Get to know ICD-10 It changes everything!
35 February 2011: ANSI v5010 / ICD-10
ICD-9-CM ICD-10-CM
3-5 characters Approximately 14,000 codes 1st character may be alpha (E or V) or numeric Limited room for new codes Lacks detail Lacks laterality Non-specific codification issues Not interoperable with other countries (WHO has adopted ICD-10)
3-7 characters Approximately 140,000 codes 1st character alpha; characters 2-3 are numeric; 4-7 are alphanumeric Flexibility to add new codes Very specific Includes laterality Improved accuracy and richness of codification Interoperable with global community (adopted in 99 countries)
X99.99 X99.XXX
What You Need to Know
36 February 2011: ANSI v5010 / ICD-10
ICD-10-CM Structure (Diagnosis Volumes 1 & 2): 3 to 6 position code with leading alpha (+ extension)
Note: ICD-9-CM diagnosis was 3 to 5 position numeric except V and E
. X X X X X X X Category
Etiology, anatomic site, severity
Extension
What You Need to Know
What Does This Mean?
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Medicare Medicaid Alignment Initiative
MMAI Initiative
Medicare Medicaid Alignment Initiative (MMAI) is effective January 1, 2014 and administers Medicare and Medicaid benefits jointly so duals experience health coverage as a single integrated program. MMAI establishes a single point of accountability for the delivery and coordination of primary, acute,
behavioral health and long term care supports and services.
Targeted Counties
1. Cook
2. DuPage
3. Kane
4. Kankakee
5. Lake
6. Will
1 3
6 4
2
5
Potential Enrollment
Cook – 93,574
DuPage – 7,107
Kane - 5134
Kankakee – 1,889
Lake – 5,565
Will – 4,781
1 3
6 4
2
5
Contracted Providers
Federally Qualified Health Centers (FQHC’s)
Community Mental Health Centers (CMHC’s)
Hospitals
Ambulatory Surgery Centers (ASC’s) Independent Physicians
Ancillary Providers (SNF, Home Health, Hospice, DME)
IPA’s
Long Term Services & Support (LTSS)
Training
The Centers for Medicaid and Medicare Services (CMS) and the State of Illinois require that the Blue Cross and Blue Shield of Illinois Plan train MMAI contracted providers, prior to the program implementation date of
January 1, 2014, on the following topics: • Patient Centered Practice • Care Coordination • Cultural Competency • Disability Literacy • Compliance with the Americans with Disability Act • Independent Living and Recovery Health • Safety and Welfare (Abuse, Neglect and Financial Exploitation Recognition and Prevention) • Wellness Principles
Training Detail
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Providers can choose the seminar location they prefer to attend per their contract
Providers are required to attend a session
Held at contracted hospital facilities
October - December
LTSS training will be conducted at neighborhood locations/community centers
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