Engaging and Empowering Consumers Transitioning into Managed LongTerm
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Engaging and Empowering Consumers Transitioning into Managed Long-Term Services and Supports (MLTSS) Diane Menio, Executive Director David Johnson, CHC Advocate © CARIE 1
We are dedicated to improving the quality of life for vulnerable older adults The Center for Advocacy for the Rights and Interests of the Elderly (CARIE) is a non-profit organization that has been dedicated to improving the quality of life for vulnerable older Pennsylvanians for more than 40 years. CARIE fulfills its core mission to promote the well being, rights and autonomy of older adults through advocacy, education, and action through a "case to cause" model of advocacy that serves to promote equal access to justice and addresses problems and issues on both the individual and the systemic levels. © CARIE Two Penn Center 1500 JFK Boulevard/Suite 1500 Philadelphia, PA 19102 T: 215. 545. 5728 800. 356. 3606 F: 215. 545. 5372 www. carie. org 2
Learning Objectives Identify strategies to educate, engage and empower consumers transitioning from a Medicaid fee for service system to Managed Long-Term Services and Supports in both home and community-based settings and nursing homes. Identify lessons learned by consumer advocates to communicate these changes to vulnerable populations in ways that are accessible and culturally and linguistically competent. Learn about a "case to cause" model for effective LTSS advocacy. © CARIE 3
Long-Term Services and Supports (LTSS) • Broad range of medical and non-medical services to aid individuals with disabling conditions or chronic healthcare needs with activities of daily living and living independently • Medicaid the most common payor of LTSS; limited coverage from other programs • Different LTSS programs based on: • Age • Disability • Chronic health condition • LTSS programs in institutional or HCBS settings © CARIE 4
Transitions from FFS to Managed LTSS • MLTSS relatively new model for meeting growing need of LTSS • Radically changes reimbursement and how consumers access needed services • National standardized LTSS qualitative measures new and evolving © CARIE 5
2018 MLTSS Map The number of states with MLTSS programs is growing. © CARIE 6
Why States Transition to MLTSS • Rebalancing Medicaid LTSS spending to more HCBS • Deinstitutionalization/improving access to HCBS • Improve coordination of care • Administrative simplification • Budget predictability © CARIE 7
State Example: Community Health. Choices (CHC) in Pennsylvania © CARIE 8
CHC Overview • CHC is Pennsylvania’s mandatory managed care program that transforms how LTSS is paid and provided (previously Fee-for-Service). • Includes adults with both Medicare and Medicaid regardless of whether they need LTSS, and those with Medicaid only and in need of LTSS. • Managed Care Organizations (MCOs) administer MA LTSS (nursing home and waiver services). • Three statewide CHC-MCOs: Ameri. Health Caritas CHC/Keystone First CHC, Pennsylvania Health and Wellness (Centene), and UPMC Community Health. Choices. • PACE programs are not part of CHC. Consumers can choose PACE as an alternative, if available in their zip code and if they meet program criteria. © CARIE 9
LTSS Moving from FFS to Managed Care FFS MLTSS • DHS works with individual providers and reimburses for each service provided. • MLTSS/CHC: DHS contracts with three MCOs and consumers receive services from providers that are paid and under contract with their selected MCO. (Medicare exceptions) MCO negotiates provider rates. • CHC: MCOs receive a monthly fixed payment per member from DHS and the MCO is responsible for paying and coordinating Medicaid services including physical health, all current Waiver services and nursing home care. MCO may offer “value added benefits” such as bridge services. Behavioral health services carved out. © CARIE 10
Consumers Transitioning into Managed Care • Majority of CHC population moving into MLTSS dually eligible for Medicare and Medicaid • MLTSS program has no effect on Medicare coverage and Medicarecovered services • MLTSS managed care organizations responsible for Medicare costsharing • Medicaid-covered services subject to provider networks of managed care organizations • Provider networks “evolving” • After continuity of care period, managed care organizations have the authority to approve person-centered service plans © CARIE 11
Managed Care Plan LTSS providers Identifying Stakeholders in MLTSS Programs Direct Care Workers Social Workers Service Coordinator Consumer Physical Health Providers LTC Ombudsman Family caregivers © CARIE 12
Three E’s of Consumer Success EDUCATION ENGAGEMENT © CARIE EMPOWERMENT 13
EDUCATION • Ensure that all participant communications are easilyunderstood and tested for lower-literacy levels • Multi-media outreach • Mail, online, phone outreach, in-person education • Must be available in whatever means a consumer needs • Allow adequate time for pre-transition education and time for informed decision-making • Ensure MLTSS education includes all stakeholders • Authorized representatives, providers, community advocates and caregivers © CARIE 14
ENGAGEMENT • Person-centered care requires consumers be heard and preferences incorporated into care planning • Need for ongoing opportunities and accessible means to communicate: • • Experiences Concerns Problems Questions • Ensure opportunities to share feedback at: • State-level • Plan-level © CARIE 15
EMPOWERMENT • Ensure consumers know their rights and how to exercise them • Working with all stakeholders to ensure consumers have the information, resources and support needed for true personcentered care planning and care • Removing barriers to independent living and needed services © CARIE 16
The Role of Advocates in MLTSS • Amplifying the voices and concerns of consumers • Resolving individual issues and concerns of consumers, many of which are vulnerable and unable to navigate complex systems alone • Stepping in when systems or providers fail © CARIE 17
Simplifying information about complex systems changes and consumer rights in easily-understood language in multiple formats CARIE’s Role to Help Consumers Soliciting the input of vulnerable populations and incorporating it into widely-distributed materials Communicating individual issues and concerns to state- and plan-level stakeholders © CARIE 18
Consumer Fact Sheets • Simplifying language • Consolidating key information onto one fact sheet • Translated into different languages with colloquial language • Accessible visual aids • Population-specific material © CARIE 19
Self-Advocacy Tools • Consolidated resources to help consumers keep track of complex information and key details • Can be designed for specific advocacy use or generalizable for broader advocacy • Fillable online, hard copies can be mailed • System-wide information and resources © CARIE 20
Community Forums • Facilitate opportunity for consumers and other stakeholders to interact with managed care organizations • Forums are consumer- and advocate-driven with active input and feedback solicited at each point of planning process © CARIE 21
Multimedia Materials • Utilizing multiple media formats to complement paper and in-person contact • Low-cost, higher reach • Can be used for quick concepts or highly-detailed topics © CARIE 22
Stakeholder Input and Feedback • Convening regular meetings to solicit information to better inform materials and outreach • Updating information and materials to reflect changing best-practices and details • Amplifying the voices and concerns of vulnerable consumers in venues they may not be able to attend themselves © CARIE 23
Case to Cause Model of Advocacy • Serves to promote equal access to justice and addresses problems and issues on both the individual and the systemic levels • Direct-service advocates may not have ability or capacity to engage all consumers in an MLTSS system • Communicating individual issues to key stakeholders can help ensure system works better for everyone, particularly those that do not have ability to advocate for themselves © CARIE 24
Case Example Pre-transition into MLTSS Ms. Jones 87 years old Eligible for Medicare and Medicaid Nursing Home Resident Ms. Jones was transitioning into CHC, the new mandatory MLTSS program. She was faced with the choice of one of three CHC plans, each with their own provider networks for Medicaid-funded services. When she tried making an informed decision by speaking with the independent enrollment broker and her providers, she was given conflicting information and wasn’t sure where to turn. The enrollment deadline was approaching quickly and Ms. Jones was anxious. © CARIE 25
Case Example Billing Issues and Barriers to Providers Ms. Garcia 67 years old Eligible for Medicare and Medicaid Clinically ineligible for LTSS Ms. Garcia was informed that she does not need to change her Medicare plan or coverage and that her new CHC plan would be responsible for Medicare cost-sharing. Ms. Garcia went to her cardiologist for an appointment and told the front desk about her new Medicaid coverage. The front desk informed her that they don’t have a contract with that plan. Ms. Garcia was not confident in asserting her rights and missed this appointment due to a fear that she would be faced with a sizable bill. © CARIE 26
Case Example Pre-transition and Billing Issues CAUSE CASE Individual Intervention: • Inform consumer of their rights and new MLTSS rules • Conference call to providers with accurate information • Prepare consumer with information and resources should problem persist Systemic Intervention • Request that state MLTSS program offer more targeted education to providers • Advocate for issuance of memos from state Medicaid program • Engage MLTSS plans to take responsibility for Medicare costsharing responsibilities as required © CARIE 27
Case Example Person-Centered Planning Process Mr. Nguyen 72 years old Eligible for Medicare and Medicaid Receiving LTSS waiver services Mr. Nguyen was receiving 90 hours/week of personal assistance services from a direct care worker at home. After a six-month continuity of care period, Mr. Nguyen was reassessed by his Medicaid managed care organization. Mr. Nguyen has cognitive impairment and found the process confusing and hard to understand. Mr. Nguyen was mailed a denial letter as his service hours were being reduced to 30 hours/week with little explanation. Mr. Nguyen’s daughter, who lived in another state, was worried that he would not be able to live safely at home. © CARIE 28
Case Example Person-Centered Planning Process CAUSE CASE Individual Intervention: Systemic Intervention • Connect consumer to legal aid to • Advocate for oversight and appeal the decision improved standards on LTSS denial notices • Reinforce consumer rights to the • Press for dementia-capable care participant and their caregivers planning • Prepare consumer with information and resources should problem persist © CARIE 29
Other Advocacy Opportunities © CARIE 30
Quality Provisions for MLTSS • In April 2016, CMS issued new Medicaid managed care regulations that now includes MLTSS provisions. • MLTSS regulations include: complying with person-centered planning and HCBS settings regulations; stakeholder advisory groups; and, creating a beneficiary support system. © CARIE 31
Beneficiary Support Systems (BSS) • Opportunity for advocates to improve managed care experience for LTSS consumers • At minimum, BSS requires: • • Choice counselling Assistance for enrollees in understanding managed care Assistance in accessing and applying for LTSS Beneficiary and/or authorized representative outreach © CARIE 32
BSS and Advocacy Opportunities • Have states expand role of BSS beyond what is required • States expected to solicit stakeholder input before development and implementation of BSS • Ensure that BSS is accessible and easy to navigate, particularly given the complexity of managed care Source: Edwards, Elizabeth. “Issue Brief 7: Medicaid Managed Care Final Regulations: BSS. ” National Health Law Program, 14 Oct. 2016, healthlaw. org/resource/issue-brief-7 -medicaid-managed-care-final-regulations-bss/. 33
HCBS Settings Rule • The Home and Community-Based Services (HCBS) Final Rule, in effect since March 17, 2014. • States must transition to full compliance by March 2022. • The purpose is to ensure that individuals receiving long-term services and supports (LTSS) through HCBS programs under 1915(c), 1915(i), and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate. • Among other components, the Final Rule includes: • Standards for acceptable qualities and characteristics of settings for the provision of Medicaid HCBS; • Excluded settings, such as nursing facilities, that are not considered home and community -based; and, • State compliance and transition requirements. • Visit The HCBS Advocacy Coalition at www. hcbsadvocacy. org for general information and state specific resources. © CARIE 34
General Advocacy Opportunities • Engage state Medicaid program at all points of MLTSS development and implementation • Engage managed care organizations on plan-specific practices and policies • Ensure that participants—particularly those most vulnerable—are engaged in all aspects of MLTSS • Regularly advocate for transparency and data sharing to track program © CARIE 35
MLTSS Resources • ADvancing States (formerly NASUAD) – www. advancingstates. org: • MLTSS - www. advancingstates. org/initiatives/managed-long-term-services-and-supports • State Medicaid Integration Tracker - www. advancingstates. org/publications/state-medicaid -integration-tracker • Long Term Care Ombudsman Resource Center - www. advancingstates. org/initiatives/longterm-care-ombudsman-resource-center • Justice in Aging - www. justiceinaging. org/keep-older-adults-home-community/ • Centers for Medicare & Medicaid Services (CMS) MLTSS www. medicaid. gov/medicaid/managed-care/ltss • Resources for Integrated Care (a collaboration among CMS’ Medicare-Medicaid Coordination Office, The Lewin Group, and the Institute for Healthcare Improvement) - https: //www. resourcesforintegratedcare. com/ • Pennsylvania’s Community Health. Choices (CHC) for • Consumers - www. healthchoices. pa. gov/info/about/community • Providers - www. healthchoices. pa. gov/providers/about/community © CARIE 36
Contact Us To Get Help or Information Contact: 215 -545 -5728 or 1 -800 -356 -3606 www. carie. org and www. caregivergps. org CHC Resources on CARIE’s website at www. carie. org/chc. Be sure to sign-up for CARIE’s Advocates Alliance/Grapevine e-newsletter! To Sign-Up for CARIE’s Newsletters visit: www. carie. org and enter email at bottom of page. © CARIE 37
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