Community Care Medical Home Community Care Medical Home EnrollmentEnrollment

For For Adult Care HomesAdult Care Homes

Hosted by:

In conjunction with: north carolinamedicaidnorthcarolinamedicaidnorth carolinamedicaidnorthcarolinamedicaid

MedicaidMedicaid

Medicaid Medicaid is a health is a health insurance program for insurance program for low-income individuals low-income individuals

and familiesand families

As of September 2012, there are As of September 2012, there are nearly 1.6 million beneficiaries of nearly 1.6 million beneficiaries of Medicaid Medicaid

Medicaid budget exceeds Medicaid budget exceeds $11Billion$11Billion

Medical Home Enrollment ProjectMedical Home Enrollment Project

Goal:Goal: To enroll each eligible Medicaid beneficiary with To enroll each eligible Medicaid beneficiary with

a Community Care of North Carolina medical a Community Care of North Carolina medical home to improve their overall health and ensure home to improve their overall health and ensure their access to high quality, medically their access to high quality, medically necessary health care in the most cost effective necessary health care in the most cost effective manner.manner.

Project FocusProject Focus Increase the number of beneficiaries enrolled Increase the number of beneficiaries enrolled

with a medical homewith a medical home Increase enrollment among the Aged, Blind, and Increase enrollment among the Aged, Blind, and

Disabled (ABD) beneficiaries to 75% of the total Disabled (ABD) beneficiaries to 75% of the total ABD population.ABD population.

Medicaid Managed Care Medicaid Managed Care ProgramsPrograms

Carolina ACCESS (CA)Carolina ACCESS (CA)

andand

Community Care of Community Care of North Carolina (CCNC)North Carolina (CCNC)

Community Care of NCCommunity Care of NC

Benefits to the beneficiary and ACH:Benefits to the beneficiary and ACH: Primary Care Doctor who will lead their medical Primary Care Doctor who will lead their medical

home teamhome team 24-hour medical advice 24-hour medical advice A care manager to help manage the health care A care manager to help manage the health care

needs of the beneficiaryneeds of the beneficiary Follow-up appointmentsFollow-up appointments Beneficiary education on self managementBeneficiary education on self management

Special help monitoring and managing Special help monitoring and managing medicationsmedications

Help when patients are transitioning from the Help when patients are transitioning from the hospital back to the facilityhospital back to the facility

Medical Home Referrals: Medical Home Referrals:

Required when seeking care for most Required when seeking care for most specialty services.specialty services.

Made at the discretion of the Community Made at the discretion of the Community Care medical home.Care medical home.

Made by telephone or in writing Made by telephone or in writing Should be obtained as needed Should be obtained as needed priorprior to to

rendering servicesrendering services

Additional Information regarding Community Care of North Carolina / Carolina Additional Information regarding Community Care of North Carolina / Carolina ACCESS is available at ACCESS is available at http://www.ncdhhs.gov/dma/basicmed/Section4.pdf

Community Care of NCCommunity Care of NC

Primary GoalsPrimary Goals Improve the care of Medicaid population while Improve the care of Medicaid population while

controlling costscontrolling costs

A “medical home” for beneficiaries, A “medical home” for beneficiaries, emphasizing primary careemphasizing primary care

Community networks capable of managing Community networks capable of managing beneficiary carebeneficiary care

Local systems that improve management of Local systems that improve management of chronic illness in both rural and urban settingschronic illness in both rural and urban settings

Community Care of NCCommunity Care of NC

How it Works: How it Works:

Coordination of local community providers Coordination of local community providers (hospitals, health departments, LMEs and others) (hospitals, health departments, LMEs and others) and primary care physicians and primary care physicians

Provides clinical and performance improvement Provides clinical and performance improvement data through CCNC Informatics Centerdata through CCNC Informatics Center

Provides support for physician driven quality Provides support for physician driven quality improvement initiatives regionally and statewideimprovement initiatives regionally and statewide

Each network provides local care managers, and at Each network provides local care managers, and at least one pharmacist, psychiatrist, and medical least one pharmacist, psychiatrist, and medical director to improve local health care deliverydirector to improve local health care delivery

Community Care of NCCommunity Care of NC

Community Care of NCCommunity Care of NC

Source: CCNC September 2012

LegendAccessCare Network Sites Community Care Plan of Eastern CarolinaAccessCare Network Counties Community Health PartnersCommunity Care of Western North Carolina Northern Piedmont Community CareCommunity Care of the Lower Cape Fear Northwest Community CareCarolina Collaborative Community Care Partnership for Community CareCommunity Care of Wake and Johnston Counties Community Care of the Sandhills Community Care Partners of Greater Mecklenburg Community Care of Southern PiedmontCarolina Community Health Partnership

Networks:Networks: Provide resources for care management, quality Provide resources for care management, quality

improvement, and cost containment improvement, and cost containment Seek to incorporate all providers, including safety Seek to incorporate all providers, including safety

net providersnet providers Have Medical Management Committee oversightHave Medical Management Committee oversight

Community Care of NCCommunity Care of NC

Community Care of NCCommunity Care of NC

Behavioral Health Integration

Disease Management

Dental Screening and Fluoride Varnish

Pharmacy Management

ED Utilization Management

High Cost –High Risk Care Management

Chronic Care Program (ABD)

Palliative Care

Pain Management

Person Centered Medical Home

Pregnancy Care Management

Care Coordination for Children

Additional Information available at Additional Information available at http://www.communitycarenc.org/

Medicaid Managed Care Medicaid Managed Care ProgramsPrograms

Enrollment ProcessEnrollment Process

EnrollmentEnrollment

Prior to rendering services:Prior to rendering services:

Verify the beneficiary’s eligibility for Medicaid Verify the beneficiary’s eligibility for Medicaid Use online verification tools like NCECS WebtoolUse online verification tools like NCECS Webtool

EnrollmentEnrollment

Determine if the beneficiary is enrolled with Determine if the beneficiary is enrolled with a medical homea medical home If yes, verify that the medical home is correctIf yes, verify that the medical home is correct

EnrollmentEnrollment

If the beneficiary is not linked to a medical If the beneficiary is not linked to a medical home:home:

Determine the beneficiary’s Medicaid Determine the beneficiary’s Medicaid Coverage Category.Coverage Category. Are they eligible for CCNC enrollment?Are they eligible for CCNC enrollment?

EnrollmentEnrollmentMANDATORYMANDATORY OPTIONALOPTIONAL INELIGIBLEINELIGIBLE

AAF/WorkFirstAAF/WorkFirst MPWMPW MQBMQB

MIC (N and 1)MIC (N and 1) HSFHSF MIC-LMIC-L

MAFMAF IASIAS RRF/MRFRRF/MRF

MAABD (w/o Mcare)MAABD (w/o Mcare) MAABD (w/ Mcare)MAABD (w/ Mcare) ““D” status beneficiariesD” status beneficiaries

SAD /SAA(w/o Mcare)SAD /SAA(w/o Mcare) SAD/SAA (w/ Mcare)SAD/SAA (w/ Mcare) MAF-DMAF-D

MICA, MICJ, MICK, MICSMICA, MICJ, MICK, MICS(NC Health Choice)(NC Health Choice)

End Stage Renal Disease End Stage Renal Disease beneficiarybeneficiary

CAP cases w/ monthly CAP cases w/ monthly deductibledeductible

SSI under age 19SSI under age 19 Aliens eligible for Aliens eligible for emergency Medicaidemergency Medicaid

Special Needs (Self-Special Needs (Self-IdentifiedIdentified

Nursing Facility residentsNursing Facility residents

Native AmericansNative Americans MAF-WMAF-W

Benefit DiversionBenefit Diversion

Yes

No

EnrollmentEnrollment

Once you confirm eligibility Once you confirm eligibility for Medicaid:for Medicaid:

If the beneficiary is not enrolled with a medical home:If the beneficiary is not enrolled with a medical home: Explain the benefits of managed careExplain the benefits of managed care Ask for information about their primary care provider Ask for information about their primary care provider Complete the enrollment formComplete the enrollment form Fax the enrollment form to DMA at 919-715-0844Fax the enrollment form to DMA at 919-715-0844

EnrollmentEnrollment

Once you confirm eligibility Once you confirm eligibility for Medicaid:for Medicaid:

If the beneficiary does not have a medical home:If the beneficiary does not have a medical home: Explain the benefits of managed careExplain the benefits of managed care Use the provider directory to help them choose a primary Use the provider directory to help them choose a primary

care providercare provider Complete the enrollment formComplete the enrollment form Fax the enrollment form to DMA at 919-715-0844Fax the enrollment form to DMA at 919-715-0844

EnrollmentEnrollment

Start by locating the county where your ACH is Start by locating the county where your ACH is located.located.

Use the provider name and demographic information Use the provider name and demographic information to identify a provider and complete the enrollment to identify a provider and complete the enrollment form.form.

EnrollmentEnrollment

Once you confirm eligibility Once you confirm eligibility for Medicaid:for Medicaid:

If the beneficiary’s medical home is incorrect :If the beneficiary’s medical home is incorrect : Obtain information about the correct medical homeObtain information about the correct medical home Complete the enrollment formComplete the enrollment form Fax the enrollment form to DMA at 919-715-0844Fax the enrollment form to DMA at 919-715-0844

EnrollmentEnrollment

EnrollmentEnrollment

For residents with For residents with both Medicare both Medicare and Medicaid.and Medicaid.

Explains benefits Explains benefits and options of and options of Community Care Community Care enrollment.enrollment.

EnrollmentEnrollment

When a resident chooses a new medical home, it is When a resident chooses a new medical home, it is imperative that they establish a relationship with that imperative that they establish a relationship with that new providernew provider

Immediately call the new medical home to make an Immediately call the new medical home to make an appointment to establish a relationship, complete appointment to establish a relationship, complete paperwork, and transfer recordspaperwork, and transfer records

If a resident has not seen their chosen medical home If a resident has not seen their chosen medical home within the past year, also call to make an within the past year, also call to make an appointment to maintain that relationshipappointment to maintain that relationship

Enrollment ResourcesEnrollment Resources

Community Care of North Carolina Community Care of North Carolina http://www.communitycarenc.org/ http://www.communitycarenc.org/

Link to webinar presentation and enrollment formLink to webinar presentation and enrollment form DMA CCNC/CA webpage DMA CCNC/CA webpage

http://www.ncdhhs.gov/dma/ca/ccncproviderinfo.htmhttp://www.ncdhhs.gov/dma/ca/ccncproviderinfo.htm CCNC/CA Recipient HandbookCCNC/CA Recipient Handbook

http://www.ncdhhs.gov/dma/ca/carechandbook.pdfhttp://www.ncdhhs.gov/dma/ca/carechandbook.pdf email: adrienne.frederick@dhhs.nc.govemail: adrienne.frederick@dhhs.nc.gov

Benefits of Being a CCNC/CA MemberBenefits of Being a CCNC/CA Member http://info.dhhs.state.nc.us/olm/forms/dma/dma-9016.pdf http://info.dhhs.state.nc.us/olm/forms/dma/dma-9016.pdf

Additional questions:Additional questions: Melanie.whitener@dhhs.nc.govMelanie.whitener@dhhs.nc.gov 828-304-2345 828-304-2345