Seniors and Persons with Disabilities

Company Overview

• Parent Company • Established in 1995• Serving TANF Population• Over 85,000 enrollees• Non-for Profit

• Wholly Owned Subsidiary of FHN

• Serving SPD Population• ICP expansion plan in Rockford & Chicago • Expecting to Serve Medicare

Advantage & DSNP Populations

FHN Company OverviewNot-for-profit created in 1995 by five safety-net hospitals

Mt. Sinai Hospital Norwegian American Hospital Presence Health (Originally: St. Mary of Nazareth) St. Anthony Hospital St. Bernard Hospital

• FHN is the only not-for-profit Managed Care Community Network in the State of Illinois• Proven track record of provider-incentive programs • Illinois company with locally dedicated resources

Program OverviewMedicaid: Temporary Assistance for Needy Families (TANF)• Current enrollment of 85,048 • Targeted Patient -Centered Care Management• Disease Management programs to coordinate care, provide education, support and

monitoring as well as appropriate medical home • Programs, incentives and additional benefits to encourage preventive care, early

diagnosis, and healthy behaviors• Pay for Quality for Providers and Healthy Incentives for enrollees to improve HEDIS

scores

Value-Added Benefits:• No copayments for physician visits and hospital services• Free Adult Dental, Weight Watchers membership, Transportation, Pregnancy Tests and

Jewel-Osco Coupons• Health Education programs and Children’s book club• Drug co-pay reimbursement for prescription copays ($2-$5)

History and Partners

Seeking a better alternative for Medicaid health care and financing, Family Health Network joined with the following allies to develop CCAI:

• Access Living of Metropolitan Chicago, a nationally recognized advocacy group

for people with disabilities

• Health & Medicine Policy Research Group, an independent policy center that

conducts research, educates and collaborates with other groups to advocate

policies and impact health systems to improve the health status of all people

• Sinai Health System and Schwab Rehabilitation Hospital recognized as

national models for urban health care delivery

CCAI OverviewMission: The Community Care Alliance of Illinois is a health plan dedicated to consumer-directed, community-based innovative health services specializing in the care of Seniors & Persons with Disabilities.

Vision:To be the leader in Choice, Access, and Quality of Health Services for the people we serve

CCAI Philosophy: • Prevention of complications through our Care Coordination Model• Empowerment of the consumer voice and use of community peer resources• Incorporation of Long Term Services and Supports • Decreased Emergency Department Visits and Hospitalizations

Program Overview

• Initial Program Roll out Date July 1, 2013

– Seniors & Persons with Disabilities (includes FFS Medicaid and Waiver Program participants)

– 5,100 consumers to be served in the Rockford Area– Currently serving Boone, Winnebago, and McHenry

Counties– Eligibility determined by the State; enrollment managed by

Maximus– Maximus responsible for initial PCP assignment– Population is required to select a MCO/MCCN (mandatory

enrollment)

Program Exclusions

• SPD Populations Excluded from ICP:

• Children under the age of 19• Those eligible for Medicare Part A or enrolled in

Medicare part B• American Indians/Alaskan Natives may voluntarily

enroll• Enrollees currently in a spend-down status• Individuals aligned with presumptive eligibility• Individuals in the Breast/Cervical Cancer Program• Participants with comprehensive third-party coverage

Enrollment Process

• Enrollees are given an initial 60 days to select a Health Plan

• Enrollees who do not choose are auto-assigned

• Enrollees are given an additional 90 days to switch health plans

• If Enrollees make no changes they remain with the health plan assigned

• Enrollees are locked in with their health plan until 2014 Open Enrollment

• Open Enrollment occurs two months prior to the Enrollee’s anniversary date

• Enrollees may switch PCPs within their health plan at any time

CCAI Values for Enrollees

• Integrated Care Team to assist with the coordination of services

• No Copayments Fees for office visits or prescriptions• Two dental cleanings per calendar year• Practice visits for Dental and OB-GYN services • Weight Watchers• Financial incentives for healthy behaviors• Transportation

Transportation

• CCAI Enrollees are eligible for transportation to receive covered medical services

• Enrollees may schedule transportation by contacting Enrollee Services at 866-871-2305

• Enrollee Services will arrange transportation and provide an authorization number

• Enrollees should schedule their transportation at least 48 hours prior to their appointment time to ensure appropriate and timely rides

• There in no cost associated with this benefit

Person Centered with Six Domains

• Medical • Functional• Environmental• Financial Security• Social Support• Psychological/Behavioral Health

Focus on the Whole Person

CCAI Model of Care

CCAI Model of Care (continued)

• Person-centered care plan• Wraparound “all-in” care, integrating medical,

psychosocial, and long-term supports and services• Focus on prevention, health, and wellness• Disability-competent primary care services with Integrated

Care Teams• Integral role for disability-trained primary care nurse

practitioners• Flexible sites of services including more home care and

fully accessible sites of care (Anchor Health Homes)

Interdisciplinary Care Team

Disability Competent Primary Care• Primary Care Physician (PCP), Nurse Practioner (NP), or MD/DO- family medicine, internal medicine, pediatrics• Nurse Care Coordinators• Long Term Support and Services Coordinator (social worker)

Specialty Care• Rehabilitation Professionals• Behavioral/mental health providers• Specialists (orthopedics, neurosurgery, pulmonary, etc.)

Model of Care Flow Diagram

PCP No, assigned to NP PCP

PCP Yes, enrollee wishes to continue current relationship with PCP

Collaborating MD Monthly meetings Consultation

Anchor Medical Homes: Gold Star Designation

 

Fully accessible and user-friendly environment for people with disabilities and complex needs, Anchor Medical Homes will provide the following:

• Physical access (parking, entrance, clinic space, bathrooms) • Communication access including interpreting services accessible • Accessible medical equipment including exam tables, wheelchair

accessible scales, transfer equipment and staff training • Knowledgeable staff regarding disability care and accommodations• Committed to incorporating health information technologies and

enhancements  • Team meetings, case reviews, etc.

Anchor Medical Homes- (continued)

Agree to jointly hire, develop collaborative agreements for NP’s• Willing to provide 24/7 access • Committed to adapted health, wellness and secondary prevention

resources of all CCAI members • Committed to incorporating consumer input, and peer support

services • Pre-existing PCP relationships that member desires to preserve.• PCP/member can access all CCAI enhanced services (NP, Nurse Care

Coordinators, Long Term Services and Support (LTSS) Coordinators)

Anchor Medical HomesRockford

Rockford Health Physicians

Crusader Community Health Center

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Cultural Competency

CCAI works to uphold the following

• Value diversity

• Assess ourselves and our processes

• Manage the dynamics of difference - through compassion and human-rights

framework, as well as legal compliance

• Acquire and institutionalize cultural knowledge through ongoing education,

diverse staff and learning from our Enrollees

• Adapt to diversity and the cultural contexts of individuals and communities

served through quality processes: ongoing review, grievances, provider

network, and other resources available to support our interfaces

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Cultural Diversity in Health Care

• We must be aware that some cultures are not comfortable going to see a health care provider

• Some cultures prefer to see a health care provider of the same gender

• Some cultures are not comfortable with self examinations• Some cultures have sensitivity around Mental Health issues

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CCAI Resources Available

• Bilingual written materials

• Language Line

• Multi-Faceted Provider Network

– PCPs – 45% Female and 55% Male

– Specialists – 35% Female and 65% Male

– PCP 43 different languages spoken

– Specialists 38 different languages spoken

– TTY (teletypewriter) is available through Enrollee & Provider

Services

Utilization ManagementAuthorizations: Physicians and Hospital providers may request Authorizations from our Utilization Management Team. Authorizations may be obtained via:

Telephone @ 866-871-2305The web portal @ www.ccaillinois.com (only for outpatient services)Fax @ 312-491-9856

Services Requiring Authorization: • Inpatient admissions• LTC/SNF admissions (Hospital face sheet is acceptable and may be faxed in)• Outpatient surgeries• High-Tech radiology• PT/ST/OT after initial evaluation • Diagnostic Testing• DME over $500 (per the Medicaid fee schedule)• Out-of-network providers• Specialty care (after initial consultation)

Please refer to our online Prior Authorization requirements for a comprehensive listing

Utilization Management

What services DO NOT require a prior authorization? • Labs at a participating hospital or lab• X-rays and ultrasounds• DME under $500 (per the Medicaid fee schedule)• Initial consult with specialty provider• Initial consult for PT/ST/OT (auth is required after treatment

plan is in place)• Emergency services

Mental Health and Substance Abuse

All mental health and substance abuse (MHSA) services are sub-contracted to a PsycHealth. PsycHealth manages both inpatient and outpatient services, as well as all UM processes related to MHSA.

• No referral or prior authorization is required for an Enrollee to seek MHSA. However, if any provider feels the Enrollee needs such services, they can refer them to PsycHealth at (800)753-5456

• Mental Health Claims should be submitted to:

PsyHealth, LTD.1121 Florence Ave., 2nd Floor

Evanston, Illinois 60202

Pharmacy Benefits• CCAI has chosen CVS Caremark as its Pharmacy Benefits Manager.• Enrollees may contact the Customer Care Line at (855)248-3446 (on the Member ID Card) or visit the CCAI website and click the CVS Caremark button on our Home Page to find a participating pharmacy nearby.

Mail Order Option: Prescriptions will be filled for up to a 30-day supply in the pharmacy. Enrollees who need long-term medication can send their prescriptions to CVS Caremark’s mail-order pharmacy at

CVS CAREMARKPO BOX 94467

PALATINE, IL 60094-4467

Formulary, PA and Step Therapy:CCAI utilizes a Preferred Drug List, which can be found on the CCAI website. There are medications that require Prior Authorization or are only accessible through Step Therapy. These, along with instructions for obtaining authorization, can be found by calling the CVS Caremark Customer Care Line at (855)248-3446.

CCAI Sample ID Card

The enrollee’s ID number is the same as their Medicaid ID number

Verifying Eligibility

• Providers are able to verify eligibility via:

– HFS MEDI system

– CCAI secure web portal

– Enrollee & Provider Services 866-871-2305

– A monthly Eligibility List will be provided to PCPs

Claims

Timely Filing Guidelines• Best efforts to submit claims within 60 days from the date of service• No later than 180 days from the date of service

Claims Instructions: CCAI follows CMS guidelines• Complete all data fields accurately• Complete CMS 1500 for Professional Services• Complete UB for Institutional Services• Include NDC numbers for J and Q codes

Claims (continued)Electronic Submissions:• Claims may be submitted online via the CCAI web portal (www.ccaillinois.com)• Individual or Batch Claim Submissions in 837P/837I format are accepted• Submit through Availity using Payor ID “CCAI”

Submission of Corrected Claims:• May be submitted via the secure portal• May be dropped to paper and mailed in • Must be clearly marked to avoid duplicate denial

Claim Appeals or Disputes:• CCAI will consider claims-payment disputes received within 90 days of the date on the EOP• Disputes may be submitted through the Provider Portal or by mail at the Claims address below• Please include original CCAI claim number and supporting documentation • CCAI will process Claims Payment Disputes within 45 days of receipt. After consideration by CCAI, the

resubmitted claim will be processed as a new claim. The resolution will be reflected in the EOP. The EOP may be accompanied by a letter, if further explanation is warranted.

Community Care AllianceC/0 Appeals Dept.

322 S. Green Street #400Chicago, Illinois 60607

Claim Forms

CMS 1500 UB-04

Professional Services Institutional Services

Common Claim RejectionsThe following items will cause a claim to be rejected prior to processing: • Enrollee unknown to CCAI • Illogical dates of service (i.e., future service dates, etc.) • Incorrect claim form • Missing Enrollee information, such as name, date of birth, ID number• Missing Provider information, such as name, tax ID or NPI number (for Medical

Providers)

Missing any of the following fields: • Valid diagnosis • Admission type • Patient status • Occurrence code or date • Valid revenue or CPT code

Rejected claims will be returned to the provider along with an applicable explanation

Claim Submissions and Inquires

Community Care Alliance of IllinoisP.O. Box 2944064 N. Lincoln AvenueChicago, Illinois 60618

Please contact 866-871-2305 with claim inquiries

Value for Providers

Timely and accurate claims payment• 99.96 % of claims are paid within 30 days• Average clean claim paid within 18 days

Access to the CCAI Web Portal• Provider Manual• Provider Directory• Authorization List• Online Forms

Access to the CCAI Secure Web Portal• Electronic Eligibility• Electronic Submission of Outpatient Authorization Requests• Electronic Claims Submissions (837 batch submission capability)• Electronic Funds Transfers

Secure Web Portal

Please visit us at www.ccaillinois.com and register today!

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Abuse, Neglect, Exploitation & Critical Incidents

What is Abuse?• Abuse is any negligent act by a caregiver or other adult that causes harm or

serious risk of harm to a vulnerable adult. • Abuse can include

-Physical -Sexual -Emotional or Mental Abuse -Confinement-Neglect-Financial Exploitation

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Abuse, Neglect, Exploitation & Critical Incidents (continued)What are the Reporting Requirements?• An allegation of Abuse, Neglect or Exploitation must be reported to the OIG

Hotline or Department on Aging minimally within four (4) hours of its initial discovery

• CCAI should also be notified of Critical Incidents or Abuse, Neglect or Exploitation of Enrollees by calling Enrollee Services at:

1-866-871-2305

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Abuse, Neglect, Exploitation & Critical Incidents (continued)

When Should You Report to the Hotline Number?Whenever you believe that an individual with disabilities or an older adult has been abused or neglected. Some examples of abuse or neglect :

• if you see someone hitting a person with disabilities in a domestic setting or in a facility

• if you see an injury on a person with disabilities' body that does not appear to have been caused by an accident

• if a person with disabilities tells you that he or she has been harmed by a care giver

• if a person with disabilities appears to be neglected, emotionally abused, or financially exploited

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Abuse, Neglect, Exploitation & Critical Incidents (continued)

Where should you report Abuse or Neglect?The Office of Inspector General at 1-800-368-1463Adults with disabilities 18-59 years of age or someone with Developmental Disabilities

The Elder Abuse Hotline at 1-866-800-1409 Adults 60 years of age and older Illinois Department of Public Health Hotline at 1-800-252-4343Complaints against long-term care facilities Senior Helpline: 1-800-252-8966 Abuse, neglect, exploitation of an adult 60 years of age older in a Nursing Home Supportive Living Facility (SLF): 1-800-226-0768Enrollees residing in SLFs Community Care Alliance of Illinois at 1-866-871-2305Enrollee Services

Questions?