MyCare Ohio
(Integrated Care Delivery System)
May 6, 2014
John Rogers
Manager, Eligibility Services
jrogers@improvefinancialhealth.com
On December 12, 2012, the Ohio Department of Medicaid entered into a
Memorandum of Understanding with CMS to create an Integrated Care
Delivery System (ICDS) for Medicare-Medicaid “Dual Eligibles.”
https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/Downloads/OHMOU.pdf
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Full vs. Partial Benefit Dual Eligibility
Full Dual Eligibility
Partial Dual Eligibility
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Medicare A and/or B, optional D
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Not eligible for full Medicaid, but some
or all of Medicare premiums and cost
sharing are covered:
- QMB (A & B premiums and CS)
- SLMB (B premiums)
- QI (block grant SLMB, limited)
- QDWI (A premium assistance
for disabled workers)
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Eligible for Special Needs Plan
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Less Medicaid stability
Medicare A and/or B, and D (most
have all three)
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Full Medicaid, where Medicaid is
secondary payer and covers Medicare
premiums, cost-sharing, and many
non-covered services, especially
nursing facility.
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Eligible for Special Needs Plan
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Typically receives SSDI/SSI
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States with automatic Medicaid
eligibility for SSI recipients:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Delaware
District of Columbia
Florida
Georgia
Idaho
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Mississippi
Montana
Nebraska
Nevada
New Jersey
New Mexico
New York
North Carolina
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
West Virginia
Wisconsin
Wyoming
209(b) states with Medicaid
eligibility criteria more
restrictive than SSI criteria
(No automatic eligibility):
Ohio
Connecticut
Hawaii
Illinois
Indiana
Minnesota
Missouri
New Hampshire
North Dakota
Oklahoma
Virginia
Source: Kaiser Family Foundation, 2013
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182,328 Full-Benefit DualEligibles (FBDE) in Ohio
(114,000 / 63% to be enrolled in
MyCare Ohio demonstration)
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108,205 Partial Dual-Eligibles
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290,533 total Medicare
recipients who are also eligible
for some form of Medicaid
*Estimates from Kaiser Family Foundation,
2009; CMS, 2010; and State of Ohio, 2012.
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Source: ODJFS, 2010
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Ohio ranks 15th among
states in Dual Eligible
spending at $2.5B
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$20,000 annually per DE
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14% of Medicaid
enrollment but 34% of total
Medicaid spending
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50% of Medicaid LTC
spending
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$300 million per annum on
Medicare premiums, costsharing, and coverage
gaps
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Dual Eligible Profile
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Age 65+ or under 65 and
permanently disabled.
At or below 75% of FPL (64% in
Ohio) for SSI-level eligibility. 75100% FPL for state- optional
“poverty level” eligibility.
>100% FPL for spend-downs,
waiver, Medicare Savings Plans.
<$2000 in resources ($1500 in
Ohio).
High chronic comorbidity.
Cognitive impairment/mental
illness.
Functional limitations.
Bio-psychosocial risk factors.
Often institutionalized (65+) or
case-managed (under 65).
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Dual Eligibles are high users of
providers across the health and
human services spectrum.
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Ohio Dual Eligible Cost Factors
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Heavy service utilization across provider spectrum
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Low managed care enrollment
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Most FBDE served in fee-for-service setting
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<3% enrolled in Medicare Special Needs Plan*
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FBDE are exempt from mandatory Medicaid managed care plans
for Aged, Blind, Disabled categories
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Redundancies, cost-overlays, cost-shifting (clawbacks, etc.)
between Medicare and Medicaid FFS exacerbated by FBDE
utilization
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Separate eligibility pathways, billing and payment systems
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Separate administration and accountability
*State of Ohio, ODJFS/Office of Ohio Health Plans ICDS
Proposal to CMS, April 2, 2012
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“MyCare Ohio” will operate in 7
regions comprising 29 counties.
114,000 FBDE age 18+ (63% of
state total), including those with
severe and persistent mental
illness, are to be enrolled into 5
managed care plans responsible for
delivering all covered Medicare and
Medicaid services to enrollees.
Three passive enrollment periods:
• May – July, 2014
Medicare Opt-In period:
• May – December, 2014
Automatic Medicare Enrollment:
• January, 2015
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Who is eligible for ICDS demonstration?
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Age 18 and older at the time of enrollment.
Eligible for full Medicare Parts A, B, and D and full Medicaid.
Reside in an ICDS Demonstration county.
Excluded:
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Individuals under the age of 18.
Individuals who are Medicare and Medicaid eligible and are on a delayed Medicaid
spend-down.
Individuals enrolled in both Medicare and Medicaid who have other third party
creditable health care coverage.
Individuals with Intellectual Disabilities (ID) and other Developmental Disabilities
(DD) who are otherwise served through an IDD 1915(c) HCBS waiver or an ICF‐IDD
Individuals enrolled in PACE.
Individuals participating in the CMS Independence at Home (IAH) demonstration.
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Consumer Enrollment Process
Enrollment letters sent to eligible consumers 60 days prior to enrollment.
Consumers may select a plan in following ways:
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By phone with enrollment contractor (800.324.8680)
In person, during regional enrollment events
Through face-to-face enrollment counseling
Eligible consumers who currently receive services through a Medicaid waiver will be
transitioned to a MyCare Ohio waiver. 37,000 waiver consumers expected to transition.
Not all Medicaid waiver consumers will be eligible, hence not all your Medicaid waiver
consumers will transition to MyCare.
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Northeast: Cuyahoga, Geauga, Lake, Lorain, Medina
Northwest: Fulton, Lucas, Ottawa, Wood
Northeast Central: Columbiana, Mahoning, Trumbull
Southwest: Butler, Clermont, Clinton, Hamilton, Warren
East Central: Portage, Stark, Summit, Wayne
Central: Delaware, Franklin, Madison, Pickaway, Union
West Central: Clark, Greene, Montgomery
Source: ODM, 2014
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Dual vs. Medicaid-Only
MyCare Membership
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Eligible Medicare-Medicaid enrollees must choose a MyCare Ohio
plan.
MyCare Ohio members may enroll for both Medicare and Medicaid
services, to maximize coordination of care and benefits. These
members are called “Dual Benefits Members”.
MyCare Ohio members may also choose to enroll as “Medicaid Only
Members” solely for Medicaid benefits, while maintaining traditional
Medicare or a Part C (Medicare Advantage) plan that is not a
contracted MyCare Ohio plan.
The Medicaid portal will be updated to provide enrollees’ MyCare Plan
name and Dual Benefits or Medicaid Only enrollment status.
Medicaid MyCare Ohio enrollment is mandatory for eligible MedicareMedicaid individuals.
Dual Members can change plans monthly. Medicaid Only can change
during first 90 days, then only during annual open enrollment.
Source: ODM, 2014
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Medicare Opt-In Enrollment
Timeline
Source: Ohio OMA, 2013
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MyCare Ohio Plans
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Northeast: Cuyahoga, Geauga, Lake, Lorain, Medina
Northwest: Fulton, Lucas, Ottawa, Wood
Northeast Central: Columbiana, Mahoning, Trumbull
Southwest: Butler, Clermont, Clinton, Hamilton, Warren
East Central: Portage, Stark, Summit, Wayne
Central: Delaware, Franklin, Madison, Pickaway, Union
West Central: Clark, Greene, Montgomery
Source: ODM, 2014
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Example Cards
Dual Member
Medicaid Only
Dual Member
Dual Member
Medicaid Only
Note: Back of Buckeye MedicaidOnly says “Medicaid Only”
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Wrap-around Care Plan Development
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Plan must conduct an initial care assessment within 90 days of enrollment
in the plan.
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High-need beneficiaries will receive an in-person assessment, while low or
medium risk beneficiaries will receive a telephonic assessment.
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Based on the initial assessment, for each enrollee, the plan will assemble a
care management team, called a Trans-disciplinary Care Management
Team (the team). The team will work with the beneficiary to create the
person-centered care plan.
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The team will be led by an personal care manager, and also include the
beneficiary, the primary care provider, the waiver services coordinator, and,
as appropriate, specialists, and the individual's family and caregiver
supports.
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If the beneficiary requires 1915(c) waiver services, the waiver services
coordinator designated by the ICDS plan will also serve as the care
manager.
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Trans-Disciplinary Care Management
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Network Adequacy Standards
• At least two community Long Term Services & Support (LTSS) Providers in each region for the following services:
Enhanced Community Living, Homemaker, Waiver, Transportation, Nutritional Consultation, Assisted Living, Social
Work Counseling, Out of Home Respite, Home Medical Equipment and Supplemental Adaptive and Assistive
Devices, Independent Living Assistance and Community Transition.
• At least two community LTSS agency providers in each region for Personal Care and Waiver Nursing.
• At least one adult day health and one assisted living provider within 30 miles of each zip code within the region.
• At least five LTSS independent providers (in addition to self-directed care options) in each region for the following
services: Personal Care, Home Care Attendant, and Waiver Nursing.
• At least one community LTSS provider in each ICDS region for the following services: pest control, home delivered
meals, emergency response, home modification maintenance and repairs and chores services.
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Plans will cover all Medicare A,B and D services, plus Ohio Medicaid state plan services,
including long term care, home and community supports and behavioral health services.
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Transition Period
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CMS and ODM specify service transition periods for new members, during
which they will be required to transition to providers within their
interdisciplinary care network in order to maximize continuity of care,
service delivery and payment efficiency. High-needs consumers may be
transitioned within 90 days.
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For specified period of time (generally 365 days), plans will honor
consumers’ existing service levels and providers in order to minimize
disruption.
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During transition periods, non-contracted providers will be paid according to
Medicare and Medicaid fee-for-service secondary payment methodologies.
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Providers can verify MyCare enrollment in MITS portal.
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Provider Payment
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Contracted providers must refer to plan payment schedules within contracts.
Many MyCare Ohio contracts contain separate payment amounts for Medicare
and Medicaid services. Service transition timeframes may also apply.
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For Medicaid Only members using services paid by Medicare or Medicare
Advantage, the fee-for-service Medicaid secondary payment methodology will
be paid by the MyCare Ohio plan.
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The transition period for non-contracted providers extends for a period of one
year after the member’s initial MyCare Ohio effective date. (Members who are
identified by the plan for high-risk care management may transition to plan
network physicians after 90 days). For Dual Benefits members using noncontracted providers, the current Medicare and FFS Medicaid secondary
payment rates apply. For Medicaid Only members, Ohio Medicaid For Medicaid
Only members, Ohio Medicaid requires MyCare Ohio plans to pay noncontracted physician “crossover” , or secondary claims, in accordance with the
fee-for-service Medicaid claims payment methodology.
Source: ODM, 2014
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Provider Payment (cont’d)
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Claims are submitted directly to plan.
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Providers must first work directly with the plan on claims and any other issues
regarding MyCare.
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Provider issues not resolved with plan can be escalated to:
https://pitd.hshapps.com/external/epc/aspx.
Source: ODM, 2014
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Ohio ICDS Risk-based Capitation Model
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CMS, ICDS plans, and state entered into 3-way contracts and conducted plan
readiness reviews.
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Providers must negotiate rates with plans (Medicare rates are likely floor).
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If providers rejected rates, CMS may have considered plan “not ready”.
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Medicare and Medicaid contribute to total capitation payment per CMS rate-setting
process guidelines.
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Medicare rate based on estimate of A & B expenditures on enrollees in absence of
ICDS, and Medicare FFS standardized county rates. Existing Part D rules apply.
Medicaid based state 1915(b) waiver spending.
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Rates adjusted for acuity levels of enrollees, based on community or institutional
level of acuity per waiver assessments and other data.
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Ohio ICDS Provider Impacts
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New Payer Contracts for FBDE: Providers will negotiate rates with ICDS plans. Medicare rates will be
likely floor. If providers reject plan rates, CMS may consider plan “not ready.”
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Minimum Medical Loss Ratio: Plans penalized for not meeting 90% threshold for payment and quality.
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Medical Necessity: Plans will use existing Medicare and Medicaid medical necessity definitions when
making coverage decisions for ICDS beneficiaries, and “apply the more generous” standard in cases where
Medicare and Medicaid medical necessity definitions overlap.
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ED admissions: Better coordination of care through ICDS Transitional Care Management Teams may lead
to increased primary care intervention and lower ED admissions for FBDE.
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Discharge Planning: Discharge planning to SNF, home care, and other institutional & community care
may be more seamless under managed care, wraparound model.
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Continuity of Care: Plans must allow enrollees to continue seeing existing medical and non-medical
providers for reasonable lengths of time; in some cases, up to a year.
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Beneficiary Appeals Process: Beneficiaries will be notified of Medicare A, B and Medicaid appeals rights
in a single, integrated notice. Medicare service denials must first be appealed to the ICDS plan. Medicaid
denials, terminations, and reductions appeals must be filed with the plan or the Bureau of State Hearings
(BSH). Unfavorable Medicare appeals decisions will be automatically forwarded to an Independent Review
Entity (IRE). Unfavorable Medicaid appeals decisions may be appealed by the beneficiary to the BSH. Plan
appeals must be resolved within 15 days or 72 hours if expedition requested. Plan must continue to pay for
services during appeal, if appeal was filed timely.
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Minimum Medical Loss Ratio
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Unique to Ohio.
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Each plan will be required to meet a Minimum Medical Loss Ratio (MMLR)
requirement.
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The MMLR sets a minimum percentage of the plan’s capitated payment that must be
used for providing care (i.e. paying claims) and addressing quality.
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If ICDS plan has an MLR above 90%, meaning, a minimum of 90% of the gross joint
Medicare and Medicaid payments are used to pay for beneficiary care, the plan is in
compliance with the MMLR requirement.
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If the plan spends 85%-90% of its rate on services, the State and CMS may issue a
corrective action plan or levy a fine.
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If the plan spends less than 85% of its rate on services, resulting in an MLR below
85%, the plan will be required to return any funds it received above the 85% mark,
multiplied by the total applicable contract revenue, back to Medicare and Medicaid.
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ICDS Plan Contacts
Source: ODM, 2014
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9 million Dual Eligibles comprise 2.8% of the national population but account
for 10% of national healthcare expenditures and 1.6% of GDP.*
By 2024, total national DE expenditures could reach $775B, or $80,000 per DE.*
*The Lewin Group, 2008: Increasing Use of Capitated Model for Dual
Eligibles: Cost Savings Estimates and Public Policy Opportunities
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Eleven states have signed MOU with CMS for ICDS Demonstration Project.
Seven others have proposals pending with CMS.
Signed:
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Ohio
Massachusetts
California
Illinois
Colorado
Michigan
Minnesota
New York
South Carolina
Virginia
Washington
Pending:
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Connecticut
Iowa
Missouri
North Carolina
Oklahoma
Rhode Island
Texas
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Additional Resources
Ohio ICDS Demonstration MOU with CMS:
https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-Coordination-Office/Downloads
CMS ICDS Homepage:
http://www.cms.gov/Medicare-Medicaid-Coordination
Ohio Governor’s Office of Health Transition:
http://www.healthtransformation.ohio.gov
Ohio Hospital Association ICDS News Page:
http://www.ohanet.org/
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