11 aging & disability resource centers: a focus on long-term care enrollment counseling june 30,...

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Aging & Disability Resource Centers:A Focus on Long-term CareEnrollment Counseling

June 30, 2008

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During this webcast…

Introduction to Enrollment Counseling Highlight key knowledge areas

– Eligibility– Benefit Options– Enrollment Counseling Process– Technical Assistance Documents

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Our presenters….

Charles Jones, Office for Family Care Expansion John O’Keefe, Bureau of Long Term Support Maurine Strickland, Office for Resource Center

Development, Bureau of Aging & Disability Resources

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Goals of Long-Term Care Reform

Choice Access Quality Cost-Effective

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Aging & Disability Resource Centers

Help people…. explore their needs access information about service options maximize use of their personal funds to delay or

prevent need for public funding learn about the benefits and programs available to

them

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ADRC’s provide….…

A welcoming place Trusted, reliable information Core services …

– Information & Assistance– Options Counseling– Enrollment Counseling– Benefits Counseling, Elder and Disability– Prevention, Information & Activities– Functional eligibility determination & coordinates enrollment

into LTC programs

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Enrollment Counseling

assisting an individual who… is found eligible for publicly funded long-term care is making a choice to enroll in

– a managed care organization– IRIS the Self-Directed Supports Waiver– or use only Medicaid card services

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Information about eligibility…

Medicaid is - Federal/State funded health care program Pays for essential health and long-term care (LTC)

services Medicaid eligibility is required for all LTC options

discussed during this webcast

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Medicaid funded long-term care

Eligibility Requirements– Functional (Level of Care)– Non-Financial– Financial

People with long-term care needs receive assistance with the eligibility process

Each ADRC has an enrollment plan that describes how the ADRC together with their partners assist people

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Functional Eligibility

Long-term care functional screen collects information on: Medical Conditions Activities of Daily Living (ADL) Instrumental Activities of Daily Living (IADL) Living Situation Supports Behaviors Risk factors

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LTC Benefit Options Based on Level of Care Results

Nursing Home Level of Care (includes ICF-MR) Family Care

– all Medicaid LTC services, including waiver services– primary & acute health care thru Medicaid card

Family Care Partnership and PACE– all Medicaid and Medicare services – including primary and acute health care

SDS Waiver – IRIS– waiver services (planning to incorporate personal care in the

future)– other long term care services thru Medicaid card– primary and acute health care thru Medicaid card

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Non-Nursing Home Level of Care Family Care

– Standard Medicaid LTC card services (but not waiver)

– Interdisciplinary care management– MCOs may provide other flexible services

Fee-for-service– All services from individual providers thru

Medicaid card

LTC Benefit Options Based on Level of Care Results

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Long-term Care Functional ScreenNursing Home Level of Care

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Long-term Care Functional ScreenNon-Nursing Home Level of Care

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Long-term Care Functional ScreenNo Level of Care

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ADRCs help people through the MA application process

Prepare for interview with Income Maintenance (IM)Medical remedial expenses

Items and services purchased “out of pocket” by consumers that are not paid or are not covered by Medicaid, waiver programs or other responsible third party.

Cost share For more information about cost sharing see program

references or the Medicaid Handbook appendix 5.9.5

http://www.emhandbooks.wi.gov/meh/

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References

Use www.access.wisconsin.gov Webcasts – Special topics

– Introduction to Publicly Funded Long-Term Care– Spousal Impoverishment– Estate Recovery & Lien Law– Medicare Part D

http://dhfs.wisconsin.gov/aging/training/index.htm

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Medicaid Eligibility Fact Sheets

Many single page fact sheets are available (some in multiple languages).

http://dhfs.wisconsin.gov/medicaid1/publications.htm#Fact_Sheets

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Systems

ADRC uses the LTC Functional Screen (LTCFS) to:– Determine level of care– Calculate individual’s budget amount for the SDS Waiver

Income Maintenance uses Client Assistance for Re-employment and Economic Support (CARES) to:

– Determine Medicaid Eligibility– Generate notices to applicants and people who are enrolled in

long-term care program – Enroll people in long-term care programs– Send information to Medicaid Management Information

System (MMIS)

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The Department and its partners use Medicaid Management Information System (MMIS) to:

– Store eligibility and enrollment information– Issue payments to Managed Care Organizations– Generate federally required reports

The Department and its partners use Program Participation System (PPS) to

– Document information regarding centralized enrollment for Managed Care

– Track participation in IRIS (SDS Waiver)– Communicate between the ADRC and the Independent

Consultant Agency

Systems continued…

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Let’s describe the long-term care options?

Managed Care– Family Care (FC)– Family Care Partnership/PACE

IRIS (Self-Directed Supports Waiver)

Medicaid Card Services - only

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Managed Long-Term Care

Family CarePartnership

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Managed Care Organizations….

Help each person…. Identify the results they want Participate in building a plan for services focused around

their outcomes Provide directly or purchase services and supports in the

service plan Coordinate LTC services with the member’s physician and

other medical care Make sure services meet expectations for quality and

timeliness

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Key Differences….Managed Care Programs

Family Care and Partnership offer the same long-term care benefit package…

In addition, Partnership includes:– Health and medical care (acute and primary

care)– Medical personnel on the care team– Drug coverage– Integration of Medicare benefits

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Managed Care Benefits & ServicesFamily Care

Full range of Medicaid LTC services including home and community based waiver, nursing facility care, medical equipment and supplies, therapies and transportation

Interdisciplinary care management (member, nurse and social worker/care manager) LTC services managed by the team

Choose services from a LTC provider network Assist with the coordination of health care

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Members select their own physician (paid for with Medicare and/or Medicaid)

People with both Medicare and Medicaid receive prescription drug benefits through the Medicare Part D plan they choose

Managed Care Benefits & Services Family Care, continued

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Managed Care Benefits & ServicesPartnership

Full range of long-term care services AND health and medical care in one benefit. Covers….

Medicaid primary, acute and long-term care services,

prescription drugs, plus home and community based

waiver services (includes Medicare services if eligible)


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Managed Care Benefits & ServicesPartnership continued

Interdisciplinary Care Management (nurse practitioner, RN, SW, Partnership doctor). LTC, acute, primary care managed by the team.

Members use providers and physicians who are in the provider network (if a person’s physician is not in the network, the MCOs may be able to add physicians)


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Individuals who are eligible for Medicare must:

Be enrolled in Medicare Part B Enroll in the MCO’s Medicare special needs plan


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Individuals who are eligible for Medicare must enroll in the MCO’s Part D prescription drug plan.

Drug coverage is integrated Members cannot use Senior Care or any other Medicare Part D Plan Members get their drugs from the MCO MCO must assure members can get drugs prescribed for them Person may want to check the formulary before enrolling to see if his/her drugs are covered



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PACE is… Very similar to Partnership (in Wisconsin) PACE-run day care centers – where people may get

some services, e.g., bathing Smaller network of primary care physicians

Managed Care Benefits & ServicesProgram of All-Inclusive Care for the Elderly

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Self-Directed Supports inManaged Care

SDS in managed care: Background

– Care management for all members incorporates consumer participation and respect for choice

– Self-Directed Supports is a new way for people to direct their LTC goods, services and supports

Available to all Family Care/Partnership members Each member can choose which supports to direct


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Members play a more active role Deciding how resources are allocated for services and

supports to meet personal outcomes - “SDS Plan” – even to buy services or supports that are not part of the MCO’s benefit package

Selecting their own workers, including family, friends, neighbors

Directing workers


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Overview of how it works:

Wish to self direct identified in assessment MCO can provide help if the member needs

assistance with learning self direction Can be just selecting and directing workers


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MCO makes budget available to member to direct the supports the member has selected

– Member creates an “SDS Plan” for how the resources will be used

– Care management team approves plan– Member carries out the plan


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MCO makes assistance with self direction available thru:

Fiscal intermediary - provides strictly payroll support – checks, withholding, tax filing, etc.

Co-employment agency - offers help with recruiting, screening, interviewing, hiring, training, firing workers


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Interdisciplinary Team Role: IDT continues to support members

– Manage supports not directed by member– Authorize resources available to member– Secure training/TA for members or workers– Monitor member’s use of resources– Monitor member’s health and safety


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About 15% of Family Care members participate in the Self-Directed Supports option Commonly self-directed services include:

–Personal care–Supportive home care–Respite care–Transportation–Vocational supports

91%


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Managed Care Summary

MCOs maintain a network of quality providers to meet members needs

Person-centered interdisciplinary care management with the member at the core of the team identifies and authorizes services and supports

Managed Care Options– Family Care– Partnership– PACE


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IRIS – Self-Directed Supports Waiver

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IRIS: Include, Respect, I Self-Direct

Include –participants are supported to be active members of their communities

Respect – participants’ preferences are honored; participants direct their own lives and long term supports.

I – (the participant) am in charge of my own plan.

Self-Direct – includes me managing my own services and life.

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IRIS

• New option in how persons receive LTC goods, services and supports

• Alternative to Managed Care• Begins July 1, 2008• Participant access is synchronized with Family Care

expansion in each county

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IRIS

Items to know… • Like other publicly funded long-term care options, IRIS is offered

to all persons including individuals who have guardians.• As part of the functional screen, an individual budget is

calculated, based on an individual’s needs. • The ADRC advises participant of the projected budget before

making the choice to participate.• Individuals who choose IRIS are expected to coordinate and

direct all of their services. Family, friends, or others are may help.

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IRIS

Regarding individual budgets:Each person will receive an individual budget allocation :

•may be reviewed/adjusted

•updated annually to reflect the cost of living adjustment (COLA)

•Includes ongoing waiver long-term care costs

The person also has access to services through Medicaid and/or Medicare.

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IRIS

Within program parameters, IRIS participants:• Make their own decisions within their allocated

budget about the goods, supports and services they will receive.

• Make their own decisions about who provides these supports and services.

• Make their own decisions about when and where supports and services are received.

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IRIS

IRIS participants select: • Their own physician and other health

care providers who accept Medicaid as payment just like in Family Care.

• Persons eligible for Medicare receive prescription drug benefits through the Medicare Part D plan they choose.

• DHS is working on allowing IRIS participants to self-direct their Medicaid Personal Care Card services.

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IRIS

• Infrequent supports (e.g. housing modification, short-term residential setting or adaptive equipment) are funded through a separate exceptional expense fund on an as-needed basis.

• For those needing workers/attendants, both co- employment and employer authority are available.

• Persons may use their budget to purchase the services of a broker, if they wish.

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IRIS

Allowable Supports and Services include:

• Goods and services include all community-based, long-term care waiver services; and

• A new option: Participant Customized Goods and Services (details at: http://dhfs.wisconsin.gov/bdds/sds/).

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IRIS

People may live in any community setting they choose, including Adult Family Home, CBRF and RCAC, and still select IRIS.

Regardless of where people chose to live, they must manage within their individual budget.

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IRIS

Role of the ADRCs

• Provide information and counseling about the individual’s publicly funded long-term care choices

• Provide key information to individuals about IRIS, which includes the individual’s budget (generated from the Long-Term Care Functional Screen)

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IRIS

Role of the ADRCs continued…

• Refer the individual who chooses IRIS to the Independent Consultant using the Program Participation System known as PPS .

• Inform the individual that he/she will receive additional information about the program at a meeting with the Independent Consultant Agency and the selected consultant.

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IRIS

State DHS manages two statewide contracts:

1. Independent Consultant Agency (The Management Group) oversees independent consultant activities and provides overall program management

2. Financial Services Agency (Milwaukee Center for Independence) completes all criminal background and employment checks, claims payment functions, and assorted program reporting.

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IRIS

Independent Consultant Agency (ICA):

• Provides orientation and skills training to all participants

• Maintains a 24/7 toll free number with on-call service after regular business hours

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IRIS

Independent Consultant Agency (ICA):

• Provides an orientation to IRIS

• Approves and monitors participant plans

• Tracks participant health and safety issues

• Meets State oversight obligations

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IRIS

Consultants:

• help people stay eligible by keeping track of program requirements;

• assist participants when necessary;

• secure training/TA for participants;

• may help participant identify when and how to get in touch with the ADRC to request an updated functional screen when there is a change in condition.

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IRIS

Financial Services Agency (Milwaukee Center For Independence):

• Completes required criminal background checks, employment verifications, and also completes all payroll tasks;

• Receives and monitors cost-share payments;

• Pays claims as listed on support/service plan after participant authorizes payment

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IRIS

Financial Services Agency (cont):• Provides orientation and skills training program to all

participants

• Maintains a toll free number with call service during business hours and voicemail service after regular business hours

• Sends monthly spending reports to participant, ICA and Department

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IRIS

IRIS Quality Management assures:• Quality Standards are followed;• Each participant has quality management

plan;• A back-up plan for worker no-shows or other

urgent situations is developed by the participant and the Independent Consultant;

• Critical Incidents are reported and tracked by the Independent Consultant Agency.

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ADRCs help people

Compare programs– Benefit packages– Program design– Approach to coordination of services

Educate people so they can choose what is best for them

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Programs are voluntary

People can change their mind.

People can disenroll at any time.

Advise people to come back to the ADRC if they want to have a conversation about reconsidering their choice.

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Process of Enrollment Counseling

Getting Ready Having a Conversation

with Individuals Tools Available

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Enrollment Counseling: Getting Ready

Familiarize yourself with the benefit packages– Family Care and Partnership/PACE– IRIS

Learn about the organizations that will be authorizing or coordinating publicly funded long-term care in your area

Understand appeals and grievance procedures Learn commonly asked questions from people

currently receiving publicly funded long-term care

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Enrollment Counseling: Getting Ready

Familiarize yourself with the financial implications that may impact the individual’s decisions– Understand and be prepared to explain

Co-pay Cost share Estate recovery

http://www.emhandbooks.wi.gov/imm/imm.htm

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Sending a “Heads Up”

Send a letter to people currently receiving waiver funded services

Send a letter to people currently on a wait list for services

Sample letters provided Consider including the “What is an ADRC?” fact

sheet Remember to check for Medicaid and to ensure that

the Long-term Care Functional Screen is current

Getting Ready…

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Step 1:Delivering the Good News (via Telephone)

Contact the consumer Introduce yourself, explain why you are calling,

reference the letter that was sent to the individual and ADRC fact sheet (if sent)

Schedule home visit (if acceptable to the consumer)

Having a Conversation…

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Step 2: Having a Face-to-Face Conversation

Find out how the person is doing! Provide an overview of the enrollment process

– Utilize the “Guide for People on a Waiting List”– Modify information for people currently on

Waivers– Double check to make sure the individual and/or

the family understand the process– Answer questions throughout the conversation

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Step 2: Having a Face-to-Face Conversation…continued

Check to ensure that the person continues to be functionally eligible – update the functional screen if needed.

With the individual’s needs in mind, review potential services or benefits that may be available to the individual.

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Step 2: Having a Face-to-Face Conversation… continued

Educate the consumer about Managed Care and IRIS.

Explore which Long-Term Care Option is best for this person. – How much of her care does the person want to

manage on her own?

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Step 2: Having a conversation…continuedResource materials

“Which Long-term Care Option is Best for Me?”

“Tell Me More about…Family Care” “Tell Me More about…Family Care

Partnership” “Tell Me More about….Self-Directed

Supports in Managed Long-Term Care” “Tell Me More about…The Self-Directed

Supports Waiver - IRIS “

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Step 2: Selecting Long Term Care Program of Choice

The consumer compares and selects the program

that is best for him/her.

In some areas, individuals may have more than one Managed Care Organization to choose from

– Utilize the “Managed Care Organization Matrix”

For individuals who choose IRIS, provide information about the roles of the ICA and FSA.

Having a Conversation…

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Step 3: Applying for Medicaid/Updating Records

Gather medical remedial information if appropriate Provide Income Maintenance (IM) pertinent

information Use Centralized Processing if appropriate

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Step 4: Enrolling

If the individual’s financial eligibility information was up-dated, share information about his/her eligibility status (cost-share)

If a Managed Care option is selected, learn what date the individual wants to enroll or begin services, complete the enrollment form and communicate information to Income Maintenance (IM) and MCO

If IRIS is selected, refer the individual to the Independent Consultant Agency where the service plan is developed and start date selected.

Note for new enrollees: Cost shares are NOT pro-rated in Managed Care, so be sure enrollment dates are chosen with this in mind. Cost-shares ARE pro-rated in IRIS.

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Step 5: Services Begin!

If the individual chooses a managed care program, he/she will take a place on the care team and the coordination and delivery of services will begin.

If the individual chooses IRIS, once the start date is selected services begin on that date.

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Step 5: Services Begin continued

Remind consumers who to turn to if they have questions or concerns; there is always someone to assist.

If the individual is enrolled in a Managed Care program they can communicate their concerns to their care team or member advocate.

If the individual is enrolled in IRIS he or she can contact the Independent Consultant to share any concerns or questions.

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Reminder of Resource Centered Technical Assistance Documents

Enrollment Plan Enrollment Counseling

Handouts– “Key Differences Between Managed Care & Fee-for Service

Programs”– “Which Long-term Care Option is Best for Me?” – “Tell Me More about…The Self-Directed Supports Waiver - IRIS“– “Tell Me More about…Family Care”– “Tell Me More about….Self-Directed Supports in Family Care”

The consumer compares and selects the program that is best for him or her

Remember to dose information

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Additional Reference materials

Being a Full Partner Booklet Member Handbooks Provider Directories Questions about Family Care for People with

Disabilities MCO website: http://dhfs.wisconsin.gov/managedltc/ IRIS website: http://dhfs.wisconsin.gov/bdds/sds/

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Options Counseling Tool Kit

Four Sections

1. Introductory Video

2. Communication Module

3. 16 Web casts

4. Supportive Materials

Sample webcasts in the tool kit Assistive Technology Spousal Impoverishment Lien Law & Estate Recovery Legal Decision making tools Medicare Choices in Assisted Living

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Disenrollment

The ADRC provides counseling regarding potential disenrollment.

Individuals can disenroll at any time. ADRC helps individuals think through this option. Remember some individuals who disenroll will lose

Medicaid if he/she has Medicaid via waiver participation. If the individual does choose another publicly funded

long-term care option, work with him/her to ensure continuity of service.

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Wrap-up

Time of change. People will have opportunities to choose from two or

more programs. Your knowledge and skill is essential in helping

people learn about these options and think through these choices.

Looking ahead to….No Waitlists!

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Contact information

ADRCs are encouraged to email questions to the Office for Resource Center Development at [email protected]

Questions regarding ……… Managed Care Programs

[email protected] Self-Directed Supports Waiver

[email protected]