Health News
Health & Disability Advocates (HDA) is monitoring the rollout of the Medicare-Medicaid Alignment Initiative (MMAI) and has heard from frustrated case managers working with consumers who are confused about the enrollment process and their rights. In response, HDA developed an enrollment timeline that explains what new enrollees can expect from Managed Care Organizations (MCOs) and plan representatives upon enrollment. To produce the timeline, HDA researched the MMAI demonstration contract developed by the State of Illinois and approved by the Center for Medicare and Medicaid Services (CMS) HDA also solicited input from health plans on whether their on-the-ground practices were accurately reflected in the timeline.
The finished product outlines important points for case managers and their clients to consider.
One Day Changes Everything
Consumers who are enrolled in a managed care plan after the 12th day of the month will not see their coverage start until the month after next. This is relevant for consumers choosing a specific managed care plan in order to see a particular provider or specialist in that plan?s network. Submitting paperwork after the cut-off date means consumers would have to wait longer than expected for necessary treatment. Helping consumers submit required documents in a timely manner can guarantee they are connected to the medical treatment they need, which promotes continuity of care.
Stratification Sets Up Future Contact Standards
Once enrolled in a plan, all enrollees can expect to complete a Health Risk Screening within 60 days. The screen collects information on the enrollee?s physical and mental health conditions and identifies their current medical providers. This is what IlliniCare?s Health Screen looks like. Health plans use the screen to establish intensity of services and frequency of contact with Care Coordinators by stratifying the enrollee as low, moderate or high risk.
Enrollees stratified as low risk will receive annual follow-ups from their Care Coordinators while those stratified as moderate or high risk will have quarterly follow-ups. Moderate and high risk enrollees will also complete a Health Risk Assessment and create an Individualized Care Plan within 90 days. These enrollees will help form their own Interdisciplinary Care Team of healthcare providers that meets quarterly to review the Individualized Care Plan.
The Care Coordinators? Role
Care Coordinators focus on enrollees? healthcare needs by connecting them to necessary tests, doctors and treatment. They also facilitate information sharing among providers by leading the Interdisciplinary Care Team. Addressing enrollees? medical needs is their priority. Care Coordinators direct less attention to linking enrollees to social supports, like housing and public benefits.
It?s also important for case managers to know that Care Coordinators must manage a substantial caseload of up to 600 enrollees. Caseloads include a blend of low, moderate and high risk enrollees, with each risk level weighted differently.
Understanding what a care coordinator can?and cannot?be expected to do is advantageous to case managers. When roles are clearly recognized, case managers know how care coordinators can be used as a resource. And in what instances an alternative referral would be more appropriate. This establishes a stronger professional relationship between case managers and care coordinators, which ultimately benefits the enrollee.
Case managers and Care Coordinators are on the front lines of healthcare reform and fostering solid working relationships between these two players will be a critical component of the success or failure of these efforts. Knowing what case managers and their clients can expect from managed care plans can lay the foundation for a strong relationship that supports the health of individuals while also furthering the goals of healthcare reform.
Bryce Marable MSW
Health Policy Analyst
Health & Disability Advocates
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Health News
What Really Happens After Enrolling in Medicaid Managed Care?
Health & Disability Advocates (HDA) is monitoring the rollout of the Medicare-Medicaid Alignment Initiative (MMAI) and has heard from frustrated case managers working with consumers who are confused about the enrollment process and their rights. In response, HDA developed an enrollment timeline that explains what new enrollees can expect from Managed Care Organizations (MCOs) and plan representatives upon enrollment. To produce the timeline, HDA researched the MMAI demonstration contract developed by the State of Illinois and approved by the Center for Medicare and Medicaid Services (CMS) HDA also solicited input from health plans on whether their on-the-ground practices were accurately reflected in the timeline.The finished product outlines important points for case managers and their clients to consider.
One Day Changes Everything
Consumers who are enrolled in a managed care plan after the 12th day of the month will not see their coverage start until the month after next. This is relevant for consumers choosing a specific managed care plan in order to see a particular provider or specialist in that plan?s network. Submitting paperwork after the cut-off date means consumers would have to wait longer than expected for necessary treatment. Helping consumers submit required documents in a timely manner can guarantee they are connected to the medical treatment they need, which promotes continuity of care.
Stratification Sets Up Future Contact Standards
Once enrolled in a plan, all enrollees can expect to complete a Health Risk Screening within 60 days. The screen collects information on the enrollee?s physical and mental health conditions and identifies their current medical providers. This is what IlliniCare?s Health Screen looks like. Health plans use the screen to establish intensity of services and frequency of contact with Care Coordinators by stratifying the enrollee as low, moderate or high risk.
Enrollees stratified as low risk will receive annual follow-ups from their Care Coordinators while those stratified as moderate or high risk will have quarterly follow-ups. Moderate and high risk enrollees will also complete a Health Risk Assessment and create an Individualized Care Plan within 90 days. These enrollees will help form their own Interdisciplinary Care Team of healthcare providers that meets quarterly to review the Individualized Care Plan.
The Care Coordinators? Role
Care Coordinators focus on enrollees? healthcare needs by connecting them to necessary tests, doctors and treatment. They also facilitate information sharing among providers by leading the Interdisciplinary Care Team. Addressing enrollees? medical needs is their priority. Care Coordinators direct less attention to linking enrollees to social supports, like housing and public benefits.
It?s also important for case managers to know that Care Coordinators must manage a substantial caseload of up to 600 enrollees. Caseloads include a blend of low, moderate and high risk enrollees, with each risk level weighted differently.
Understanding what a care coordinator can?and cannot?be expected to do is advantageous to case managers. When roles are clearly recognized, case managers know how care coordinators can be used as a resource. And in what instances an alternative referral would be more appropriate. This establishes a stronger professional relationship between case managers and care coordinators, which ultimately benefits the enrollee.
Case managers and Care Coordinators are on the front lines of healthcare reform and fostering solid working relationships between these two players will be a critical component of the success or failure of these efforts. Knowing what case managers and their clients can expect from managed care plans can lay the foundation for a strong relationship that supports the health of individuals while also furthering the goals of healthcare reform.
Bryce Marable MSW
Health Policy Analyst
Health & Disability Advocates
- Providers Will Make Medicaid Care Coordination A Success
If the opening of the health insurance marketplace taught people anything, it?s that choosing health insurance is tough. Suddenly, people had to make a thorough evaluation of their finances, the types of care they depended on, the medications they needed,...
- Accountable Care Entities (aces): A New Coordinated Care Model In Illinois
SB 26 to be signed by the Governor into law on July 22, 2013, will expand Medicaid to over 600,000 new potential enrollees but it will also usher in a new form of coordinated care in Illinois for these new Medicaid enrollees as well as existing families...
- Illinois Medicaid Redetermination -- What It Is & What To Tell Your Clients
In 2012, the Illinois Legislature passed the Save Medicaid and Resources Together (SMART) Act. One portion of this Act aimed to address the backlog of Medicaid redeterminations that has accumulated over the years. From this Act came the 'Illinois...
- What Happens To The Pre-existing Condition Plans On Jan. 1, 2014?
This post is the first in a series on the Illinois State Partnership Exchange Blueprint Application, which is pending approval by the Federal Government. For years, health insurance carriers refused to sell coverage to individuals...
- A Brief Case For Saying Thanks
Have you ever worked with a case manager at a hospital? They are the people who help patients understand their health status, what is being done, and what treatments to expect. The case department managers at LifeBridge Health institutions are composed...