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Hi. We are going to go ahead and get started.
Welcome to the first of a series of webinars for One Care.
This is an introduction for One Care care providers.
My name is Laney Bruner Canhoto and I am with the UMass medical school.
And I am pleased to have as our presenter today Robin Callahan.
So before I turn things over to Robin I have a few housekeeping items
and a couple of questions for you.
Please note that this webinar is being recorded and will be made available at a later date.
Also we have some accessibility features in case you need captions or other accessibility items.
For this webinar we are using the mute feature on the conference call line.
The audio is provided through your phone line.
So please call in to 617 410 9095 to join in.
For best results we have found that you should turn off your computer speakers.
If you want closed captioning, make sure
to click the show captions button at the top of your screen.
Otherwise if you don't want closed captions please click hide captions.
Even though the phone line is on mute, we welcome your participation
and we have a couple of ways for you to participate.
First there will be a question and answer time at the end of the webinar.
We will give you specific instructions at that time.
Also during that time we will start off with some of the questions that came
in through the registration process.
Second we will be polling you throughout the presentation.
A question will appear on your screen and you can choose your answer.
We will wait about 20 seconds or so and then the results will be revealed
to everyone before we move on to the next slide.
Finally you may not be able to view the entire slide right now.
If that's happening to you you may need to scroll in order to see the full slide.
You may also reduce the size of the slide
by pressing the control and minus keys at the same time.
Your screen view will be updated once you refresh your browser or when the presenter moves
on to the next slide which I am going to do right now.
We wanted a chance for everyone to find out a little bit about who is attending this webinar.
One Care is bringing together a lot of different experts.
So right now we would like you to answer the question what,
is your primary area of expertise.
You can select as many answers as apply.
We know from the preregistration that we had a wide variety of primary care, care coordinators,
behavioral health and long term services support folks.
And the results of this first polling question are,
so we have the highest one is other which sort of makes sense.
And then we have the behavioral health and care coordination and care management.
So as you see One Care encompasses all of these areas.
The next polling question is about in what part
of Massachusetts do you provide most of your services.
Again you can choose as many as apply.
One Care is statewide.
So we hope that we are seeing a good representation
of folks from all areas of Massachusetts.
And we will just give a few more seconds for folks to enter their answer.
So a lot of folks are coming from the Boston area and from Central.
Welcome everyone to the webinar.
Today's webinar will give you a high level overview of One Care.
Future webinars and other training efforts will provide additional, more specific information.
After today's webinar you will be able to describe the essential and unique elements
of One Care, identify characteristics of the One Care population,
explain how care will be delivered and what services are available,
specify eligibility criteria and enrollment processes
and summarize enrollee rights and protections.
To address these objectives I will now turn things over to Robin Callahan.
Take it away, Robin.
[ROBIN CALLAHAN] Great.
Thank you, Laney.
I want to thank all of you so much for participating in the webinar today.
We are really excited to be talking to you about One Care.
And you might have heard over the last year and a half or two years MassHealth, CMS,
a large number of stakeholders have been talking about something
that we have called a duals demonstration.
And we are happy to be able to give it a name and it is called One Care.
So One Care will be for us a new option that we are able to make available to people age 21
to 64 who are eligible for both MassHealth
and Medicare benefits otherwise known as dual eligibles.
This will enable those folks to receive care as part of a single plan offering,
comprehensive benefits that cover both the MassHealth and Medicare programs.
The services that will be covered by One Care are all Medicare services.
Those are Part A, Part B and Part D, inpatient, outpatient and pharmacy.
They will also be available all Medicaid state plan services
that the dual eligibles are entitled to and most importantly those include long term services
and supports that we will talk a little bit more about a little bit more in a minute
but those are services that are offered by Medicare Medicaid but not offered in Medicare.
And generally they help to support the functioning level of our members.
One Care will also include behavioral health, diversionary services,
a set of community based services developed to help folks
with significant behavioral health issues to receive support in a community setting.
What we also made available through the One Care
or want to make available are some additional flexibilities that we hope will be important
for folks that enroll that would offer some community support services that can be used
in a flexible way in a care plan, that are not available to this to this group
of folks in the fee for service world.
So we hope that all of these aspects of care, all these care will be brought together.
And the point is to integrate them in order to improve quality of care and hopefully over time
to have a more cost effective way to provide care.
Why are we doing this now?
I think that for those of you who worked with folks who are dually eligible you have known
that the Medicare, Medicaid programs have not had the type of integration that supports care
across all domains of care for these folks.
Certainly services are different sets of services are provided by the (inaudible)
but they are not really brought together.
And there certainly isn't in the fee for service system anything
that is helping our members manage their care.
We have recognized this and so has the federal government.
So there was a special program authorized under the Affordable Care Act
as federal health care reform, and Massachusetts is one
of the 15 states awarded a planning contract from the CMS, Center for Medicare
and Medicaid Innovation which encouraged states to develop approaches
to integrating care between Medicare and Medicaid.
So that the grant that Massachusetts received was
to help support the development of the design of One Care.
The goals of One Care are very important.
The first goal is to improve health and functional outcomes
for our dually eligible population.
We are going to see a little bit more on future slides what some characteristics of the group
of people that we are hoping to serve under One Care
that make this a particularly important and challenging goal.
We intend for One Care to have be based on a model of person centered coordinated care.
We want to see that more and more in the way the MassHealth program
and I believe the Medicare program deliver its services to people.
We are interested in seeing a reduction in the fragmentation of care
where we each develop we each sort of provide our own one off services here and there,
but there is an awareness and assistance for the members receiving that care to bring it together
in a way that makes sense for them and to it optimizes the benefits
that these folks have entitlement to.
We are also looking to move from a fee for service focus
on how services are delivered to a more outcome focused.
So we don't want to pay by the widget.
We would like to pay by how services are combined
to produce a better outcome that is measurable.
We also try to adjust address cost shifting between these programs.
I am sure as providers you are probably aware that the (inaudible) between Medicare
and Medicaid some time as to who should pay for service.
There are hoops that providers have to jump through to bill one and the other.
There are denials that you need to get on one bill before another program will pay for.
These are cost shifts and these come about when programs are not aligned.
And I think, you know, a major goal of One Care is to create alignment between Medicare
and Medicaid so that the cost of cost shifting can be transferred
in to actual provision of services.
And another thing we have to think about is that for both the Medicaid
and Medicare programs there has been a trend of growth in cost that has to be addressed somehow.
We in developing One Care we are saying we have a solution that we think can work
that we believe there is a window in which we can improve service delivery while
at the same time bringing down costs.
Diverting people from more expensive care in to more community based care
which not only is less costly but certainly suits the preferences of our members better.
So again the general care model for One Care is going to be based
on providing person centered care.
Understanding that there is really no one solution for each person.
Each person has to have their own solution to how the care comes together
and how they can get the most out of entitlement to benefits.
What we are proposing to One Care based on goals and preferences of the individual,
looking at their situation in their own terms and figuring out with them the best way
to put together a package of services that make sense.
There is a focus on the individual, again you will see as we talk more
that there is an assessment process and a care plan process and a care team that is
for a given enrollee or individual and will look different from person to person depending
on what issues are present and how that person would
like to receive their care around those issues.
So the individual is going to be involved in the care team activities.
They are going to attend meetings.
They are going to be expressing their preferences, talking about the options.
And their involvement is to be respected and to be integral to the care plan.
So we are looking for a program that focuses on meeting health needs, meeting functional needs
but doing so with recognizing choices, dignity, respect, self determination
and purposeful living for the folks that would be enrolled.
So who are the target population for One Care?
Who are the folks we are talking about?
Well, as you know there are generally two ways to be eligible for Medicare.
And that is through age.
If you are over 65 but if you are under 65 as this target population is,
you get eligible for Medicare based on the fact that you have a long term disability.
So everyone in the target population for One Care will be a person with a disability.
These are going to be adults with physical disabilities, intellectual
or developmental disabilities, serious mental illness, substance abuse disorders.
They will involve folks that have multiple chronic illnesses or functional
and cognitive limitations and we look at some of the social manifestation and is homelessness.
And we think in this population group we have a significant section of folks who are homeless.
When we look at eligibility, again we have found in our sort of set of options in MassHealth
that while we have options around coordinated care for many populations, for example,
elders have access to a problem a program called senior care options which is similar.
There are a group of folks with disabilities who are between the age of 21
and 64 who currently do not have an option available to them to access integrated care.
That's the target population.
This is persons who will be between the age of 21 and 64.
They will be eligible for MassHealth standard or CommonHealth and they will be enrolled
in Medicare Parts A and B and eligible for Part D.
For the time our target population will not include those
that have other comprehensive insurance.
In other words, the only two coverages that this person has will be Medicare and Medicaid.
For our initial program we are not going to be enrolling people who are
in other comprehensive programs, like program of all inclusive care for elders,
SCO or home community based waivers.
Those folks will not be in One Care or be able to enroll in One Care
and they will not be residing in this term ICF/MR.
This is a term for certain types of residential programs for people
with developmental disabilities at this point would not be included,
would not be enrolled in One Care.
When we look at the characteristics
of the One Care population we see some very interesting facts that really drive the types
of services and the type of model that we think is important.
We see that there are about 67% of target population
and again entire target population I neglected to say it is about 111,000 folks
and we have behavioral health diagnoses.
About 50% with chronic medical issues and 8% with intellectual or developmental disabilities
and about 25% currently use long term services and supports and these are services
that address functional challenges.
Services like personal care attendance, home health, rehabilitation, nursing facility.
And about 96% of the target population resides in the community.
The other 4% in residential long term care facilities.
Care will be delivered through in the One Care plan to a care team
and a provider network through the health plan.
There will be an integration of primary care specialists, behavioral health
and LTSS, long term services and supports.
There will be a person centered assessment for each enrollee,
planning and service delivery using a medical home or health home model as its foundation.
The care teams will be comprised of you will see on the slide enrollee in the middle
and that's exactly what our attention is.
Enrollee is in the middle of the care team.
They are not outside the care team and not hearing about things from the care team.
They are an integral part of their own care team.
Each member will be assigned or have a care coordinator.
That is their major point person to connect with their health plan.
That is available to them at all times.
They folks that have serious or complex medical need also
to have access to a clinical care manager.
This team will also be their primary care provider.
Behavioral health provider if that's indicated
and long term supports coordinator if that is indicated as well.
And an enrollee must play the central role in the care team.
You will see that the care team could be many more folks depending
on the enrollee's preferences and needs and who is involved
in the life of that member of that enrollee.
So it could include family, peer support, advocates.
Folks might be involved with state agencies who they are providing a good deal
of support already that they wanted to be involved in a care team.
We are asking that the health plans that offer One Care are creative about bringing in new
and different types of workforce such as community health workers that may support people
in their wellness objectives or disease management goals,
but this will really be a personalized care team.
So one of the questions that we have
for you today is have you ever been involved in a person centered care team.
If you could let us know that we would appreciate it.
As we are waiting for the results to come in on that question,
we will go to the role of a care coordinator.
This is critical.
What we hear from many, many people as they are trying to navigate the benefits
of the Medicare/Medicaid programs the services might be out but we need someone
to help us access them and make sense of them.
So that is the role of a care coordinator.
This person will ensure the completion of a person centered individual assessment
within 90 days of enrollment in to the One Care plan.
They will be responsible for coordination, monitoring, following up
and scheduling care team meetings and making sure
that the plan is actually delivered for the enrollee.
We mentioned before that there is a clinical care manager who will be assigned to enrollees
who have particularly complex care needs.
We find that many of the folks in the population that we expect to enroll
in One Care have multiple diagnoses or multiple issues
that they are trying to manage at the same time.
There will be expertise around having about managing that.
We have also introduced a role called a long term support coordinator.
And this is a person who is meant to be or will be independent from the health plan.
They will be contracted by the health plan as an expert in long term services
and supports and community based support.
So they will bring to the care team to the member expertise
around long term services and supports.
They will advocate for the provision of those supports in the care plan and they will help
to facilitate community integration for the enrollee.
And they will assist the enrollee in accessing personal assistance and other services.
The personal care plan is going to be a major feature.
The first thing that will happen once a person is enrolled is they will work
with their care team to develop a plan.
That will be informed by a comprehensive inperson assessment directed with the enrollee
and it will cover the whole range of medical, functional, behavioral health and social
and support needs that that person has.
If that care plan that the member is presented with at the end
of this process does not meet their needs
or the enrollee does not believe it reflects their needs they have the right
to appeal that plan.
Polling question, another question we have is do you currently work with any members
that receive both MassHealth and One Care.
[LANEY BRUNER-CANHOTO] If you can give folks a few minutes to answer the question, please.
[ROBIN CALLAHAN] Okay.
We will talk a little bit about the enrollment process for any given enrollee.
When a person enrolls in one of these One Care plans, well, the first thing we are going
to do is offer One Care plans to folks that would like to choose to be in it.
And we are going to send out to the entire group of 111,000 eligible members a letter
from MassHealth with enrollment information about One Care plans.
At that point folks can choose to opt in which means they can select a plan.
Or they can tell us that they do not want to be in One Care.
There will be a lot of information between now and when we get to that point for people
in the community who are helping members make that choice, providers,
community based organizations and others to get the information they need to help
to help our members who are eligible to be in One Care.
So Laney is going to talk about at the end
of this presentation what you can expect in terms of more information.
In the next phase of the program we will start to do some auto assignments for folks
and these are for people who don't make any choice at all.
They don't tell us they want it; they don't tell us they don't want it.
We will start to have a process where we approach
and say here is a plan that we think will work for you.
They will have an option to say okay, that's fine.
Or they can tell us at that point I would like a different plan or I don't want to be involved.
There will be this opt in or opt out features that we don't see in any of our programs today.
The choice of the enrollee has as they said they are going to be able to enroll or disenroll
from any given One Care plan at any time.
They will be able to choose a different One Care plan at any time.
They can say this is not right for me but I think this other one might be.
That is in the context of understanding that enrollment
in a One Care plan is from month to month.
So a person is enrolled in a plan for a month and if they say they don't want to stay in,
then we will change that enrollment at the beginning of the next month.
There may be situations under which a member who is enrolled
in a One Care plan would have access to certain nonnetwork providers.
There is going to be rules around that.
We hope it will be the exception rather than the rule because we think it is very important
that the providers that are members who are enrolled with are a member
of the team that's set up by that health plan.
So it will be we will try very hard to make sure that the providers that are important
to our members are participating in the health plans
so that our members can get full advantage of the new program.
There will be enrollment assistance through a MassHealth customer service,
trusted state agencies and community resources.
And there are counselors out there called Shine counselors which provide counseling
to Medicare beneficiaries generally about the options available through the Medicare programs.
And we will be working with them specifically to educate them and make sure they are comfortable
and have the information they need to help dually eligible members who could be enrolled
in One Care understand that program as well.
It is important as we talk about this that you know as providers that a big part
of the decision making that members are going to make about whether to join
or not is whether their trusted providers,
their programs they are already enrolled are a member of these One Care plans.
We really hope that you will be participating with our members in joining up to these plans.
This slide talks about an assessment timeline
and what our expectation is when a person enrolls.
Once enrollment is complete, there is a 90 day period
that the enrollee keeps the current providers and services
that they are receiving at the point of enrollment.
So that there is no disconnect; there is no gap; there is no interruption.
During that 90 day assessment period it is our expectation that health plans will make sure
through the care coordinators that each enrollee is met with
and a personal care plan is developed and it is not until that happens
that the person will perhaps if necessary see an adjustment towards the network providers.
It is critical that any need that the person has addressed right away
and I think a particular importance to us is understanding that there are people
that are receiving long term services and supports that they use every single day.
So we want to make sure that when they enroll in to a One Care plan there is no interruption
in their lives or their ability to function because there is a change in really payer.
So speaking of continuity of care, you know, the One Care plans have
to provide written notification if the person care plan proposes changes
to how the services are authorized.
So there is this 90 day process where they are working with this new enrollee and talking
about what their needs are, and if they are going to change anything they have
to provide written notice to give them a chance to understand if it is going to work for them
or register any appeals or complaints.
We want the clinicians and the providers and the folks that are working with our members,
now particularly our members with disabilities,
we want them to bring their expertise in to these care plans.
So there is activity going on right now through the health plans and we will talk
about who they are in a minute to set up their provider networks.
I believe that you will be very welcomed in these provider networks and it is very important
that you join in order to become part of a care plan that the folks that you are working
with now are going to have access to.
There will be an official grievance process for people who enroll where they can file
if they have a compliant about a care plan, their health plan that they are in to make sure
that we are monitoring and have a process to make sure that people are treated with respect
and can get answers to their questions and are able to develop positive
and effective relationships right away with the One Care plans.
There are particular timelines about response to those and there is access to the Medicare
and Medicaid processes and enrollee protections for folks in this process and we will be talking
in a lot more detail about grievance and appeal processes in future webinars.
Importantly, you know, any time that one of the health plans denies, terminates or suspends,
reduces services, or causes any kind of a delay in service it is certainly an appealable action.
It is our intent to be very, very vigilant about making sure that folks that enroll
in these new One Care plans have full access to all of their appeal rights through both CMS
and MassHealth board of hearings.
So more information will be coming out about that soon.
Another line of protection that we have we will bring
in to this process is the role of an Ombudsman.
We are in a process of procurement, MassHealth is procuring for an extra party
to provide services for people to help us identify systemic complaints or difficulties
to provide advocacy for enrollees in a way that enrollees are sure that this person is outside
of the system and can speak without conflict and advise us
about how the system is going without conflict.
Because the entire target population of One Care persons with disabilities,
attention to ADA compliance is going to be key.
We are requiring every plan to have an ADA officer
so that we can see what what they have done in terms
of providing reasonable accommodations and sharing access.
And we are talking about accommodations such as communication access, ASL interpreters,
physical access to the physical plan and the equipment in doctor's offices and flexibility
in scheduling and this will be a high area of interest as we roll this plan out.
So who are the prospective One Care plans?
At this point through procurement MassHealth is MassHealth and CMS are working
with five health plans that have come forth to say they wanted to offer this program.
Those are Blue Cross Blue Shield that has a new plan called Blue Cross Partnership.
Boston Medical Center, Health Net, Commonwealth Care Alliance and Network Health.
They are working with us now on readiness activities and I have to caution until we get
to the point of signing contracts with them they are not One Care plans yet.
We are working very hard to get them there.
They are in a process now of something called a readiness review.
They have to pass a number of hoops that the state
and federal government has set up for them.
And key areas that we are looking at is what their process is around care coordination,
what the network adequacy which is why you might have been working
with them and/or negotiating with them to join networks.
We need to make sure they have in place appropriate enrollee and provider communication
and that their computer systems relate in a way they need to
and they have the appropriate organizational structure and staffing
to take on the enrollees of One Care.
Plans that pass this and are in a state where they continue to want to be
in this program will then go on and sign a three way contract
between the health plan, MassHealth and CMS.
How will they be paid?
The plans will be paid in a capitated way.
They will get a three part capitation.
A separate one for the Medicare D and then a capitation based
on what the Medicare portion of the service is.
So you will see that there is risk adjustment through a typical sort
of Medicare advantage risk adjustment process, a Medicare Part D risk assessment goes on
and on the Medicaid side we have developed rating categories that are based on the needs,
the long term service needs and the behavioral health needs that sort
of stratify in to different payment rates.
We are also encouraging One Care plans
to use alternative payment methodologies for their provider contracts.
Many of them have in place certain shared service arrangements
or primary care behavioral integration arrangements that they are pursuing.
And we encourage that because we think that will add significantly to the involvement
of providers and share savings that might be accrued from controlling
for unnecessary hospitalizations and institutional care and readmissions.
How will providers be paid?
So providers again are being I think each of these health plans are reaching
out to the provider community to form the networks.
Health plans will negotiate directly with the providers on the payment rates and methods.
The rates will not be set by either MassHealth or Medicare.
However, we have encouraged the all involved parties to look at the current Medicare
and Medicaid fee for service payment as a baseline or starting point for negotiations.
So during the 90 day continuity of care period that we talked about earlier
for the first 90 days of enrollment the health plan is not allowed to change providers.
They have to wait for a care plan to be provided.
The payment rate for those services will be current MassHealth
or Medicaid care for fee service rates.
That's how the plans will pay the existing perhaps
out of network providers during this 90 day period.
Quality reporting will be really a high priority.
It is very important that we look at not only the spending levels
but making sure we don't see reductions in spending that are due to bad care.
We need to see both a high level of quality improving quality of care as we go along.
And we will be monitoring that very closely and we will be working
with our stakeholders including an implementation council
that is a very important part of this project that is built with about with half
of the implementation council are consumers and another half are providers
and other interested parties that will help advise us
and watch this program as implementation takes part.
So we will get some input in to what we need to track, that the program gets a good start.
That we can make any adjustments necessary, and part of that tracking will be constantly
to be looking at enrollees to see what their level of satisfaction is
as they start to join these new programs.
So in conclusion I mean I think that we are very excited to be offering a new model of care
for a very significant population group.
This is a group of people who receive and are entitled to both Medicare and Medicaid benefits.
They are the highest cost and most complex need population in both programs.
It is a group that ironically currently does not have access to integrated care.
We really very strongly hope to fix that and a program that we hope to launch this fall
and the goals are clear for us, enhancing the focus on person centered care and outcomes,
reducing cost shifting, lessening our reliance on acute care.
That's a very important feature.
Acute emergency care.
A plan that a model of care that can serve the enrollee
in their own culture and their own community.
Therefore the focus on community based services both for long term services and supports
and for behavioral health services particularly.
And reducing fragmentation of care, where a person just has to pick up a phone book
to figure out how to get help with services.
We like to see that rectified.
We like to see a cohesive integrated supportive model of care
for these really, you know, complex members.
So we are excited about this and we really hope to work with you
over the next several months to bring this program up.
And thank you for your time and attention.
[LANEY BRUNER-CANHOTO] Now we are going to have some time to ask questions.
So to ask a question please just click the ask a question button
at the upper left hand side of your screen.
Type in your question and click send question.
We will answer questions in the order that they are received.
I want to let everyone know that we may or may not be able to get to all the questions today.
We will try to answer as many as possible.
But we will definitely be taking these questions and using that information to help with content
for future trainings and other activities around the One Care plan.
You may also be able to find additional information to answer your question
at the mass.gov One Care website.
We are going to start with the preregistration questions.
The first question is how will our patients learn of One Care
and what additional resources will we need to have to enroll our patients?
[ROBIN CALLAHAN] The most important thing for you to know that we are now embarking
in a public information campaign that we are starting that was recently started
and will really be in place throughout the duration.
We believe that the one plan or target is
for the one plan enrollment to launch some time this fall.
So between now and then we have planned a lot of information to go out.
There is currently a website called the Duals website for now
but we are setting up a One Care space for that.
We will be putting information up over time.
We have a consumer guide, something called introduction to One Care coming out.
We have posters coming out.
We have flyers.
We have FAQs that will be posted.
We are also in the process of developing some community meetings
that will be that will be coming out.
As Laney said there will be additional webinars for providers.
So we believe that we have many, many different places and ways that we will be reaching
out to community based organizations, meeting with them, meeting with consumer groups from all
from all segments of the disability community.
So this will be we are just starting it.
Right now we are trying to get very high level information out.
But I can be sure that as we get closer and closer
to implementation you will be seeing more.
And we will be providing you with specific information about how to get how
to get the information you need to support your patients or The persons that you are interested
in in helping through this process.
[LANEY BRUNER-CANHOTO] Great.
A question that's on a lot of people's minds, what's the effective date?
[ROBIN CALLAHAN] I think we have had those of you following this project
for awhile we put a number of different dates out over time.
I believe we are at the point in the process where we can start
to see much more realistically when we will be able to launch.
And again we are right now using fall of 2013 as our, you know,
I know it is not pinpointing a date for you but you can expect that some time
in the fall we will actually start enrollment.
We expect to put out probably within the next month a more specific timeline.
We are now looking at where the the prospective One Care plans are in their readiness,
what their provider networks are like to date
and how much more time they are going to need for that.
And then a process we have to go through to actually get contracts signed.
So I believe that we will be seeing in the next month a much more detailed
and definitive timeline.
[LANEY BRUNER-CANHOTO] Great.
And finally the last preregistration question we just talked about time.
Now we are going to talk about money.
What are the fee schedules that will be used?
[ROBIN CALLAHAN] As I said, you know, in this model the health plans,
the One Care plans will be negotiating directly with providers to provide the services.
So there will not be MassHealth will not be setting rates per se.
Again what we have asked the plans to do to look at a fee schedule that exists today in Medicare
and exists today in Medicaid and involve negotiations using that as sort of a guide post.
It doesn't mean that they are required.
It doesn't mean that providers are required to accept them but we think that's the right place
to start because what we are what we are going to be doing is really funding these health plans
through what we currently pay for fee for service.
The idea is that paying for a care plan through One Care,
a program like One Care is a better way to pay for services than fee for service.
So there isn't new money so to speak coming in.
The current estimated cost for the target group that we are talking about right now is
about 3 billion dollars a year in spending.
We don't expect or it is not our goal to increase dramatically.
So we have to be all conscious of that.
We do have a budget of sorts but the reason that we have asked for the health plans
to use the current fee for service structure it is important to us that the folks
that have been providing faithful service to our members for all this many years in the fee
for service world are not disadvantaged financially by us going to this model.
On the other hand, it is not meant to be an opportunity to, you know,
do a lot more than what we see in fee for service spending.
So I hope that that's close enough to an answer to you.
And I really would hope that there is, you know, an expected there is good faith
on both sides of these negotiations.
Health plans need an adequate provider network.
Our members need experienced providers and I think that as we see
that the One Care plans offer a lot more to our members than fee for service does I hope
from the provider side you understand that you need to be involved in One Care plans
so that your patients are able to take full advantage of what those plans have to offer.
[LANEY BRUNER-CANHOTO] Great.
Our first question online is what is auto assignment criteria?
[ROBIN CALLAHAN] Okay.
Auto assignment for those of you that don't know is when what when MassHealth determines
that a person is in the eligible target group and chooses a plan for that person to enroll in.
Now MassHealth will only do that if the person either has not expressed another choice,
has not told us that or has not told us that they don't want to be in One Care.
So in that circumstance under those circumstances we will auto assign a person.
The first thing is they have to meet all their eligibility criteria that they talked
about earlier, that they were eligible for both Medicare and MassHealth standard CommonHealth.
We will not be auto assigning anyone who is already
in a pace plan or Medicare advantage plan.
We will not be we will be looking at our system to those who have opted out.
In other words, when someone tells us I don't want to be in a plan, we put that in our system
so that our systems knows not to auto assign that person.
What will happen when someone is auto assigned we will send them a notice of that
at least 60 days before their enrollment is effective to say, you know,
there is this new health plan and we have already given you information about it
and here is some more information.
Here is a plan that is available in your geographic area.
We would, you know, we would like to enroll you in this plan.
Your enrollment will be effective in two months.
Let us know if you don't want it.
Let us know if you want to change.
So we expect that auto enrollments will happen in sort of groups over time.
We will not start auto assignments until after we have had a significant amount of time
to fully inform people about the One Care options.
So that they can choose, you know, at will, so they can get have conversations
with those people who can help advise them.
So they will have a lot of time to sort of pick a plan.
After a number of months and we will start to auto assign certain groups of people
and we are our plan right now is to start with folks who our data shows us are some
of the the less complex cases and the folks that have the less complex need.
That's where we will start.
And we will sort of move from there as we get more experienced with the program.
[LANEY BRUNER-CANHOTO] Okay.
Is there one person on the care team
who approves the final care plan before it is operationalized?
[ROBIN CALLAHAN] The care plan is a collaborative process.
The enrollee is the major player.
Their major contact, primary contact person
through the care plan process is their care coordinator.
So once the care plan is developed it will it will involve care team members
across the whole spectrum of care that the person has needs for.
If the person has particularly high behavioral health needs,
I am sure the behavioral health provider will be very prominent
and that might not be the case in someone who doesn't.
There might be more prominence with a long term support coordinator,
for a person who has physical functional needs.
It will really depend on the individualized situation of that member.
The important thing is that and the care coordinator will go about all
of the internal health plan processes necessary to gain approvals
for the services that the care team advises.
So there will be health plan authorization processes.
So specific to health plans.
And you would want to talk to the specific health plans about how they work.
But in a final analysis if the care plan that results from that is should be something
that the member agrees with and understands and there are many, many as we mention
in the presentation avenues for that member if that turns out not to be the case.
[LANEY BRUNER-CANHOTO] Okay.
Thank you.
Can you clarify the difference in roles between the care coordinator and the care manager?
[ROBIN CALLAHAN] Sure.
This is an either/or role.
A person won't have both.
Generally speaking that major touch point for an enrollee with regard
to the plan would be their care coordinator.
However we are going to find that there is a fairly significant portion of the population
who will enroll who have very complex medical needs.
And what we expect is that those folks once they have been identified
as having those needs will instead of having a care coordinator will have a clinical
case manager.
This is a person with specific clinical expertise that might be that is more specific
around being able to coordinate medical services than a more generic type of care coordinator.
If a person has a clinical care manager, they will not also have a care coordinator.
That person will serve as their care coordinator.
So I hope that distinction is clear.
[LANEY BRUNER-CANHOTO] Okay.
Great. Thank you.
Someone is asking for a clarification.
Individuals can use their non-contracted providers for 90 days.
Is that does that mean that they must be able to use them for 90 days even
if a care plan has been developed prior to the 90 day period?
[ROBIN CALLAHAN] Well, what we said is that if a care plan is developed prior to the 90 days only
if the member fully agrees to that can the health plan and the continuity of the fee
for service providers that they had coming in.
Otherwise if there is any question about that, if there is a challenge to it,
if the health plan hasn't gotten around to finishing it,
the 90 days is guaranteed to the member.
It would have to be with the full consent of the member to have anything short of that.
[LANEY BRUNER-CANHOTO] Okay.
And I think we have time for just one more question but please feel free
to e mail your question keep on entering your questions and we will be able to use
that information for future trainings.
Will the initial mailing to the dually eligible have clear markings or alerts on the envelope
so that beneficiaries will easily recognize this?
[ROBIN CALLAHAN] Yes, that's a very good point and we have heard that a lot.
Plus we are going to do a lot of mailings and we have we will be doing very specific markings
and making sure that the general community knows what they look like so
that they can help our members know this is a very important piece
of information is coming their way.
[LANEY BRUNER-CANHOTO] Great.
Thank you so much, Robin.
And as Robin mentioned throughout the webinar there will be a lot of opportunities
for more training and more information in the months to come.
These will include live and recorded webinars, online modules and face
to face learning sessions throughout the state.
So please stay tuned.
To formally complete this webinar and receive a certificate of completion go
to the link that's on your screen.
You can either click directly from the webinar or copy and paste the link in to your browser.
And we hope you take the time to give us some feedback on this first webinar as well.
Thank you so much, Robin, and thank you to everyone on the computer
for your participation in this webinar.
Have a great day.