Bureau of TennCare 2009

1. Bureau of TennCare 2009 TennCare is Tennessee’s Managed-Care Medicaid Program serving approximately 1.2 million culturally and racially diversified low-income children, pregnant women and disabled Tennesseans, with an annual budget of $7.6 billion.

2. TennCare Enrollment Health Care Cultural Competency MCC Change Schedule Fraud & Abuse Long Term Care Community CHOICES Act of 2008 Provider Reminders Topics:

3. TennCare Enrollment(As of 09/01/09) Total Enrollment - 1,143,376 392,999 – East Tennessee 8,668 – Nursing Facility 2,020 – HCBS 358,368 – Middle Tennessee 7,426 – Nursing Facility 1,427 – HCBS 331,415 – West Tennessee 6,240 – Nursing Facility 1,200 - HCBS 60,594 – TennCare Select 166 – Nursing Facility

4. MCO Enrollment Numbers(As of 09/01/09) East Tennessee AmeriChoice 161,255 BlueCare 231,744 Middle Tennessee AmeriChoice 179,320 AmeriGroup 179,048 West Tennessee AmeriChoice 150,786 BlueCare 180,629 TennCare Select 60,594 Total Enrollment 1,143,376

5. Cultural Competency in TennCare • 59.1% White • 30.7% Black • 4.6% Hispanic • 5.6% Other • Considerations • Cultural perspectives • Gender • Religious or moral preferences • Limited English Proficiency

6. MCC Change Schedule Starting next year (2010), members will be allowed to change their health plan during one month of the year. March 2010 West TN Grand Region May 2010 Middle TN Grand Region July 2010 East TN Grand Region

7. REPORTING FRAUD & ABUSE Office of Inspector General 1-800-433-3982 FAX: 615-256-3852 http://www.tn.gov/tnoig/ Tips can be anonymous Cash for Tips Policyhttp://www.tn.gov/tnoig/Documents/IncentiveProgram_OIG.pdf • Tip cannot be anonymous • Can claim cash reward if your tip leads to prosecution • Details of how program works available at the link above • Posters available at TennCare help desk

8. Office of Inspector General Statistics

9. Office of Inspector General Statistics

10. Long-Term Care Services “Carved Out” of Managed Care Long-Term Care (LTC) Services have traditionally been carved out of managed care Nursing Facilities (NFs) Intermediate Care Facilities for persons with Mental Retardation (ICFs-MR) Home and Community-Based Services (HCBS) waivers

11. The Long-Term Care Community Choices Act of 2008 Passed unanimously by the Tennessee General Assembly Fundamentally restructures the Medicaid long-term care system for the elderly and adults with physical disabilities in Tennessee

12. Why restructure the long-term care system?

13. Fragmentation Access to LTC services scattered across different points of entry with no coordination Nursing Facility Services Home and Community Based Waiver Services Home Health and Private Duty Nursing Difficult for individuals and families to navigate Fragmented quality strategy, with regulatory focus for Nursing Facility services

14. Limited Options Heavy reliance on Nursing Facilities (NF); home and community options extremely limited Only one community-based residential alternative to NF care – Assisted Living Facility Few choices or decision-making opportunity Few services aimed at preventing or delaying need for more costly care

15. Inefficient Use of Limited Resources 98% of LTC spending for Nursing Facility services Heavily dependent on most costly services (NF/HH/PDN) even when lower-cost alternatives would better meet needs/desires of individuals and families Supplants, rather than supports, existing natural support networks of family and other caregivers Payment systems do not reward efficiency/not based on level of need of persons receiving care New recurring dollars extremely limited

16. How will CHOICES change the current LTC system?

17. Reorganize the LTC system Simplified access (Single Entry Point) Streamlined (expedited) enrollment Comprehensive care coordination across acute/LTC services Integration of LTC services within existing TennCare managed care delivery system Continuous quality improvement strategy across acute/LTC continuum

18. Refocus LTC services Increased use of HCBS Self-directed care—ability to hire non-traditional providers such as family and friends to provide in-home care More community-based residential alternatives to Nursing Facility care

19. Rebalance LTC funding Single LTC funding stream (global budget) Money follows the person into the appropriate, cost-effective setting of their choice Serve more people with existing LTC funds More equitable balance of Nursing Facility/HCBS expenditures over time

20. How will CHOICES impact persons who need LTC?

21. Single Point of Entry One access point for new Medicaid applicants seeking access to LTC services – HCBS and Nursing Facility Public Education and Outreach Information and Referral Screening and Assessment Facilitate eligibility and enrollment Area Agencies on Aging and Disability (AAADs)

22. TENNESSEE AREA AGENCIES ON AGING & DISABILITY 1 4 2 5 7 6 8 3 9

23. Member Choice Members eligible for LTC choose between NF and HCBS (even if HCBS would be more cost-effective) Members in HCBS must be able to have needs safely met in the community at a cost that does not exceed NF care Members will be able to choose their Nursing Facility provider Contracted with the MCO Able to admit the member Able to provide the needed services

24. Current LTC Services Covered under CHOICES Nursing Facility Care Same HCBS Services Available Adult Day Care - Assisted Care Living Facility Assistive Technology - Attendant Care Home Delivered Meals - Homemaker Services Personal Care - PERS Pest Control - Minor Home Modifications Respite Care (In-Home, In-Patient)

25. Current LTC Services Covered under CHOICES Individual Service Limits (HCBS) Individual Cost Neutrality Cap - Combined cost of all services in home or community setting cannot exceed average cost of NF care Includes all HCBS Includes HH/PDN

26. Additional Benefits Covered Under CHOICES New Community Based Residential Alternatives Critical Adult Care Homes 24-hour residential care in a homelike environment to no more than 5 elderly or disabled adults Level II – Specialized and/or Skilled Services for Ventilator Care and Traumatic Brain Injury Continuum Model – Allows members to age in place Rules expected to be promulgated by January 2010 Companion Care Live-in caregiver hired and supervised by the member (consumer direction)

27. Consumer Directed Options Under CHOICES Consumer Direction Allows consumers to select, direct, and employ their own caregivers Personal Care Attendant Care Homemaker In-Home Respite Companion Care Self Direction of Health Care Tasks Allows members to direct and supervise a paid personal aide in the performance of health care tasks Initially limited to administration of oral, topical, and inhaled medications Limited to consumer directed workers

28. Care Coordination in CHOICES Comprehensive, continuous, holistic, and person-centered approach to care coordination Help the member maintain or improve physical or behavioral health status or functional abilities Maximize member independence Ensure the member’s health, safety and welfare Delay or prevent the need for institutional placement Integrated model of coordination of care –medical as well as social Addresses physical, behavioral, functional (ADL) and psychosocial needs Coordinates ALL Medicaid services for the elderly and disabled – physical, behavioral and long term care

29. Care Coordination for Nursing Facility Residents Leverage existing NF Plan of Care May supplement NF plan of care with additional targeted strategies related to improving health, functional, or quality of life outcomes or to increase and/or maintain functional abilities Focus on better management of chronic conditions and coordination of services outside the scope of the NF benefit Assess member potential and interest for transition to community (based on member choice) Care Coordination Contact Requirements Quarterly grand rounds Semi-annual member face-to-face contact

30. Electronic Visit Verification (EVV) EVV System Required for CHOICES Track the provision of services Facilitate timely payment Increased ability to detect and resolve problems Service gaps Delays in service delivery Log-in/Log-out by phone

31. What happens when CHOICES is implemented? Members receiving NF care will continue to qualify for and receive NF care Members will be able to stay in the NF where they currently reside, so long as the NF meets CMS conditions of participation Members are transitioned into CHOICES LTC Services are provided via CHOICES LTC Services are NO LONGER provided via the current fee-for-service system Payment will come from the MCOs

32. What if Nursing Facilities don’t want to contract with an MCO? Nursing Facilities are NOT obligated to contract with each MCO BUT…………… Existing Medicaid fee-for-service system will no longer exist once CHOICES is implemented Non-contracted facilities will be reimbursed by MCO for services provided to existing Medicaid/LTC members – but at a lower payment rate than if contracted with the MCO 80% of the lowest rate paid by the MCO to participating network providers for the same service (as set forth in TennCare Rule) MCOs will seek to admit all new residents to contracted facilities

33. Authorization of NF Services Immediate authorization of Nursing Facility services for CHOICES members In accordance with level of nursing facility services approved by TennCare, i.e., TennCare level of care (reimbursement) decision drives prior authorization of NF services MCO cannot authorize a lesser level or duration of services than approved by TennCare MCOs will conduct concurrent review of Level II services and may initiate a request to TennCare to reduce when appropriate

34. NF Role in Level of Care Eligibility NFs may continue to complete and submit PAEs to TennCare (also hospitals, SPOEs, MCOs) Level I Nursing Facility Care Level II Skilled Nursing Facility (SNF) Care TennCare will continue to determine level of care (reimbursement)

35. When will CHOICESbe implemented?

36. CHOICES Approval Timeline May 30, 2008 – LTC CCA passed by General Assembly July 11, 2008 – CHOICES Concept Paper submitted to CMS October 2, 2008 – 1115 Waiver Amendment submitted to CMS June 26, 2009 – Finalized MCO CRA amendment July 22, 2009 – CMS Terms and Conditions for Approval of 1115 Waiver Amendment August 2009 – Formal execution of CMS approval for CHOICES

37. CHOICES Implementation Phased Implementation Middle Region – March 1, 2010 East and West Regions to follow – likely first of FY 2011 (July 1, 2010)

38. Medical Necessity State law establishes five components (prongs) of medically necessity and the service must satisfy all five components before TennCare will pay for the service. The five components are: • It must be recommended by a health care provider • It must be required to diagnose or treat the medical condition • It must be safe and effective • It must not be experimental or investigational • It must be the least costly alternative course of diagnosis or treatment that is adequate for the enrollee’s medical condition

39. Provider Inquiries 1. Contact “Provider Services” at the MCC 2. Contact your assigned MCC Provider Representative 3. Escalate the complaint to a MCC Managerin the Provider Relations Department

40. Provider Inquiries 4. TennCare Provider Service Department by phoning 1-800-852-2683, and telling them you need to file a MCC provider complaint-Goal of MCC provider complaint system -Considered “On Request Report”

41. Provider Inquiries • Official Provider Complaint Process orIndependent Review Process through Tennessee Department of Commerce & Insurance at http://tn.gov/commerce/tenncare/PCIR.shtml

42. The Bureau of TennCare will NOT accept nor act on requests from providers for reimbursement of claims that would have otherwise been the responsibility of the former MCC Partners Independent Review Process outlined in T.C.A. 56-32-126 is no longer available All Independent Review Requests sent to the TN Dept. of Commerce & Insurance (TDCI) will be processed as an official Provider Complaint as long as the company has an active license on file with TDCI Former MCC Partners Claims

43. There are 2 ways to verify eligibility directly with the Bureau of TennCare: Call TennCare Provider Services at 800-852-2683 Use the Tennessee Anytime online internet website portal TennCare Eligibility Verification

47. How is someone retro eligible for TennCare? Most common scenario is someone who gets approved for SSI In TN, when approved for SSI Disability you are automatically approved for TennCare Retro Eligibility

48. Formerly known as “State Only” or “Judicial” Members Effective 1/1/2009 are handled directly by TDMHDD (Tennessee Department of Mental Health & Developmental Disabilities) Do not have TennCare benefits Member may be viewable on Tennessee Anytime’s website due to past coverage but will state Not Eligible for TennCare & No MCO on record and No BHO on record Mental Health Only Coverage

49. Eligibility verification and claims are handled by TDMHDD For additional information: https://mhddapps.state.tn.us/Uninsured/(S(mpzslwnjmlcjzy45tsupjczm))/Default.aspx Mental Health Only Coverage (continued)

50. TPL Policy January 1, 2010, an updated TPL policy will become effective.