Medicaid and Managed Care Benefits Sara George RN BSN MSN CCM Health Services Manager Kelly Velazquez, United Relationship Specialist
Objectives • Medicaid overview • Fee for Service and Managed Care • United Healthcare: Who we are and what we do for you • Care Coordination Services • United Healthcare Community Collaborations • Managed Care Choices • Q&A
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Ohio Medicaid: Who is Covered •
Income Based Program •
Pregnant Women
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Children
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Parents
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Childless adults
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Individuals with disabilities
Aspe.hhs.gov/poverty-guidelines 3 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Qualifying for Medicaid •
US Citizen or meet Medicaid non-citizen requirements
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Must have a Social Security Number
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Ohio resident
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Meet financial and resource requirements (vary based on age, disability, family status)
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Introduction • Ohio Medicaid- State & Federally funded •Ohio’s largest health payer •Covering over 3 million Medicaid Beneficiaries, or 26% of Ohio’s population. (HPIO, 2017) •2.5 Million are served by 5 contracted Medicaid Managed Care Plans (MCP) •Program cost over $25.5B in 2016 (HPIO, 2017)
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Medicaid Benefits – Fee for Service • Primary care • Preventative services • Specialty care for chronic conditions • Emergency services • Required to contract with any willing provider
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Fee For Service Medicaid • Acute health care services • Doctor visits • Inpatient/Outpatient hospital services • Skilled nursing and long-term care • Labs and radiologic diagnostics • Prescriptions • Durable Medical Equipment (DME) • Home Health • Vision • Dental 7 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Managed Care Plans • Privately operated health insurance companies •
Reimbursed by state for a set PMPM capitation regardless of costs incurred to cover members
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Covers all medically necessary Medicaid covered services
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Contract with providers to deliver services
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Panel of providers vetted by insurance company
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Guarantee access to care if network gap occurs
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May also offer enhanced benefits
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Managed Care Plans •
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Reimbursement structure intended to •
Reduce Costs
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Improve quality
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Improve coordination of care
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Improve continuity of care
Methods •
7 Pay for Performance quality (HEDIS) measures
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Minimum performance standards
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Provider episode-based payment models (Value based payments)
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Managed Care Plans •
Targeted improvement efforts align with ODM priorities •
Preventative Care
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Control of chronic conditions
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Variety of approaches proven to promote health and wellbeing
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Provide Transition of Care (TOC) services
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Managed Care Plans •
Servicing special populations •
Foster care / Adoptive families
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BCMH – Bureau for Children with Medical Handicaps
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BCCM- Breast and cervical cancer
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Developmentally / Intellectually Delayed individuals (DD/ID)
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Adult Extension Waiver
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QIT/Miller Trust
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1915i SRSP (Specialized Recovery Services)
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Managed Care Plans: Additional Benefits •
Expanded care and provider network access
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Participation incentives
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Health and wellness programs
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Care Management / Care Coordination
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Dedicated points of contact •
Toll-free Member Services call centers
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24/7 Nurse Advice Line
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Assistance with health advice, transportation, securing providers
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Managed Care Plans in Ohio • Buckeye Health Plan • CareSource • Molina Healthcare • Paramount Advantage • United Healthcare Community Plan • Aetna (MyCare only)
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United Healthcare Community Plan UnitedHealthcare Community Plan is part of the United Healthgroup family. We have been providing benefits and support to our members for more than 30 years in communities across the United States.
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Also partnering with the State of Ohio and Centers for Medicaid Services on:
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What We Do
Our mission is to help people live healthier lives. We work with you and your family to give you the care you deserve.
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Benefits & Services For You
Dental
Care Management and Member Services
Vision
Prescriptions and Over the Counter Medications
24/7 NurseLine
Doctors/Primary Care Providers, Hospitals, Urgent Care
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Transportation Other Services & Benefits: • My Advocate • Healthify • Health and Wellness programs and information • Community Events
Transportation Benefits
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If you must travel 30 miles or more from your home to receive medically necessary covered health care services, we will provide transportation to and from the provider’s office.
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The benefit is 30 one-way or 15 round trips per year for medically necessary health appointments and for Medicaid redetermination at your local Job and Family Services Office.
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Please contact Member Services at least 48 hours in advance of appointment to schedule your transportation.
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Members Matter Welcome Call
Care Management Services •
Care coordination activities mandated by ODM with ODM, NCQA, & HSAG oversight
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Stratification methods used to target high-risk populations for intensive services
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Intensive orientation with continuing education to keep up with evolving change and needs of the specific populations
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Specialize in linkage with valuable community resources to reduce barriers to care
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Care Management Services •
Field-based RN, Social Worker, and Community Health Workers • Conduct in-person and telephonic member assessments based on physical, psychosocial, spiritual, environmental, and cognitive domains • Collaborate with multidisciplinary providers to develop care plans / service plans • Integrate medical and behavioral health needs • Priority is to ensure member safety and access to care • Facilitate Prior Authorizations and locate services
• Access to Care Management: Contact Member Services 20 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Help for Moms and Babies Healthy First Steps Program: A personal Nurse Care Manager is assigned to assist with: • Finding a doctor for you and your baby. • Coordinate prenatal appointments • Assist with enrollment in nutrition, weight and wellness programs • Finding local resources for items like: • Food supplements • Baby items • Prenatal classes • Support programs Text4baby provides important health and safety tips timed to your baby’s age up until baby’s first birthday. Enroll at: UHCCommunityPlan.com/OH/text4babies. 21 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Rewards for Moms and Babies Baby Blocks Rewards program for pregnant women and new moms. • Earn gift cards, toys, and gear for your baby just by going to your prenatal visits. • Register for the program on your smartphone or computer. • Check in via smartphone or computer after each prenatal visit to earn your rewards.
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myuhc.com • •
• • • • •
Member benefit information Pharmacy and provider searches for medical, vision, dental, behavioral, and ancillary services Access to Member Handbook Print Member ID cards Take a Health Assessment Get valuable health and wellness information Ask a Question
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Benefits Unique to United Healthcare Community Plan • Healthy First Steps • Baby Blocks • Covered Over the Counter Medications • Housing assistance • Employment assistance • On My Way (foster care)
• • • • • •
Health4Me ExactCare Pharmacy Expanded Dental Services Members Matters Member Advisory Council Member Community Days
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United Healthcare Community Plan
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United Healthcare Community Plan
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United Healthcare Community Plan
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Benefits Unique to United Healthcare Community Plan •
Linkage to Community Resources • Healthify • My Advocate • NET (Non Emergency Transport) • 211 • Furniture Bank (Mid-Ohio, Cleveland) • Help Me Grow • Ohio Benefit Bank
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Links to Community Supports and Resources Includes live Advocate support at 1-855-759-5342 and online at www.myadvocatehelps.com.
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United Healthcare Community Plan: Special Relationships Celebrate One Moms2B Community Action Agencies Area Agencies on Aging Federally Qualified Health Centers (FQHCs) Comprehensive Primary Care (CPCs) Nationwide Children’s / Partners for Kids Community Computers Program Community Grants Program
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United Healthcare Community Plan
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Enrolling in Managed Care & Selecting a Plan
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Medicaid Hotline (800)324-8680
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Online MCP provider search at https://www.ohiomh.com/
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Ohio Managed Care Choices
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References Health Policy Institute of Ohio (2017, April 11). Ohio Medicaid Basics 2017. Retrieved from http:// www.healthpolicyohio.org/wp-content/uploads/2017/04/MedicaidBasics_2 017_Web_04112017.pdf Office of the Assistant Secretary for Planning and Evaluation, n.d. U.S. Federal Poverty Guidelines Used to Determine Eligibility for Certain Federal Programs. Retrieved from https://aspe.hhs.gov/poverty-guidelines Ohio Department of Medicaid http://medicaid.ohio.gov/ Ohio Medicaid Consumer Hotline https://www.ohiomh.com/ United Healthcare Community Plan http://www.uhccommunityplan.com
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