Download to read offline
Uploaded byPam Perry
Mi Health Link / MMAP
The MI Health Link program integrates Medicare and Medicaid benefits into a coordinated delivery system for eligible individuals in specific regions of Michigan. It offers various health services without co-payments or deductibles, emphasizing person-centered care and support. Enrollment begins in early 2015, with advisory committees and protections established for enrollees to ensure continuity of care and access to necessary services.
More Related Content
Similar to Mi Health Link / MMAP
Mi Health Link / MMAP
- 1.
- 2. Today’s Agenda • MIHealth Link Overview • Eligibility Criteria • Benefits of MI Health Link • Covered Services • Enrollee Protections • What to Consider • Enrollment and Beyond
- 3. MI Health Link ProgramOverview 3
- 4. MI Health Link Anew program that joins Medicare and Medicaid benefits, rules and payments into one coordinated delivery system called MI Health Link 4
- 5. MI Health Link •Three year program beginning no earlier than March 1, 2015 • Three-way contract between Center for Medicare and Medicaid Services (CMS), Michigan Department of Community Health (MDCH) and MI Health Link health plan – The health plan contracts with Pre-paid Inpatient Health Plan (PIHP) to deliver behavioral health services • Provided in four regions in the state
- 6. Four Regions • Region1 - Entire Upper Peninsula • Region 4 - Southwest Michigan (Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph and Van Buren counties) • Region 7 - Wayne County • Region 9 - Macomb County 6
- 7. Region 1 –Upper Peninsula 7 • MI Health Link health plan – Upper Peninsula Health Plan • Pre-Paid Inpatient Health Plan – NorthCare Network
- 8. Region 4 –Southwest Michigan 8 • MI Health Link health plan options – Aetna Better Health of Michigan – Meridian Health Plan • Pre-Paid Inpatient Health Plan – Southwest Michigan Behavioral Health
- 9. Region 7 –Wayne County 9 • MI Health Link health plan options – Aetna Better Health of Michigan – AmeriHealth – Fidelis SecureCare – HAP Midwest Health Plan – Molina Healthcare • Pre-Paid Inpatient Health Plan – Detroit-Wayne Mental Health Authority
- 10. Region 9 -Macomb County 10 • MI Health Link health plan options – Aetna Better Health of Michigan – AmeriHealth – Fidelis SecureCare – HAP Midwest Health Plan – Molina Healthcare • Pre-Paid Inpatient Health Plan – Macomb PIHP
- 11.
- 12. Eligibility Criteria People maybe eligible for MI Health Link if they: • Live in one of the four regions • Are age 21 or over (CSHCS exluded) • Are eligible for full benefits under both Medicare and Medicaid and • Are not enrolled in hospice 12
- 13. Eligibility Criteria • Peopleenrolled in PACE and MI Choice are eligible, but must leave their programs before joining MI Health Link • People with a deductible are not eligible for MI Health Link • People in a nursing home are eligible and must continue to pay their patient pay amount to the nursing home 13
- 14. Benefits of JoiningMI Health Link 14
- 15. Benefits of MIHealth Link • No co-payments or deductibles for in- network services, including medications – Note that nursing home Patient Pay Amounts will still apply • One health plan to manage all Medicare and Medicaid covered services • One card to access all services 15
- 16. Benefits of MIHealth Link • Person-centered care with a focus on supports for community living, not just doctor-driven medicine • Access to a 24/7 Nurse Advice Line to answer questions 16
- 17. Benefits of MIHealth Link • Each enrollee will have a care coordinator who will –work with the enrollee to create a personal care plan based on the enrollee’s goals –answer questions and make sure that the enrollee’s health care issues get the attention they deserve –connect the enrollee to supports and services needed to be healthy and live where they want 17
- 18. Benefits of MIHealth Link • Each enrollee will have access to an Integrated Care Team that will –include the enrollee’s doctors, providers, and anyone else the enrollee would like to include –work with the enrollee to identify their goals and preferences for care and services 18
- 19.
- 20. Covered Services • Allhealth care covered by Medicare and Medicaid –Medications –Dental and vision services –Equipment and medical supplies –Physicians and specialists –Emergency and urgent care 20
- 21. Covered Services • Allhealth care covered by Medicare and Medicaid (cont.) –Hospital stays and surgeries –Diagnostic testing and lab services –Nursing home services –Home health services –Transportation for medical emergencies and medical appointments 21
- 22. Covered Services • LongTerm Supports and Services (LTSS) –Personal care –Equipment to help with activities of daily living –Chore services –Home modifications –Adult day program –Private duty nursing 22
- 23. Covered Services • LongTerm Supports and Services (LTSS) (cont.) –Preventive nursing services –Respite –Home delivered meals –Community transition services –Fiscal intermediary services –Personal emergency response system –Nursing home care 23
- 24. Covered Services • BehavioralHealth Services –Behavioral health services are those that are provided to individuals who have a mental illness, intellectual/developmental disability or substance use disorder. 24
- 25. Covered Services • BehavioralHealth Services (cont.) –Behavioral Health services are accessed through the Health plan, PIHP or local Community Mental Health Service Provider (CMHSP) –If currently receiving services through the CMHSP, services will not change or be interrupted 25
- 26. Covered Services Behavioral healthservices are medically necessary services. Examples of behavioral health services may include: –Individual, group and/or family therapy –Medication review –Supported employment –Community living supports (meal preparation, laundry, chores, food shopping) –Substance abuse treatment services (assessment, treatment planning, stage-based interventions, referral and placement) 26
- 27. Covered Services • Additionalservices offered by the plan –Health plans can offer services not covered by Medicare and Medicaid –Plans can enhance Medicaid and Medicare services • May cover supplies or services more often • May cover a higher dollar amount when there is a dollar limit on a service –Check Plan finder for enhanced services 27
- 28.
- 29. Enrollee Protections • MIHealth Link follows the current grievance and appeal processes for Medicare and Medicaid services • Enrollees will be offered appropriate appeals rights and directed through the notice letters which entity they should contact if they wish to appeal an action 30
- 30. Enrollee Protections • AMI Health Link Ombudsman Program will be available to help enrollees resolve problems and answer questions • Health plans must offer a choice of providers and care coordinators • Health plans must honor the continuity of care requirements 31
- 31. Enrollee Protections • EachMI Health Link health plan is required to have a separate Advisory Council specific to the program –1/3 of the Advisory Council must be enrollees –The majority of members must be enrollees, family members of enrollees and advocates 32
- 32. Enrollee Protections • TheState will form a MI Health Link Advisory Committee for enrollees, allies, and advocates to give input and suggestions to help improve MI Health Link – Organized by MDCH – Provides a way for enrollees and stakeholders to offer suggestions and feedback – Membership will represent the diverse interests of stakeholders, especially enrollees 33
- 33. Enrollee Protections • Applicationforms for the MDCH Advisory Committee can be found here: http://www.Michigan.gov/MIHealthLink – Call 517-241-4293 if you need the form mailed to you • A completed application form is required for consideration; a letter of reference is optional • Completed applications can be sent to MDCH by email, fax or regular mail – Email: IntegratedCare@michigan.gov 34
- 34. Enrollee Protections Continuity ofCare The health plan must • Allow enrollees to continue to see current doctors and providers during the transition period • Pay out-of-network doctors and providers during the transition period at no cost to the enrollee • Allow choice of personal care service providers including paying family members or friends to provide the service • Work to bring providers into the health plan’s network • Cover current medications 35
- 35. The health planmust • Honor current authorizations for services – These could be reported to the plan by the enrollee – Personal Care authorization information is provided to the plan by MDCH 36 Enrollee Protections Continuity of Care
- 36. • Those whowant to join MI Health Link and are already in nursing homes are not required to move to a different nursing home in the health plan’s network • The health plan must enter into single-case agreements for enrollees currently residing in out-of-network nursing homes 37 Enrollee Protections Continuity of Care
- 37. • Enrollees havethe right to live in an out-of- network nursing home for the life of the program if the enrollee: – Resides in the nursing home at the time of enrollment; – Has a family member or spouse that resides in the nursing home; or – Requires nursing home care and resides in a retirement community that includes a nursing home. 38 Enrollee Protections Continuity of Care
- 38. • Timeframes – ScheduledSurgeries • The health plan must honor specified provider and prior authorizations for surgeries scheduled within one hundred eighty (180) calendar days of enrollment – Dialysis • The health plan must maintain current level of service and same provider at the time of enrollment for one hundred eighty (180) calendar days 39 Enrollee Protections Continuity of Care
- 39. • Timeframes – Chemotherapyand Radiation • Treatment initiated prior to enrollment must be authorized by the plan through the course of treatment with the specified provider – Organ, Bone Marrow, Hematopoietic Stem Cell Transplant • The health plan must honor specified provider, prior authorizations and plans of care 40 Enrollee Protections Continuity of Care
- 40. • Timeframes –Durable MedicalEquipment • The plan must honor prior authorizations when the item has not been delivered and must review ongoing prior authorizations for medical necessity –Dental and Vision • The health plan must honor prior authorization when an item has not been delivered 41 Enrollee Protections Continuity of Care
- 41. • Timeframes –Home Health,Personal Care and Physician/Practitioners • For people receiving services from the PIHP specialty services and supports program or HAB supports waiver, the health plan must maintain current provider and level of services at the time of enrollment for one hundred eighty (180) calendar days 42 Enrollee Protections Continuity of Care
- 42. • Timeframes –Home Health,Personal Care and Physician/Practitioners • For all other enrollees, the health plan must maintain current provider and level of services at the time of enrollment for ninety (90) calendar days 43 Enrollee Protections Continuity of Care
- 43. • Timeframes – MIChoice (HCBS) Waiver services • For enrollees previously participating in the MI Choice HCBS waiver, the health plan must maintain the providers and level of services at the time of Enrollment for ninety (90) calendar days 44 Enrollee Protections Continuity of Care
- 44. What to considerwhen joining MI Health Link 45
- 45. What to Consider •Do current doctors and other providers participate in the MI Health Link plan? • If not, would the provider consider joining the MI Health Link plan? • Are current medications covered by the MI Health Link plan? • Each plan offers its own list of covered medications
- 46. What to Consider •Participants of PACE or MI Choice have to leave that program to join MI Health Link –People may have to wait for an opening if they choose to return to MI Choice 47
- 47. What to Consider •MI Choice services are different than the MI Health Link waiver services – Private duty nursing (maximum hours vary) – Personal care (eligibility differences) – Personal emergency response system (eligibility differences) • These are important considerations if you are in an expanded eligibility category and do not need waiver services under MI Health Link 48
- 48. What to Consider •For MI Choice participants living in an adult foster care home or a home for aged –this setting may not be approved under the new rules for the MI Health Link waiver –discuss this issue with your current MI Choice supports coordinator 49
- 49. What to Consider- PACE • PACE integrates all Medicare and Medicaid services - Services are primarily provided in the PACE Center - Participants must use the PACE primary care physicians in the PACE centers and other providers like hospitals that are contracted with the PACE organization - PACE provides social interaction for in the PACE Center for its participants 50
- 50. What to Consider– Home Help • Personal care services in MI Health Link will be provided through the health plans and not DHS • MI Health Link enrollees can have the same providers they had in Home Help • The same plan of care (time and task) will be provided until a new assessment is performed 51
- 51. What to Consider •People with employer or union sponsored insurance plans who join MI Health Link may not be able to return to those insurance plans – check with your retiree benefits management system/human resources • letters sent to potential enrollees will warn those in employer or union sponsored plans not to enroll unless they meet with retiree benefits manager and are prepared to lose plan 52
- 52. What to Consider •Most people eligible for both Medicare and Medicaid who are enrolled in a Medicaid managed care plan and opt-out of MI Health Link will receive Medicaid services through original Medicaid • Only people with Medicare employer or union sponsored health plans may continue to receive Medicaid services through a Medicaid managed care plan if they don’t participate in MI Health Link 53
- 53.
- 54. Enrollment Periods UP andSouthwest Michigan • Opt-in enrollment – People can enroll no earlier than February 1, 2015 – Services start no earlier than March 1, 2015 • Passive enrollment of eligible individuals if they do not opt-out – People will receive notices 60 days and 30 days before they are passively enrolled – Services start no earlier than May 1, 2015 55
- 55. Enrollment Periods Wayne andMacomb counties • Opt-in enrollment – People can enroll no earlier than April 1, 2015 – Services start no earlier than May 1, 2015 • Passive enrollment of eligible individuals if they do not opt-out – People will receive notices 60 days and 30 days before they are passively enrolled – Services start no earlier than July 1, 2015
- 56. Enrollment People eligible forMI Health Link will receive a letter explaining: • How to enroll in a MI Health Link plan • Whom to contact for help • How to opt-out if they don’t want to be part of MI Health Link 57
- 57. Enrollment • People maychange plans or opt out at any time • If people opt-out, the state may not automatically enroll them into a plan –These people are still eligible to enroll if they wish 58
- 58. What Happens AfterEnrollment? 59
- 59. What Happens afterEnrollment? • Enrollees receive a member packet from the health plan including –A new MI Health Link card –Provider directory –Summary of benefits –Member handbook 60
- 60. What Happens afterEnrollment? • Enrollees will receive an initial screening • Enrollees will receive a Level I Assessment • If needed, enrollees will also receive a Level II Assessment • Each enrollee will help develop his or her own Individual Integrated Care and Supports Plan (IICSP) 61
- 61.
- 62. Initial Screening • Nine“yes” or “no” questions to –Identify current services –Identify immediate or unmet needs • People calling to enroll will be asked these simple questions during the call • For people choosing not to answer on the phone, the plan will work with the person to complete the questions 63
- 63. Level I Assessment •A broad assessment used to identify and evaluate current health and functional needs • Completed within 45 days of enrollment start date • Serves as the basis for further assessment 64
- 64. Level II Assessment •Completed within 15 days of the Level I Assessment for people identified with – Behavioral Health needs – Intellectual developmental disabilities (I/DD) needs – Long term supports and services (LTSS) needs • Health plans will collaborate with PIHPs and LTSS agencies • Additional supports and services will be coordinated to meet the needs identified 65
- 65. Level II Assessment Forpeople needing nursing home or waiver services • The Nursing Facility Level of Care Determination tool will be completed to determine if the enrollee meets the requirements for these services • The health plan will coordinate with long term supports and services providers to meet the enrollee’s needs 66
- 66. Level II Assessment Forpeople identified with a behavioral health need • the health plan will make a referral to the PIHP • the PIHP will complete a telephonic screen to determine mental health service need and referral to a provider. 67
- 67. Individual Integrated Careand Supports Plan (IICSP) 68
- 68. Individual Integrated Careand Supports Plan (IICSP) • Each enrollee will help develop their own care and supports plan with his care coordinator and will choose the people to participate in the process – Selected family, friends and providers – Invited integrated care team members 69
- 69. Individual Integrated Careand Supports Plan (IICSP) • Follows a person-centered planning process • Is completed within 90 days of enrollment start date • Is the single plan that coordinates care for all services and providers and includes the PIHP and LTSS service plans 70
- 70. Individual Integrated Careand Supports Plan (IICSP) • Contains plan for addressing concerns and goals, as well as measures for achieving them • Identifies specific providers, supports and services including amount, scope and duration • Lists the person responsible and time lines for specific interventions, monitoring and reassessment 71
- 71. Individual Integrated Careand Supports Plan (IICSP) The IICSP contains • Enrollee’s preferences for care, support and services • Enrollee’s prioritized list of concerns, goals, objectives and strengths • Screening and assessment results 72
- 72. Ongoing Coordination Care coordinatorswill maintain ongoing relationships with enrollees to assure • assessments and care plans are revisited and updated periodically • questions and concerns are answered and addressed • health issues get the attention they deserve • the enrollee is satisfied with MI Health Link 73
- 73.
- 74. Reporting requirements 75 These 9Special Use Fields to be used by states approved for data collection for Integrated Care in NPR ShipTalk.
- 75. Reporting Requirements What isthe source of this referral into the Duals Program? (Select One): 1. Referred from State Medicaid Office 2. Referred from Enrollment Broker (Michigan ENROLLS) 3. Referred from 1-800-MEDICARE 4. Referred from CMS Federal Coordinated Health Care Office (FCHCO) 5. Referred from the Appeals Process 6. Self referred 7. Other 76
- 76. Reporting Requirements Was enrollmentbroker a topic discussed or service provided? Y = Yes N = No 77
- 77. Reporting Requirements Was letterreceived from State Medicaid Office a topic discussed or service provided? Y = Yes N = No 78
- 78. Reporting Requirements Was managedcare options a topic discussed or service provided? Y = Yes N = No 79
- 79. Reporting Requirements Was enrollmentassistance a topic discussed or service provided? Y = Yes N = No 80
- 80. Reporting Requirements Was otherMedicare issues a topic discussed or service provided? Y = Yes N = No 81
- 81. Reporting Requirements Was givenpublications and other materials a topic discussed or service provided? Y = Yes N = No 82
- 82. Reporting Requirements Was theduals client referred out and if so, to where? 1. Referred to State Medicaid Office 2. Referred to enrollment broker 3. Referred to 1-800-MEDICARE 4. Referred to CMS Federal Coordinated Health Care Office (FCHCO) 83
- 83. Reporting Requirements 5. Referredto the appeals process 6. State Ombudsman 7. Not referred out 8. Other 84
- 84. Reporting Requirements Beneficiary Disposition 1.Beneficiary decided to opt out of the duals program 2. Beneficiary enrolled in the program, but enrolled in a different managed care plan instead of the one to which they were assigned 85
- 85. Reporting Requirements 3. Beneficiaryactively enrolled in program and managed care plan of their choice 4. Beneficiary chose to remain enrolled in the program and managed care plan to which they were assigned 5. Beneficiary decision in progress 86
- 86.
Editor's Notes
- #3 Introduction should include Demonstration Goals
- #5 New health plans and current Michigan Pre-paid Inpatient Health Plans (PIHPs) receive payments to provide covered services
- #6 5
- #13 Adults 21 or over enrolled in the Children’s Special Health Care Services program are not eligible for MI Health Link. They should not receive any enrollment notices. People enrolled in Hospice should not receive any enrollment notices as they are also not eligible for MI Health Link.
- #14 NOTE: If people leave PACE or MI Choice to join MI Health Link and would later like to return to PACE or MI Choice, their spot is not guaranteed. If there are no spots available under the MIHealth Link waiver, they will need to go on the waiting list. For those over 100% of FPL, those with full Medicaid, i.e. PACE, Waiver and LTC will protect the Medicaid eligibility.
- #16 NOTE: DO NOT LOSE OR DISCARD RED, WHITE, and BLUE MEDICARE CARD OR GREEN MEDICAID CARD. (In the event eligibility status changes, the beneficiary will still need these other cards to access services.
- #17 Translation services for care coordinator and nurse advise line. HP required to have line for Multilanguage use.
- #21 Dental services include preventive visits to the dentist for cleanings and restorative covered services like fillings. Dentures (full and partial) are also a covered benefit. Each health plan is required to have a choice of dental providers for enrollees. Your care coordinator can help you get access to a dentist if this has been a problem in the past. Plans must cover emergency services when people travel out of state and outside of demonstration regions in the state.
- #22 Transportation for routine medical care as well as dental, vision and mental health; any medical care provider. No limits on the number of medical transportations provided. Non-medical transportation is part of the waiver within MHL adult care program, i.e. religious services, etc.
- #23 Personal Care – hands on assistance with activities of daily living (eating, dressing, bathing, grooming, etc) and IADLs (shopping, cooking, laundry, light housecleaning, etc.) Equipment – shower chairs, grabbers, medication boxes, adaptive eating utensils or weighted bowls, etc. Home modifications – widening doorways, ramps, etc. NOTE: some LTSS services are covered only if individuals meet the necessity requirements, meaning they qualify for the MI Health Link HCBS waiver and are determined to have need for a service via assessment.
- #24 Fiscal intermediary services – for using self-directed care and will be working with care coordinator.
- #25 Medicare mental health benefit will be delivered under PIHP.
- #26 CMHSP = Community Mental Health Services Provider
- #28 Additional Services might be hearing aids, gym memberships, dental partials and OTC supplies.
- #31 In general if it was a Medicaid benefit, they would request the hearing through DCH and if a Medicare benefit, they would request a hearing through Medicare. Process still waiting approval from CMS. Enrollees will be offered appropriate appeals rights and directed through the notice letters the entity they should contact if they wish to appeal an action. If the ICO takes an action they are required to send the action notice and it will tell the individual where they can file appeals. They can also contact the MI Health Link Ombudsman (once it is implemented) if they seek assistance in understanding appeal rights.
- #32 The Ombudsman Program will likely be implemented around the same time as MI Health Link. The Ombudsman toll-free telephone number will be made available to MMAP as soon as the entity is selected and the number is known. Advocacy group and legal aid services my contact the DCH or DHS helpline or contact MMAP.
- #33 Health plans are required to include MI Health Link enrollees on their advisory councils to give program feedback to the plan
- #34 Grant funding to support transportation
- #36 Personal Care: Changes in state regulation or law regarding requirements for personal care providers will apply to MI Health Link.
- #42 Dental coverage is equal to current Medicaid dental coverage. Crowns not included.
- #43 HAB = habilitation
- #45 Home and Community Based Services = MiChoice
- #47 Formularies vary the same as it does with Part D drug plans. Information is on Plan Finder
- #48 MI Choice has a waiting list in some areas of the state. There are openings for PACE in all the regions in which MI Health Link is being implemented (except there is no PACE organization in the UP)
- #49 Suggest that PACE and MI Choice folks compare current benefits to what’s available in MI Health Link since they are different. May have to be reassessed if enrollee wishes to return to one of these programs. Private duty nursing is limited to 16 hours per day under MI Health Link. MI Choice offers 24 hours per day of PDN. Hands on person-care is not a waiver service. It is provided as a state plan benefit under MI Health Link. Personal Emergency Response Systems are a supplemental benefit under MI Health Link and needing this services doesn’t qualify someone for a waiver slot. Doesn’t need waiver slot to receive. For example: Waiver differences: Private Duty Nursing in MI Choice can be up to 24 hours a day while Private Duty Nursing for MI Health Link is limited to 16 hours a day. If you receive PDN for more than 16 hours a day, you may not want to leave MI Choice. People in MI Choice cannot receive the state plan personal care service (currently provided through the Home Help program administered by DHS). Under MI Health Link, people can receive state plan personal care (hands-on care) and be on the waiver if they have need for a waiver service. People requiring prompting and cueing to complete personal care tasks would receive this service as the expanded community living supports waiver service under MI Health Link. If a person receives hands-on care through MI Choice Community Living Supports, the person would receive this service through MI Health Link under the personal care benefit without using a waiver slot. People need to consider the current waiver services they receive to determine if they are a basic benefit or waiver service under MI Health Link. Being in MI Choice does not ensure the person will be approved for a MI Health Link waiver slot.
- #50 The new Home and Community Based Rules require persons on a waiver to live in an independent setting. Some AFCs and HFA facilities may not meet these new requirements. For people in the MI Health Link waiver, these settings must be in compliance with this new setting rule. For people in the MI Choice Waiver program, these settings are allowed a 5 year transition period to come into compliance with the rules for the person to continue to receive services in these settings. There is no transition period for the MI Health Link waiver, so a person currently on MI Choice living in one of these settings that doesn’t meet the new rule requirements could not receive waiver services in this setting if they joined MI Health Link and needed waiver services. Their options would be to stay in that setting and continue with MI Choice or enroll in MI Health Link and not receive waiver services or move to another setting that is in compliance with the new rule.
- #51 PACE
- #52 Individual Home Help providers would have to meet the same policy requirements that have been established for background checks for personal care providers in Home Help. Enrollees need to inform their Care Coordinators who their Home Help providers are if they want to have them continue as their providers. The providers will need to have a provider agreement with the MI Health Link plan.
- #53 If the person has this type of insurance and calls the enrollment broker to enroll, the enrollment broker will confirm that the person understands that by enrolling in MI Health Link, he and anyone on his insurance plan may not return to the employer/union sponsored insurance. Enrollment broker = Michigan Enrolls
- #54 Note for MMAP: This is the duals lite issue.
- #56 People in these regions will receive an introductory letter in telling them their options and how to opt-in or opt-out. Enrollees will be advised to contact MMAP for additional information. Phase 1 will receive letters informing them of enrollment options in late January 2015. Individuals will be able to enroll beginning February, with services beginning no sooner than March 1, 2015, with passive enrollment for those that do not opt out, beginning May 1, 2015. Phase 2 implementation timeline will not change, with the program running through December 2018 instead of December 2017, If these people don’t opt-in or opt-out and are eligible for passive enrollment (to be assigned to a health plan), they will receive the 60 day letter which will include information on how to enroll or opt-out as well as the plan they will be assigned to. If they don’t take any action, they will receive a reminder letter 30 days prior to passive enrollment with the same information reminding them of their options. If no action is taken to opt-out, enrollment will be effective April 1, the first day they can receive services.
- #57 No change to Phase 2 implementation timeline. There will be three waves of passive enrollment in Macomb and Wayne counties- July, August and September.
- #58 MMAP will be included in the letter as a contact for help.
- #59 Passive enrollment – If a person was passively enrolled into a Medicare or Medicaid plan during the current calendar year, he is excluded from passive enrollment until the beginning of the next calendar year. This person is still eligible for MI Health Link and would receive the introductory letter.
- #61 Enrollees should keep their Medicare and Medicaid cards even though they are not needed for the MI Health Link services. Enrollees can use the welcome letter to receive services for scheduled appointments or emergency services before the new MI Health Link card is received. Take the Medicare and Medicaid cards to the appointment until you receive the MI Health Link card as these cards contain information that will help the provider confirm enrollment in MI Health Link.
- #62 Initial screen consists of 9 yes or no questions done when the call into Michigan Enrolls Level I assessment can be done by phone or in person. Level II is with care coordinator.
- #65 Should be done by care coordinator or other medically trained staff person. Level I assessment may be done after client is passively enrolled.
- #66 Existing assessments may be adopted if they are still current (not due for reassessment). This will help reduce the assessments for the enrollee. This assessment will be used during the development of the Individual Integrated Care and Supports Plan. Care Coordinators will be collaborating with PIHPS and LTSS to coordinate care. I/DD = Intellectual developmental disabilities. BH = Behavioral Health LTSS = Long term supports and services
- #67 Initial assessment done by Michigan Enrolls Everyone gets a Level I assessment Depending on Level I assessment, they would get level II assessment for LTSS or Level II for PIHP and then yet another level of assessment for mental health services referral. LOCD tool = 7 doors of need for care Door One (1) - 87% qualify through door 1 based on four (4) activities of daily living. Client requires six (6) points to come through door one (1). Provider would need to score manually. Door Two (2) – Addresses cognitive issues. There are three (3) qualifiers for clients to come through this door. It is the second most probable door of eligibility (10% of clients come through this door) Individuals that are severely impaired in decision making, have memory issues and trouble making themselves understood. Door Three (3) – Physician Involvement (visits and orders). Necessary to make sure and count the number of days in which the order was changed and number of days in which an exam was done by the physician. (not the amount of exams or changes, but the DAYS these were done) An emergency exam must not be counted and is not inclusive on this assessment. Scoring - To qualify through door three (3), there are two (2) ways in which the client can qualify. FIRST - Beneficiary must have one (1) physician exam and four (4) days in which the orders were changed. SECOND – Physician must have examined the client twice (2 days) and that the physician ordered changes in the last fourteen (14) day timeframe. Door Four (4) - Treatments and conditions. One (1) area is needed to qualify for entrance through this door. Door Five (5) -– Skilled rehabilitation therapies. The individual must have required at least 45 minutes of active PT, OT or ST (scheduled or delivered) in the last 7 days and continues to require rehabilitation therapies to qualify under door 5. Door Six (6) – Behavioral Issues (2% qualify through this door). This door covers wandering, verbally/physically abusive, resisting care, etc. Scoring – 2 options to qualify. Door Seven (7) - Service Dependency. The applicant is currently being served by either the MI Choice Program, PACE program or Medicaid reimbursed nursing facility. Scoring – Applicant must be a current participant and demonstrate service dependency to quality under Door 7.
- #74 Enrollees must be reassessed at least annually, at a change in condition or at the request of the enrollee or enrollee’s representative (family, friend, guardian, POA, DPOA, provider, etc.)