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©2018 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association
June 2018
True Blue Special Needs Plan (HMO SNP):
A Medicare/Medicaid Coordinated Plan
2 Confidential and proprietary Blue Cross of Idaho.
• MMCP: Medicare Medicaid Coordinated Plan • A & D: Aged and Disabled • HCBS: Home and Community Based Services • LTSS: Long Term Services and Supports • DD: Developmental Disability Waiver • TSC: Targeted Service Coordination • TCM: Targeted Case Management • CBRS: Community Based Rehabilitation Services • IDHW: Idaho Department of Health & Welfare • LTC: Long Term Care • JIVA: Blue Cross of Idaho’s online authorization system • NOD: Notice of Decision • Re-Dat: Redetermination • SOC: Share of Cost • ICT: Interdisciplinary Care Team • NSA: Negotiated Service Agreement • ISP: Individual Service Plan • UAI: Universal Assessment Instrument • SSP: Support and Spending Plan
Acronyms
Idaho Dual Eligibles
Age 21 or Older
Enrolled in Medicare Part A and B
Receives full “Medicaid” Coverage
Live within 22 eligible counties
*Current ESRD diagnosis are prohibited from enrollment
27,000
More Women
Mental Illness
Lack high school diploma
Rural Region
50%+ below FPL 5+ Chronic Conditions
Living Limitations
Dual Eligibles
Institution/Nursing Home
More hospital stays/ readmissions
1/3 African-American or Hispanic
5 Confidential and proprietary Blue Cross of Idaho.
• The National Commission on Fiscal Responsibility and Reform estimated that enrolling Dual Eligibles in Medicaid managed care plans would save...
• $12 billion through 2020
Fiscally Responsible
Why have MMCP?
Blue Cross of Idaho
Medicare
Medicaid
Care Coordination
7 Confidential and proprietary Blue Cross of Idaho.
• True Blue Special Needs Plan provides services for full-benefit, dual-eligible Medicare & Idaho Medicaid beneficiaries.
• The plan is available in 22 counties in Idaho
– Ada, Bannock, Bingham, Boise, Bonner, Bonneville, Boundary, Canyon, Cassia, Clark, Elmore, Fremont, Gem, Jefferson, Kootenai, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, Twin Falls
True Blue Special Needs Plan
8 Confidential and proprietary Blue Cross of Idaho.
• Plan enrollment is voluntary for all participants
• Provides coverage for Aged and Disabled (A & D) Waiver Services
» Home and Community Based Services (HCBS)
» Long Term Services and Supports (LTSS)
• Ensures necessary services; including primary and acute care, pharmacy, behavioral health, and long-term services and supports are provided, coordinated, and managed.
True Blue Special Needs Plan
9 Confidential and proprietary Blue Cross of Idaho.
• Hospital
• Medical
• Prescription Drugs
• Behavioral Health – Community Based Rehabilitation Services
• A & D Waiver Services
• Personal Care Services
• DD Targeted Service Coordination (TSC)
– All other DD Waiver services will continue to be provided through Idaho Medicaid Fee for Service
• Nursing Home and ICF/ID
• Community Based Rehabilitation Services (CBRS)
Member Benefits
10 Confidential and proprietary Blue Cross of Idaho.
Member’s Favorite Benefits
$0 monthly premium and $0 copay for services*
One Blue Cross of Idaho Member Card Access to the True Blue network 24-hour Nurse Line Local and highly rated customer service Fitness center benefit Home and community based services Prescription drug coverage Vision coverage Care Coordination
*Share of cost may apply to waiver services
11 Confidential and proprietary Blue Cross of Idaho.
Universal Assessment Instrument (UAI), Individual Service Plan (ISP) and/or Support and Spending Plan (SSP) is requested from Idaho Department of Health and Welfare (IDHW) by Blue Cross of Idaho. Applicable authorizations are entered into Blue Cross of Idaho’s authorization
system (JIVA) once received and are honored through the UAI redetermination or ISP end date
Long Term Care (LTC) authorizations are entered into JIVA once Blue Cross of Idaho identifies where enrollees resides
Care Management Episode is auto-created in JIVA for all enrollees
Care Coordinator is assigned by Blue Cross of Idaho within 14 days of enrollee effective date.
Expanded Mental Health (LMSW, LMFT, LPC, TCM and CBRS) No prospective data is sent to Blue Cross of Idaho to identify these services. Providers must submit authorization requests to Blue Cross of Idaho to continue
services. Providers need to include a copy of the Optum authorization and
description of service when requesting authorization. If no Optum authorization, records indicating service was being received.
New Member Enrollment
12 Confidential and proprietary Blue Cross of Idaho.
• Member benefits and providers remain the same for 90 days from the effective date of enrollment.
Transition of Care
13 Confidential and proprietary Blue Cross of Idaho.
• Eligibility for clients who have enrolled/converted to the True Blue Special Needs Plan can be verified on the Blue Cross of Idaho provider Web Portal by conducting a Member Search within Eligibility & Claims.
• After the UAI, ISP and/or SSP is received from IDHW, applicable authorizations are entered into the Blue Cross of Idaho authorization system and a Notice of Decision (NOD) is sent to respective servicing providers.
• Authorizations from the UAI are good through the redetermination date (re-dat).
• Every member is assigned a Care Coordinator within 14 days and offered a Face-to-Face visit within the first 90 days of effective date.
• Alpha prefix to assist in identifying member is XMX.
• A Share of Cost (SOC) may apply to Waiver Services (HCBS & LTSS), which is located if applicable on the Blue Cross of Idaho provider web portal, under eligibility and claims.
Tips to Know
14 Confidential and proprietary Blue Cross of Idaho.
• $0 Premium, $0 Part D Deductible & $0 copayment for medical services
• How do providers know if the Medicaid rate changes? – Rates may change depending on the provider type.
– Some rates may change at the re-dat date or others may change when Medicaid changes the facility rate. (i.e., LTC)
– Some rates are determined by the State and usually change with the new plan year.
– Other rates may change if the State changes the rates during the year.
Tips to Know (cont.)
15 Confidential and proprietary Blue Cross of Idaho.
Interdisciplinary Care Team
Member
Care Coordinator
Family
Primary Care
Physician
Home Care
Nursing Home
Mental Health
16 Confidential and proprietary Blue Cross of Idaho.
• A member’s Individualized Care Plan is made available upon request to enrollee’s identified interdisciplinary team on the Blue Cross of Idaho provider portal. – Primary Care Physician – Care Coordinator – Targeted Service Coordinator (when applicable)
• The primary care physician is informed what services each member receives and has ongoing communication with care coordinator.
Individualized Care Plan
17 Confidential and proprietary Blue Cross of Idaho.
• An enrollee-centered, goal-oriented, culturally relevant, and logical, written plan of care that assures that the Enrollee receives medical, social, behavioral, and necessary covered services, including LTSS, in a supportive, effective, efficient, timely, and cost-effective manner.
• Emphasizes prevention and continuity of care.
• Developed by an Enrollee and an Enrollee’s ICT.
Individualized Care Plan
18 Confidential and proprietary Blue Cross of Idaho.
• Health status including all clinical and non-clinical needs • List of diagnoses and medications • List of medical, behavioral health, LTC, and social service
needs already in place • Results of and needs identified in the comprehensive
Health Risk Assessment • Specific interventions • Prioritized list of concerns • Educational and vocational opportunities • Measureable goals including target dates, expected
outcomes and identified barriers • Participant requested services • Participant preferences for care
Elements of the Care Plan
19 Confidential and proprietary Blue Cross of Idaho.
• Patient education • Medication monitoring and adherence • Care setting transition • Physicians are better informed, patients are more
engaged which results in better outcomes of care • Gaps in care are filled, patient volume increases
and the cost of delivering care can be more accurately quantified
• Increased preventative care leads to higher quality and more efficient coordinated care
• The nation benefits from reduced healthcare costs, better disease management and a generally healthier population.
Why Care Coordination?
20 Confidential and proprietary Blue Cross of Idaho.
• One set of comprehensive benefits: primary, acute, prescription drug and long-term supports & services
• One accountable entity to coordinate delivery of services
• One care management team that develops care plans and coordinates care
• Health care decisions are based on beneficiary needs and preferences to promote improvement in health and quality of life
Why Care Coordination? (cont.)
21 Confidential and proprietary Blue Cross of Idaho.
• Home Community Based Services (HCBS) agencies receive a copy of the UAI when they are chosen to provide services.
• Please contact Blue Cross of Idaho at 1-866-588-6174 or by email at [email protected] to request a copy of the UAI, Negotiated Service Agreement (NSA) or Care Plan.
• Agencies must notify Blue Cross of Idaho when a member changes agencies, is admitted or discharged, moves, or has significant changes in care, etc.
• Notification of Change Form –Used when a member changes agencies. Blue Cross of Idaho must receive form on or before the 25th of the current month for changes to be effective by the 1st. This form is available on the Blue Cross of Idaho Web Portal under Home and Community Based Services Provider Administrative Policy HCBS303.
• Significant Change Form –Used when an agency would like to request a change in authorized time/units due to change in member’s condition. This form is available on bcidaho.com found under Home and Community Based Services Provider Administrative Policy HCBS302.
• Forms can be emailed to [email protected]
Agency Requests
22 Confidential and proprietary Blue Cross of Idaho.
• Enhanced LTC (Long Term Care/Institutionalized): – HCBS Provider Administrative Policy 259 – Member lives in an Extended Care Nursing Facility – Considered Custodial Level of Care – Blue Cross of Idaho responsible for payment of claims – When billing for LTC on our Direct Claim Entry tool
• Place of Service = 99 • CPT/HCPCS = T5999 • Additional Claim Information Field = Enter admit date of 07/01/2014 or later along
with rev code (rev 0100).
– Notification of admission needed, fax to 208-472-5070 or email [email protected]
– Including: • Level of Care • Admit Date • Member Demographic Information • Facility Information • Facility Contact
Long Term Care
23 Confidential and proprietary Blue Cross of Idaho.
• Available to all members based on Medical Necessity and requires prior authorization – Includes: Community Based Rehabilitation Services (CBRS),
Targeted Case Management (TCM), Treatment Plan Development, Peer Support and Psychotherapy* • HCBS Provider Administrative Policies 254, 257, 300 and 307.
• Provider Administrative Policy HCBS300 on the Blue Cross of Idaho web portal provides further information on Prior Authorization for Expanded Mental Health Services
*Psychotherapy services may require prior authorization based on provider credentials. Please contact Blue Cross of Idaho Health Care Operations for additional information.
Expanded Mental Health
24 Confidential and proprietary Blue Cross of Idaho.
• Authorization Requirements – HCBS Provider Administrative Policy 235
– Requester Information
– Enrollee Information
– CPT Code(s)
– Date span requested, units requested
– Reason for request
– Attach Optum authorization
– Attach care plan
– Fax to 208.472.5070 or email to [email protected]
Community Based Rehab Services (CBRS) ~ Authorization Requirements
25 Confidential and proprietary Blue Cross of Idaho.
• New ISP Request:
– Provider Administrative Policy HCBS 322
– Requester Information
– Enrollee Information
– CPT Code (Typically G9007)
– Date Span
– Units Requested
– Reason for Request (such as Initial ISP Development)
• ISP Renewal:
– Provider Administrative Policy HCBS 322
– Targeted service coordinator must contact Blue Cross of Idaho to request annual plan development authorization.
Targeted Service Coordination – Authorization for ISP Development
26 Confidential and proprietary Blue Cross of Idaho.
Targeted Service Coordination – Authorization for ISP Development (cont.)
• Targeted Service Coordination Billing Requirements
– Provider Administrative Policy HCBS 257
– Bill services for the ISP using the appropriate codes for service coordination, plan development and crisis assistance.
– Targeted service coordinators must meet with the member face-to-face at least every 90 days.
– Bill face-to-face TSC visits (G9002) with an SC modifier.
– Fax to 208.472.5070 or email to [email protected]
27 Confidential and proprietary Blue Cross of Idaho.
• Eligibility Verification: Eligibility can be verified on the Blue Cross of Idaho Web portal by conducting a Member Search within Eligibility & Claims.
• Authorization Verification: Authorizations can be verified on the JIVA application of the Blue Cross of Idaho portal.
• Submitting Notification of Change or Significant Change forms when applicable.
• Submitting authorizations for expanded mental health services.
• Required Mandatory Annual Training On Web Portal
– Cultural Competency, Fraud Waste and Abuse, Discrimination and Model of Care
• All providers must document care for their patients the same way documentation has been done for the State of Idaho Health and Welfare.
Provider Responsibilities
28 Confidential and proprietary Blue Cross of Idaho.
• Call Customer Service at (888) 495-2583 • Apply online at www.truebluesnp.com • Ask Blue Cross of Idaho or Medicaid for an application
to be mailed • Contact Blue Cross of Idaho Outreach Staff – by phone
or email – Jacob Curtis - Dual Eligible Outreach Specialist
• 208-810-2731
– Jen Johnson - Dual Eligible Outreach Specialist
• 208-810-2437
Member Enrollment Options
29 Confidential and proprietary Blue Cross of Idaho.
MMCP Contacts
Member Line Dual Special Needs Plan 1-888-495-2583
Waiver Providers Support Line 1-866-588-6174
Care Coordinator Line 1-800-682-9329
All Requests FAX : 208-472-5070 Email : [email protected]
Provider Enrollment Medicare Medicaid Coordinated Plan (MMCP): HCBS, Expanded Mental Health, ICF/Long Term Care, Certified Family Homes Statewide.
Christina Sears, CPC Provider Network Management Specialist
1-866-283-5723 ext. 1896 Fax 208-331-7669
Training and Web Site Assistance
Kathy Brock, CPC-P, CRC Sr. Provider Relations Representative
Statewide MMCP 1-866-283-5723 ext. 8307
Fax 208-286-3561 [email protected]
30 Confidential and proprietary Blue Cross of Idaho.
