NAMI Michigan

Integrating Care for People Eligible for Both Medicare and Medicaid
SERVICE ARRAY AND PROVIDER NETWORK WORK GROUP
Meeting Summary for Nov. 16, 2011

Questions/Topics Discussed

• What additional services could or should be made available to beneficiaries?

• Which services and supports that are currently available only to people eligible for the MI Choice of Habilitation Supports Waivers might be beneficial to all beneficiaries?

2. How would you prioritize these services?

Key Points of Discussion

Question 1

How can the services and supports that are going to be covered in the integrated model be enhanced?

Workgroup members began by reviewing a list of services and supports that are currently available to dually eligible beneficiaries through Medicare and Medicaid, including state plan and waiver services that are available to the beneficiaries who meet certain eligibility criteria. The list of services and supports also included those that will be available through a Traumatic Brain Injury Waiver if the state’s application is approved by the Centers for Medicare and Medicaid Services (CMS). While care management services available through the Office of Services to the Aging are not covered by Medicare or Medicaid, these services were included in the document to ensure work group members were aware of these other services that are available to older adults in Michigan. These services are available to individuals age 60 and over who have complex medical issues and are at risk or in need of long-term care.

As members began to identify ways to enhance the initial list of benefits, many asked questions and/or offered clarifying statements based on their knowledge of the current system. Staff from the MDCH in attendance at the meeting also offered clarification when necessary. Several work group members indicated concern that services and supports available through Medicare might duplicate those available through Medicaid, or that supports offered through one waiver may also be offered in another. It was clarified that the state will be responsible for creating a single benefit package based on the services and supports that are currently available and the recommendations made by this work group for potential additional services and supports.

• Can cost-effective preventive programs that are not currently included in Medicare or Medicaid be included in the integrated plan for dually eligible beneficiaries?
• Many health plans currently develop and provide services that they have found to help reduce the cost of care for people with chronic conditions. We should expect that these types of services would be offered by plans in the integrated model.
• Like a restaurant menu, having more choices can produce better results for the individual
• If we add services, we have to reduce costs; services should provide some kind of return on investment
• It is difficult to identify the services that should be added without knowing what the reimbursement model will be.
• Credentialing for non-traditional providers (e.g. refrigerator repairs) may be needed
• There are a variety of eligibility criteria for existing programs and waivers. The MDCH expects to current criteria to remain in place.
• The legislature may have some influence on how this program ultimately works given its role in appropriating funds. We’ll have to be sure they understand the importance of the services and supports made available through the integrated care model so they do not cut funding for services funded by Medicaid.
• Perhaps the legislature could require that any savings generated by the program be spent on the dual eligible population and the services available through the integrated care model.
• What billing codes will be covered under the integrated plan, and how are differences in service definitions and codes between Medicare and Medicaid going to be resolved?
• The state will be responsible for blending and meshing the services; the work group’s focus is on determining the array of services.
• How do we help integrate care if all services in both programs are included, no matter how duplicative?
• Through coordination of care by the contracted entities and their provider networks, the integrated program will offer unified beneficiary cards, unified billing, and coordinated, person-centered care.
• If we decide to expand mental health, we may have to recommend that the legislature pass mental health parity
• Limits on home and community-based services should be relaxed
• Transportation is problematic for many dually eligible beneficiaries
• Mental health services are preventative; they help people hold jobs and learn better language skills. If they are not provided, overall health can just deteriorate.
• Substance abuse is not considered a disability, so those patients don’t have access to the array of services that could really help them and lower costs.
• Self-directed programs offer more flexibility, allowing people to tap into good services that can be cheaper, like ordering medication online. Self-direction is proven to reduce costs.
• We need to affirm as a group that we want the state to continue to cover every service and support that is currently covered. We don’t want there to be any question about that.

VOTE
The work group voted to affirm that all of the currently covered services for dually eligible beneficiaries, whether through Medicare, Medicaid, or a state plan or waiver should continue to be covered in the integrated care model.

• The 32 members participating in the meeting voted unanimously in favor.

Potential Additional Supports and Services

Work group members offered a wide variety of suggestions for enhancing and adding services. Those getting the most emphasis were:

• Memory care for adults with conditions such as Alzheimer’s disease, dementia, or traumatic brain injuries, which is limited or non-existent under the current waiver programs; possibly including a reminder service to help people stay on track with their care
• Explicit coverage for the coordination of each beneficiary’s personal plan of care, regardless of whether that is primarily medical, behavioral, nursing, HCBS, etc.
• Coverage for personal consultations/coaching and group visits/classes on nutrition, home injury control (fall prevention), chronic diseases, fitness, money management
• Explicit coverage of medication management, including consultation regarding prescriptions, for each beneficiary by nurses and pharmacists to help prevent adverse drug interactions
• Expansion of substance-abuse services, which are now limited under Medicaid, including federally funded services provided by coordinating agencies
• Expanded coverage for dental and vision care
• Expanded access to preventive services, mental health, and personal assistance
• Transportation, including relaxed eligibility requirements regarding home and car ownership

Work group members also suggested the following additions to services covered by the integrated plan for dually eligible individuals:

• Cognitive evaluations
• Assistive technology
• Training and educational services for unpaid caregivers
• Room and board for substance-abuse detox
• Chiropractic services
• Medications not covered under formularies
• Communication supports for staying in touch with patients, e.g. offer cell phone minutes, provide laptop computers

Question 2

How would you prioritize these services?

While work group members were identifying and suggesting additional services for inclusion in the integrated care plan, many also identified criteria that might help the MDCH prioritize which services should be added. They expanded on the list after continued discussion to arrive at the following initial set of prioritization criteria:

• The services and supports should control or reduce costs, perhaps even be able to demonstrate a return on investment
• The services should be evidence-based and improve outcomes
• Prevent the need for higher-acuity care such as inpatient or residential
• Promotes self-directed care

Work group members also indicated that as the MDCH designs the service array, it should keep things simple, allow for innovation, and ensure that provider networks exist to make the services available and accessible.

Public Comment

• An observer who works in the MDCH mental health and Alzheimer’s programs commented that, along with emphasis on person-centered care and self-direction, she would like to see support for caregivers, since 70 percent of the care is provided by families. She said coverage is needed for such things as counseling, training and education on diseases, and for respite care, whether the caregivers work in homes or institutions, since they tend to have high levels of morbidity.

Next Steps

Work group members requested that a single comparison grid showing all covered services by program be developed for its next session. Having a single list will help highlight gaps in programs, they indicated. Where possible, the number of beneficiaries covered by a specific program should be included.

Another person asked that a list of all types of providers who would serve beneficiaries of the integrated plan also be created.

With the re-organized list of services in hand, the work group will revisit the questions posed at this meeting and perhaps identify additional criteria for prioritizing the list of additional recommended services at its next meeting. If time allows, the work group may begin discussing ways to ensure that provider networks are comprehensive.

The next meeting of the Service Array and Provider Network Work Group is scheduled for 1:30 to 5:00 PM on Thursday, December 1 at the Causeway Bay Hotel in Lansing.