The Medicare-Medicaid Alignment Initiative

Medicare-Medicaid Alignment Initiative (“MMAI”) was recently approved and will greatly affect home health care providers in Illinois. This article first provides background details on the initiative, including how it may affect a home health care company’s Medicare and Medicaid payments, and then outlines how home health care patients can opt-out of the program.

ACTION PLAN FOR HOME HEALTH CARE COMPANIES:

Notify all visiting nurses of the automatic loss of patients.

  1. Nurses should advise their patients, emphasize they could lose their nurse, and request appointment as representative.
  2. Nurses should contact Client Enrollment Broker and opt out prior to enrollment for all patients wanting to remain with company. 
  3. For all patients that are enrolled without patient consent, obtain appointment and opt out post enrollment. 

I.                   Background on MMAI

a.      Implementation of MMAI

The Medicare-Medicaid Alignment Initiative is a test program run by a state government and the Centers for Medicare and Medicaid Services (“CMS”). The goal of the test program is to provide individuals eligible for both Medicare and Medicaid (“dual eligibles”) with better care by testing a different program’s impact on a beneficiary’s care experience, quality, coordination and costs in different states. The MMAI test project in Illinois will provide coordinated care to more than 135,000 dual eligibles in the Chicagoland area and throughout central Illinois. Illinois is the fourth state to participate in this test program with CMS. The program in Illinois becomes active on June 1, 2014.

b.      Passive Enrollment

Each month beginning June 1, 2014, the Illinois Department of Healthcare and Family Services (“Department”) will automatically assign several thousand eligible Medicare-Medicaid beneficiaries to a Demonstration Plan. This automatic assignment is called Passive Enrollment. Each Passive Enrollee will be able to choose from one of several Demonstration Plans, depending on the Passive Enrollee’s location. A Demonstration Plan is a Managed Care Organization (“MCO”) that enters into a three-way contract with CMS and the Department to provide services to dual eligibles.

Dual eligibles will receive a notice of Passive Enrollment at least sixty days prior to the effective date of their enrollment in MMAI and can choose to opt-out of the program or choose a health plan provider at that time. The notice will include an enrollment letter from the Department, along with various program materials, including brochures on how to choose a health plan, how to enroll in a health plan and a list of which basic health benefits are available through each health plan.

c.       How MMAI Will Affect Home Health Care Companies in Illinois

Once enrolled in MMAI, the dual eligible will have the option of choosing between several different MCOs to manage their care, depending on where they live. In the greater Chicago area (including Cook, DuPage, Kane, Kankanee, Lake and Will counties), dual eligibles will be able to choose from health plans provided by Aetna Better Health, Blue Cross Community, Cigna-Healthspring, Humana, IlliniCare and Meridian. In central Illinois (including Champaign, Christian, DeWitt, Ford, Logan, Macon, McLean, Menard, Peoria, Piatt, Sangamon, Stark, Tazewell and Vermillion counties), dual eligibles can choose between Health Alliance Connect and Molina Healthcare. If a home health care company does not have a relationship with any of these particular health plan providers, it may be difficult for the home health care company to be reimbursed for services provided.

Medicare Providers must take steps to ensure they continue to receive payments from Medicare and Medicaid for the services provided to patients. First, the home health care company should confirm which of the above-noted health care providers they work with. Next, they can inform their patients that when the patient is given the option to choose from an MMAI health plan provider, they should choose one of the health plan providers that the home health care company works with. Alternatively, the home health care company could assist their patient in opting out of the MMAI program.

II.                Opting-Out of MMAI

A dual eligible cannot opt out of MMAI until sixty days prior to the effective date of their passive enrollment. Each patient’s passive enrollment date may differ, so it will be important to keep track of each patient’s information.

The dual eligible has two ways of opting out of MMAI:

  1. Calling the Client Enrollment Broker at 1-877-912-8880 or 1-800-633-4227 to opt-out over the phone; or
  2. Filing a Personal Representative Designation form with the Department to allow the designated Personal Representative to opt-out on the dual eligible’s behalf.

If the dual eligible does not opt-out of MMAI, they will be automatically enrolled in one of the health plans.

a.      Client Enrollment Broker

If the dual eligible wishes to opt-out and is able to do so over the phone, they can call the Department Monday to Friday, from 8 a.m. to 7 p.m. and Saturday from 9 a.m. to 3 p.m. at 1-877-912-8880. TTY users should call 1-866-565-8576. The dual eligible may also call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

If the dual eligible has already been enrolled in MMAI, they can opt-out of the program over the phone by calling the numbers listed above. The dual eligible can also change their health plan provider by calling the same number.

b.      Personal Representative Designation

A patient can also allow another individual to opt-out of MMAI on their behalf by filing a Personal Representative Designation (“PRD”) with the Department. The PDR names one or more people a patient’s Personal Representative. This Personal Representative is then given all the rights that the patient would have regarding their health information. The rights of the Personal Representative may be limited by the patient in the body of the PDR. Once filled out and signed, the PRD should be mailed to the following address:

Privacy Officer

Healthcare and Family Services

P.O. Box 19159

Springfield, Illinois 62794-9159

This address is also found at the bottom of the PRD. The PRD can also be faxed to the Department at 312-596-0249. Once accepted by Department, the Personal Representative named in the PRD may opt-out of MMAI on the dual eligible’s behalf.

If the dual eligible is not competent or is unable to sign the PDR, the PRD may be signed by that dual eligible’s power of attorney or power of attorney for healthcare.

If you have any questions regarding the MMAI or need guidance on how the MMAI will affect you as a home health employer, please contact Lavelle Law, Ltd. at (847) 705-7555