Charting New Territory

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Presentation transcript:

Charting New Territory The Ombudsman Experience Francine Chuchanis, Director of Entitlement Rights Certified Ombudsman Program Director

Traveling a New Boulevard Initiation into variety of home care services & delivery mechanisms Necessity to advocate with multiple providers Medicaid rules in community settings Utilization of a 3-Way Contract No one size fits all model

Maneuvering with Caution Developing relationships with My Care Plans and providers Identifying one point of contact with plans Struggle with leadership versus care management contact Securing role at Member Advisory Councils Partnering with Ohio Department of Medicaid

Navigation Challenges Multiple My Care Plans Diverse leadership styles Variations in timeliness of communications Differences in structures of member Advisory Councils Differences in regional access to providers Diversity of care management models Different appeal processes and rules

Divergent Routes Role of AAAs carved in for waiver service coordination only Full delegation of care management in AAAs by some plans, not others Some Ombudsman Programs in AAAs, others not Access to information by Ombudsman varies LTCOP firewalls instituted in AAAs

Early Bumps in the Road Enrollment Confusion about Opt-In/Opt-Out rights Timely assessments Transportation Access to primary care physicians Confusion about transition requirements Problems with provider billing and payments

Plotting a Smoother Pathway Ombudsman identify systemic issues Complaints against plans & Ohio Department of Medicaid (ODM) opened by Ombudsman Office of State Ombudsman reports complaint data to CMS ODM meets with plan stake holders Adjustments initiated to correct systemic issues & collect relevant data

Current Roadblocks Limited access to providers Untimely delivery of durable medical equipment Provider payment issues Timing of service start ups with transitions between care settings Care plans not person centered Shortage of home care attendants Absence of real exposure in nursing homes

Finding Detours Quarterly meetings with plan leadership Direct contact between Care Managers and Ombudsman Interaction with members at Advisory Council meetings Role of Ombudsman integrated into My Care Ohio

A Route to Success: Lessons Learned Early education of providers and consumers important DME process needs to be leaned Provider payment mechanisms need to be streamlined and timely Enrollments & authorizations during transitions must be well-timed Training needed on person centered care Rate adjustments for home care attendants essential

Mapping the Future Demonstration ends 2019 Many issues identified and being addressed MLTSS to go statewide in 2018? Move to One Waiver Some efforts to delay this in Ohio legislature Managed Care Plans submit intent to participate this Summer, ODM to choose by Fall Role of AAAs carved in for waiver service coordination Role of Ombudsman expanded

And FINALLY… Ombudsman can help direct the future of managed long term care to the satisfaction of all

Direction Home Akron canton Presentations Monday 3:15-4:30 M33) P4P: Support MCO Performance-Based Payment Programs with Quality Measures & Cost Modeling For a Competitive Market Advantage 4:45-5:15 FT05) Tapping Into the Business Acumen Brain Trust: Q & A With Experts

Direction Home Akron canton Presentations Tuesday 1:00-2:15 T19) Putting a Down Payment on the Future: Financing your Agency's Strategic Plan 2:30-3:45 T29) Charting New Territory: Ombudsman Programs and Dual Demonstrations