11 Aging & Disability Resource Centers: A Focus on Long-term Care Enrollment Counseling June 30, 2008

22 During this webcast… Introduction to Enrollment Counseling Highlight key knowledge areas – Eligibility – Benefit Options – Enrollment Counseling Process – Technical Assistance Documents

33 Our presenters…. Charles Jones, Office for Family Care Expansion John O’Keefe, Bureau of Long Term Support Maurine Strickland, Office for Resource Center Development, Bureau of Aging & Disability Resources

44 Goals of Long-Term Care Reform Choice Access Quality Cost-Effective

55 Aging & Disability Resource Centers Help people…. explore their needs access information about service options maximize use of their personal funds to delay or prevent need for public funding learn about the benefits and programs available to them

66 ADRC’s provide….… A welcoming place Trusted, reliable information Core services … – Information & Assistance – Options Counseling – Enrollment Counseling – Benefits Counseling, Elder and Disability – Prevention, Information & Activities – Functional eligibility determination & coordinates enrollment into LTC programs

77 Enrollment Counseling assisting an individual who… is found eligible for publicly funded long-term care is making a choice to enroll in – a managed care organization – IRIS the Self-Directed Supports Waiver – or use only Medicaid card services

88 Information about eligibility… Medicaid is - Federal/State funded health care program Pays for essential health and long-term care (LTC) services Medicaid eligibility is required for all LTC options discussed during this webcast

99 Medicaid funded long-term care Eligibility Requirements – Functional (Level of Care) – Non-Financial – Financial People with long-term care needs receive assistance with the eligibility process Each ADRC has an enrollment plan that describes how the ADRC together with their partners assist people

10 Functional Eligibility Long-term care functional screen collects information on: Medical Conditions Activities of Daily Living (ADL) Instrumental Activities of Daily Living (IADL) Living Situation Supports Behaviors Risk factors

11 LTC Benefit Options Based on Level of Care Results Nursing Home Level of Care (includes ICF-MR) Family Care – all Medicaid LTC services, including waiver services – primary & acute health care thru Medicaid card Family Care Partnership and PACE – all Medicaid and Medicare services – including primary and acute health care SDS Waiver – IRIS – waiver services (planning to incorporate personal care in the future) – other long term care services thru Medicaid card – primary and acute health care thru Medicaid card

12 Non-Nursing Home Level of Care Family Care – Standard Medicaid LTC card services (but not waiver) – Interdisciplinary care management – MCOs may provide other flexible services Fee-for-service – All services from individual providers thru Medicaid card LTC Benefit Options Based on Level of Care Results

13 Long-term Care Functional Screen Nursing Home Level of Care

14 Long-term Care Functional Screen Non-Nursing Home Level of Care

15 Long-term Care Functional Screen No Level of Care

16 ADRCs help people through the MA application process Prepare for interview with Income Maintenance (IM) Medical remedial expenses Items and services purchased “out of pocket” by consumers that are not paid or are not covered by Medicaid, waiver programs or other responsible third party. Cost share For more information about cost sharing see program references or the Medicaid Handbook appendix

17 References Use Webcasts – Special topics – Introduction to Publicly Funded Long-Term Care – Spousal Impoverishment – Estate Recovery & Lien Law – Medicare Part D

18 Medicaid Eligibility Fact Sheets Many single page fact sheets are available (some in multiple languages). #Fact_Sheets #Fact_Sheets

19 Systems ADRC uses the LTC Functional Screen (LTCFS) to: – Determine level of care – Calculate individual’s budget amount for the SDS Waiver Income Maintenance uses Client Assistance for Re- employment and Economic Support (CARES) to: – Determine Medicaid Eligibility – Generate notices to applicants and people who are enrolled in long-term care program – Enroll people in long-term care programs – Send information to Medicaid Management Information System (MMIS)

20 The Department and its partners use Medicaid Management Information System (MMIS) to: – Store eligibility and enrollment information – Issue payments to Managed Care Organizations – Generate federally required reports The Department and its partners use Program Participation System (PPS) to – Document information regarding centralized enrollment for Managed Care – Track participation in IRIS (SDS Waiver) – Communicate between the ADRC and the Independent Consultant Agency Systems continued…

21 Let’s describe the long-term care options? Managed Care – Family Care (FC) – Family Care Partnership/PACE IRIS (Self-Directed Supports Waiver) Medicaid Card Services - only

22 Managed Long-Term Care Family Care Partnership

23 Managed Care Organizations…. Help each person…. Identify the results they want Participate in building a plan for services focused around their outcomes Provide directly or purchase services and supports in the service plan Coordinate LTC services with the member’s physician and other medical care Make sure services meet expectations for quality and timeliness

24 Key Differences…. Managed Care Programs Family Care and Partnership offer the same long-term care benefit package… In addition, Partnership includes: – Health and medical care (acute and primary care) – Medical personnel on the care team – Drug coverage – Integration of Medicare benefits

25 Managed Care Benefits & Services Family Care Full range of Medicaid LTC services including home and community based waiver, nursing facility care, medical equipment and supplies, therapies and transportation Interdisciplinary care management (member, nurse and social worker/care manager) LTC services managed by the team Choose services from a LTC provider network Assist with the coordination of health care

26 Members select their own physician (paid for with Medicare and/or Medicaid) People with both Medicare and Medicaid receive prescription drug benefits through the Medicare Part D plan they choose Managed Care Benefits & Services Family Care, continued

27 Managed Care Benefits & Services Partnership Full range of long-term care services AND health and medical care in one benefit. Covers…. Medicaid primary, acute and long-term care services, prescription drugs, plus home and community based waiver services (includes Medicare services if eligible) Family Care Partnership

28 Managed Care Benefits & Services Partnership continued Interdisciplinary Care Management (nurse practitioner, RN, SW, Partnership doctor). LTC, acute, primary care managed by the team. Members use providers and physicians who are in the provider network (if a person’s physician is not in the network, the MCOs may be able to add physicians) Family Care Partnership

29 Managed Care Benefits & Services Partnership continued Individuals who are eligible for Medicare must: Be enrolled in Medicare Part B Enroll in the MCO’s Medicare special needs plan Family Care Partnership

30 Individuals who are eligible for Medicare must enroll in the MCO’s Part D prescription drug plan. Drug coverage is integrated Members cannot use Senior Care or any other Medicare Part D Plan Members get their drugs from the MCO MCO must assure members can get drugs prescribed for them Person may want to check the formulary before enrolling to see if his/her drugs are covered Managed Care Benefits & Services Partnership continued Family Care Partnership

31 PACE is… Very similar to Partnership (in Wisconsin) PACE-run day care centers – where people may get some services, e.g., bathing Smaller network of primary care physicians Managed Care Benefits & Services Program of All-Inclusive Care for the Elderly

32 Self-Directed Supports in Managed Care SDS in managed care: Background – Care management for all members incorporates consumer participation and respect for choice – Self-Directed Supports is a new way for people to direct their LTC goods, services and supports Available to all Family Care/Partnership members Each member can choose which supports to direct Family Care Partnership

33 Self-Directed Supports in Managed Care Members play a more active role Deciding how resources are allocated for services and supports to meet personal outcomes - “SDS Plan” – even to buy services or supports that are not part of the MCO’s benefit package Selecting their own workers, including family, friends, neighbors Directing workers Family Care Partnership

34 Self-Directed Supports in Managed Care Overview of how it works: Wish to self direct identified in assessment MCO can provide help if the member needs assistance with learning self direction Can be just selecting and directing workers Family Care Partnership

35 Self-Directed Supports in Managed Care MCO makes budget available to member to direct the supports the member has selected – Member creates an “SDS Plan” for how the resources will be used – Care management team approves plan – Member carries out the plan Family Care Partnership

36 Self-Directed Supports in Managed Care MCO makes assistance with self direction available thru: Fiscal intermediary - provides strictly payroll support – checks, withholding, tax filing, etc. Co-employment agency - offers help with recruiting, screening, interviewing, hiring, training, firing workers Family Care Partnership

37 Self-Directed Supports in Managed Care Interdisciplinary Team Role: IDT continues to support members – Manage supports not directed by member – Authorize resources available to member – Secure training/TA for members or workers – Monitor member’s use of resources – Monitor member’s health and safety Family Care Partnership

38 Self-Directed Supports in Managed Care About 15% of Family Care members participate in the Self-Directed Supports option Commonly self-directed services include: – Personal care – Supportive home care – Respite care – Transportation – Vocational supports 91% Family Care Partnership

39 Managed Care Summary MCOs maintain a network of quality providers to meet members needs Person-centered interdisciplinary care management with the member at the core of the team identifies and authorizes services and supports Managed Care Options – Family Care – Partnership – PACE Family Care Partnership

40 IRIS – Self-Directed Supports Waiver

41 IRIS: Include, Respect, I Self-Direct I nclude –participants are supported to be active members of their communities R espect – participants’ preferences are honored; participants direct their own lives and long term supports. I – (the participant) am in charge of my own plan. S elf-Direct – includes me managing my own services and life.

42 IRIS New option in how persons receive LTC goods, services and supports Alternative to Managed Care Begins July 1, 2008 Participant access is synchronized with Family Care expansion in each county

43 IRIS Items to know… Like other publicly funded long-term care options, IRIS is offered to all persons including individuals who have guardians. As part of the functional screen, an individual budget is calculated, based on an individual’s needs. The ADRC advises participant of the projected budget before making the choice to participate. Individuals who choose IRIS are expected to coordinate and direct all of their services. Family, friends, or others are may help.

44 IRIS Regarding individual budgets: Each person will receive an individual budget allocation : may be reviewed/adjusted updated annually to reflect the cost of living adjustment (COLA) Includes ongoing waiver long-term care costs The person also has access to services through Medicaid and/or Medicare.

45 IRIS Within program parameters, IRIS participants: Make their own decisions within their allocated budget about the goods, supports and services they will receive. Make their own decisions about who provides these supports and services. Make their own decisions about when and where supports and services are received.

46 IRIS IRIS participants select: Their own physician and other health care providers who accept Medicaid as payment just like in Family Care. Persons eligible for Medicare receive prescription drug benefits through the Medicare Part D plan they choose. DHS is working on allowing IRIS participants to self-direct their Medicaid Personal Care Card services.

47 IRIS Infrequent supports (e.g. housing modification, short-term residential setting or adaptive equipment) are funded through a separate exceptional expense fund on an as-needed basis. For those needing workers/attendants, both co- employment and employer authority are available. Persons may use their budget to purchase the services of a broker, if they wish.

48 IRIS Allowable Supports and Services include: Goods and services include all community-based, long-term care waiver services; and A new option: Participant Customized Goods and Services (details at:

49 IRIS People may live in any community setting they choose, including Adult Family Home, CBRF and RCAC, and still select IRIS. Regardless of where people chose to live, they must manage within their individual budget.

50 IRIS Role of the ADRCs Provide information and counseling about the individual’s publicly funded long-term care choices Provide key information to individuals about IRIS, which includes the individual’s budget (generated from the Long-Term Care Functional Screen)

51 IRIS Role of the ADRCs continued… Refer the individual who chooses IRIS to the Independent Consultant using the Program Participation System known as PPS. Inform the individual that he/she will receive additional information about the program at a meeting with the Independent Consultant Agency and the selected consultant.

52 IRIS State DHS manages two statewide contracts: 1. Independent Consultant Agency (The Management Group) oversees independent consultant activities and provides overall program management 2. Financial Services Agency (Milwaukee Center for Independence) completes all criminal background and employment checks, claims payment functions, and assorted program reporting.

53 IRIS Independent Consultant Agency (ICA): Provides orientation and skills training to all participants Maintains a 24/7 toll free number with on-call service after regular business hours

54 IRIS Independent Consultant Agency (ICA): Provides an orientation to IRIS Approves and monitors participant plans Tracks participant health and safety issues Meets State oversight obligations

55 IRIS Consultants: help people stay eligible by keeping track of program requirements; assist participants when necessary; secure training/TA for participants; may help participant identify when and how to get in touch with the ADRC to request an updated functional screen when there is a change in condition.

56 IRIS Financial Services Agency (Milwaukee Center For Independence): Completes required criminal background checks, employment verifications, and also completes all payroll tasks; Receives and monitors cost-share payments; Pays claims as listed on support/service plan after participant authorizes payment

57 IRIS Financial Services Agency (cont): Provides orientation and skills training program to all participants Maintains a toll free number with call service during business hours and voic service after regular business hours Sends monthly spending reports to participant, ICA and Department

58 IRIS IRIS Quality Management assures: Quality Standards are followed; Each participant has quality management plan; A back-up plan for worker no-shows or other urgent situations is developed by the participant and the Independent Consultant; Critical Incidents are reported and tracked by the Independent Consultant Agency.

59 ADRCs help people Compare programs – Benefit packages – Program design – Approach to coordination of services Educate people so they can choose what is best for them

60 Programs are voluntary People can change their mind. People can disenroll at any time. Advise people to come back to the ADRC if they want to have a conversation about reconsidering their choice.

61 Process of Enrollment Counseling Getting Ready Having a Conversation with Individuals Tools Available

62 Enrollment Counseling: Getting Ready Familiarize yourself with the benefit packages – Family Care and Partnership/PACE – IRIS Learn about the organizations that will be authorizing or coordinating publicly funded long-term care in your area Understand appeals and grievance procedures Learn commonly asked questions from people currently receiving publicly funded long-term care

63 Enrollment Counseling: Getting Ready Familiarize yourself with the financial implications that may impact the individual’s decisions – Understand and be prepared to explain Co-pay Cost share Estate recovery

64 Sending a “Heads Up” Send a letter to people currently receiving waiver funded services Send a letter to people currently on a wait list for services Sample letters provided Consider including the “What is an ADRC?” fact sheet Remember to check for Medicaid and to ensure that the Long-term Care Functional Screen is current Getting Ready…

65 Step 1: Delivering the Good News (via Telephone) Contact the consumer Introduce yourself, explain why you are calling, reference the letter that was sent to the individual and ADRC fact sheet (if sent) Schedule home visit (if acceptable to the consumer) Having a Conversation…

66 Step 2: Having a Face-to-Face Conversation Find out how the person is doing! Provide an overview of the enrollment process – Utilize the “Guide for People on a Waiting List” – Modify information for people currently on Waivers – Double check to make sure the individual and/or the family understand the process – Answer questions throughout the conversation

67 Step 2: Having a Face-to-Face Conversation…continued Check to ensure that the person continues to be functionally eligible – update the functional screen if needed. With the individual’s needs in mind, review potential services or benefits that may be available to the individual.

68 Step 2: Having a Face-to-Face Conversation… continued Educate the consumer about Managed Care and IRIS. Explore which Long-Term Care Option is best for this person. – How much of her care does the person want to manage on her own?

69 Step 2: Having a conversation…continued Resource materials “Which Long-term Care Option is Best for Me?” “Tell Me More about…Family Care” “Tell Me More about…Family Care Partnership” “Tell Me More about….Self-Directed Supports in Managed Long-Term Care” “Tell Me More about…The Self-Directed Supports Waiver - IRIS “

70 Step 2: Selecting Long Term Care Program of Choice The consumer compares and selects the program that is best for him/her. In some areas, individuals may have more than one Managed Care Organization to choose from – Utilize the “Managed Care Organization Matrix” For individuals who choose IRIS, provide information about the roles of the ICA and FSA. Having a Conversation…

71 Step 3: Applying for Medicaid/Updating Records Gather medical remedial information if appropriate Provide Income Maintenance (IM) pertinent information Use Centralized Processing if appropriate

72 Step 4: Enrolling If the individual’s financial eligibility information was up-dated, share information about his/her eligibility status (cost-share) If a Managed Care option is selected, learn what date the individual wants to enroll or begin services, complete the enrollment form and communicate information to Income Maintenance (IM) and MCO If IRIS is selected, refer the individual to the Independent Consultant Agency where the service plan is developed and start date selected. Note for new enrollees: Cost shares are NOT pro-rated in Managed Care, so be sure enrollment dates are chosen with this in mind. Cost- shares ARE pro-rated in IRIS.

73 Step 5: Services Begin! If the individual chooses a managed care program, he/she will take a place on the care team and the coordination and delivery of services will begin. If the individual chooses IRIS, once the start date is selected services begin on that date.

74 Step 5: Services Begin continued Remind consumers who to turn to if they have questions or concerns; there is always someone to assist. If the individual is enrolled in a Managed Care program they can communicate their concerns to their care team or member advocate. If the individual is enrolled in IRIS he or she can contact the Independent Consultant to share any concerns or questions.

75 Reminder of Resource Centered Technical Assistance Documents Enrollment Plan Enrollment Counseling Handouts – “Key Differences Between Managed Care & Fee-for Service Programs” – “Which Long-term Care Option is Best for Me?” – “Tell Me More about…The Self-Directed Supports Waiver - IRIS“ – “Tell Me More about…Family Care” – “Tell Me More about….Self-Directed Supports in Family Care” The consumer compares and selects the program that is best for him or her Remember to dose information

76 Additional Reference materials Being a Full Partner Booklet Member Handbooks Provider Directories Questions about Family Care for People with Disabilities MCO website: IRIS website:

77 Options Counseling Tool Kit Four Sections 1. Introductory Video 2. Communication Module Web casts 4. Supportive Materials Sample webcasts in the tool kit Assistive Technology Spousal Impoverishment Lien Law & Estate Recovery Legal Decision making tools Medicare Choices in Assisted Living

78 Disenrollment The ADRC provides counseling regarding potential disenrollment. Individuals can disenroll at any time. ADRC helps individuals think through this option. Remember some individuals who disenroll will lose Medicaid if he/she has Medicaid via waiver participation. If the individual does choose another publicly funded long-term care option, work with him/her to ensure continuity of service.

79 Wrap-up Time of change. People will have opportunities to choose from two or more programs. Your knowledge and skill is essential in helping people learn about these options and think through these choices. Looking ahead to….No Waitlists!

80 Contact information ADRCs are encouraged to questions to the Office for Resource Center Development at Questions regarding ……… Managed Care Programs Self-Directed Supports Waiver