CareSource and L.A. Care are two plans following different models for transitioning dual eligible beneficiaries to their Medicare-Medicaid plans but have similarities when it comes to data sharing and developing a health neighborhood.
They are among demonstration plans contracted with the Centers for Medicare & Medicaid Services and states to contain costs with managed fee-for-service and capitated models, to improve care with more coordination for beneficiaries, many of whom have a number of complex and chronic medical and non-medical needs that impact each other.
CareSource, a managed Medicaid plan in Dayton, Ohio, will offer a duals plan in partnership with Humana in Cleveland, Akron and Youngstown. Voluntary enrollment starts in March 2014 and mandatory enrollment follows on a monthly basis, said Janet Grant, CareSource executive vice president of external affairs and corporate compliance officer.
"By July of 2014 we should have all regions live across the state," she said at a recent conference sponsored by America's Health Insurance Plans in Washington. "Eligibles will be able to opt out as in all of the states on the Medicare side, but Ohio has received a [Section] 1915 waiver to mandate on the Medicaid side, including behavioral health and long term care services."
CareSource has a strategy in the first year to consider the use of more quality metrics and then to narrow their network to the highest quality providers going forward.
Providers and social and health services, such as agencies on aging, partner with the health plans on care coordination. "They already have sophisticated care management capabilities within those agencies," Grant said. Agencies on aging have administered a large home- and community-based system of services for seniors.
Health plans also for the first time in Ohio are contracting directly with community mental health centers and integrating mental and physical health. For those centers that are acting as health homes within the community mental health system, they will be the primary care management for individuals who are in both the health homes and in the demo, she said.
"We have built fairly sophisticated systems along with those relationships in order to have data sharing and developed methods for integrating historical data so that they will have a good idea when patients come in whom they have been seeing and the services that they have received right at the first contact that our care management team makes," Grant said.
Bruce Pollack, senior director for the project management office at L.A. Care Health Plan, said that the California dual eligible program, referred to as Cal MediConnect, will provide similar comprehensive health, medical, behavioral and social services and better care coordination starting next year.
Duals members in Los Angeles County will enroll in either HealthNet or L.A. Care, which operates and manages a direct network of contracted provider groups and hospitals. In L.A. Care's delegated model, physicians may participate in several medical groups and the medical groups will have contracts with multiple health plans.
Like CareSource, L.A. Care needs to access beneficiaries' historical Medicare and Medicaid claims in order to know how to line up care with the right doctor. And various assessments conducted by community organizations are all housed in different places.
"But we are convinced that if we can gather all the information, it will feed into the proper risk stratification, health risk assessment process and care plan development," Pollack said.
Many of the community-based programs, such as in-home support services, mental health, substance abuse and multi-purpose senior services, will be brought into the interdisciplinary care team, he said.
"All the data is going to feed into one big pot and help us by connecting members with their services, transitions of care, continuity of care concerns and the risk assessment," he said. "When we get the data, we can set up the right programs and care plans and connect all the members of the team, and that will get us off to a good start."