Download Tufts Health Unify training document

Tufts Health Unify
A One Care plan (Medicare-Medicaid)
for people ages 21-64
March 16, 2017
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About Tufts Health Plan
Founded in 1979, Tufts Health plan is a nonprofit organization nationally
recognized for its commitment to innovative, high-quality health care coverage.
Our plans offer an array of health management programs, which support
evidence-based approaches to health and wellness.
 Tufts Health Public Plans, Inc. (THPP) is a licensed health maintenance
organization but does business under the name Tufts Health Plan. THPP is
the legal name of our division of Tufts Health Plan.
 Our headquarters is located in Watertown, Massachusetts.
 Tufts Health Public Plans was rated 4.5 out of 5 among health insurance
plans in NCQA’s Medicaid Health Insurance Plan Ratings in 2015-2016 and
was the No. 1 Medicaid Health Plan in the U.S. for 2014-2015.
 We currently offer three plans in Massachusetts:
-
Tufts Health Together (MassHealth)
Tufts Health Direct (a focused-network plan for individuals and small
groups)
Tufts Health Unify (Medicare-Medicaid Plan), a One Care plan for people
ages 21-64
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Tufts Health Plan’s mission and vision
Our mission
 To improve the lives of the diverse communities we serve
Our vision
 Every life improved through access to high-quality, affordable health care
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About One Care
•
Starting in 2013, MassHealth (Medicaid) and Medicare joined
together with health plans in Massachusetts to offer One Care.
•
One Care is an easier option for people with disabilities to get
the full set of services provided by both MassHealth and
Medicare.
•
With One Care, a patient has one plan, one card and one
person to coordinate their care, in addition to their health care
providers.
•
By bringing care together, we support patients to live healthier,
more active lives in the community.
•
For more information about One Care or provider trainings,
please visit: http://www.mass.gov/eohhs/consumer/insurance/one-care/
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Tufts Health Unify, a One Care plan
•
Tufts Health Unify is a plan that participates in a demonstration program
integrating Medicare and Medicaid benefits into the One Care program in
Worcester and Suffolk counties.
•
In April 2017, Tufts Health Unify is expanding its service area into the greater
Lowell region.*
•
Tufts Health Unify is the first Medicare-Medicaid plan in Massachusetts to
expand its footprint since the launch of the duals demonstration program in
October 2013.
•
For more information about Tufts Health Unify, please visit:
tuftshealthplan.com/provider/our-plans/tufts-health-unify
•
Tufts Health Unify covers eligible Massachusetts residents, ages 21-64. Eligible
enrollees may have one or more of the following health care needs:
•
•
•
Physical and developmental disabilities
Mental illness and/or substance use disorders
Chronic illnesses and/or cognitive limitations
*For a complete listing of expanded zip codes, see next slide.
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Tufts Health Unify expansion
The following table includes the zip codes of the April 2017
service area expansion:
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City/town
Zip codes
Billerica
01821, 01822
Chelmsford
01824
Dracut
01826
Lowell
01850, 01851, 01852, 01853, 01854
North Billerica
01862
North Chelmsford
01863
Tewksbury
01876
Tyngsboro
01879
Westford
01886
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Key goals
•
The aim of Tufts Health Unify is to provide better care at lower
costs through improved care coordination for members. This is
achieved through collaboration with our providers, a dedicated
care team and personal care support.
•
Recognize and address care needs holistically, keeping
enrollees central in their own care plans
•
Improve quality of care by addressing Member needs across
the care continuum
•
•
•
Promote independence in the community
Improve health and functional outcomes
Collaborate with care providers
Footnote area
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Tufts Health Unify
Model of care
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Philosophy of care management model
•
“Nothing
Our care model is member-centric and
focused on the needs, values and preferences
of individual members
•
without
Our efforts focus on areas where we make a
meaningful difference for our member
•
Care planning is inclusive and based on the
principle of shared decisions between
members and their interdisciplinary team
•
Care coordination is designed around a
collaborative and inter-professional model of
care management
•
Care management strategies follow the
member’s “personal” commitment to overall
health management and self-direction
about me
me.”
Gorski, David. “Dr. Donald Berwick and “patient-centered” medicine: Letting the woo into the new health care law?”. Jul 20
2010. https://sciencebasedmedicine.org/dr-donald-berwick-and-patient-centered-medicine-letting-the-woo-into-the-newhealth-care-law/
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Key principles
•
•
All members are assigned their own care manager
•
Member assessments and reassessments are conducted to
ensure a foundation for effective and member-centric care
management and ongoing attention to a member’s changing
needs
•
Activities of Daily Living (ADL) and Independent Activities of
Daily Living (IADL) assessments are conducted to enable
access to supportive services, which have demonstrated
independence and self-directed care in the community
Primary care management contributes to a personal and
member-centric approach, built on trust and collaboration
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Care management framework
•
An interdisciplinary care team (ICT) of medical, behavioral
and social care management offers a holistic care
management approach to meet the needs of members who
are clinically complex and vulnerable
•
The Primary Care Physician (PCP) is a critical component of
the member’s ICT, as well as other providers, such as
specialists, community-based organizations and personal
supports
•
Care management, in collaboration with the PCP and other
Utilization Management clinicians, focuses on cost-effective
service planning that promotes wellness, reducing high-cost
services whenever possible
•
Members are stratified based on complexity, including
potential for clinical exacerbation and/or unstable support
and living situations
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Care plan/central enrollee record (CP/CER)
Set up a Tufts Health Provider Connect* account. The member
account can be set up through Tufts Health Member Connect.*
Tufts Health Provider Connect is our convenient self-service
tool that allows you to:
•
•
•
•
View claims and enrollee-reported health information
•
Automate data entry and medical record consistency
Facilitate ICT collaboration
Allow members to access their own care plan
Enable members to delegate records access via variable
permission levels
For questions, please call Provider Services at 888.257.1985.
To access Tufts Health Provider Connect go to: https://thpprovider.healthtrioconnect.com/app/index.page?
To access Tufts Health Member Connect go to: https://thpmember.healthtrioconnect.com/index.cfm?
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Care management process
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Member signs up for
Tufts Health Unify plan
Care manager
completes a
comprehensive
assessment, including
LTSS needs
Care manager and
member create personal
care plan within first 90
days
Member and care
manager develop the
ICT listing and review
care plan with ICT and
obtain member’s
consent
Care manager uploads
key information into the
CP/CER
(Provider Connect
portal)
ICT ensures delivery of
appropriate care
ICT confers per the
request of member
and/or per member’s
level of care
Care manager
reassesses member and
updates the ICT and
care plan
Continual outreach to
determine member
engagement and
assessment of needs
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Behavioral health model of care
Emergency
Services
Program
Partial
Hospitalization
Program
In-home
therapy
Primary
Care
Provider
(PCP)
Member
Specialists
& Other
Ancillary
Providers
(inclusive of
advocate &
family)
Tufts
Health Plan
Care
Manager
Community
Crisis
Stabilization
Services
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Enhanced
Acute
Treatment
Services
Interdisciplinary
Care Team
Group
Counseling
Structured
Outpatient
Addiction
Program
Tufts Health Plan’s model
of care is designed around
an interdisciplinary care
team that is memberfocused.
Other
Member
Supports
Psychiatric
Day
Treatment
Community
Support
Services
Clubhouse
Long-term
Services
and
Acute
Supports
treatment
(LTSS)
Services
(detox)
Peer
Support
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Coordination of health
services, including mental
health, substance use,
and primary care, is
necessary to achieve
positive outcomes for
people with complex
health care needs.
Tufts Health Unify: Member impact story (pt. 1)
A female member in her 50s moved to Boston several years ago from
the South and found herself homeless. In October 2016, she met with
her Tufts Health Unify care manager for the first time. She reported to
her care manager that her mother had died a year ago and that she
had a relapse with heroin. She had been “off” of it for 30 years. She
did, however, use cannabis, cocaine, ETOH and pills. She had also been
assaulted the previous year and sustained a head injury, which she said
makes her forgetful. Medically, she has COPD, PAF, hepatitis C, CHF,
adrenal insufficiency and hypertension. She also has been diagnosed
with anxiety, depression, bipolar disorder and ETOH dependence.
Soon after her meeting, she had a PCP appointment and reported being
on 20 different medications, including methadone. She was staying at a
recovery home for women that managed her medications. She reported
that her time ran out at the recovery home and that she needed help
finding a place to live.
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Tufts Health Unify: Member impact story (pt. 2)
The member’s care manager worked with her to set goals so she could
become healthier and more independent. A referral was placed to a
community health worker through the Tufts Health Unify program to help
with housing, appointments and transitioning her to the community. The
member agreed to the plan of care and agreed to work with her PCP and
nutritionist. Over time, the care manager assisted the member with housing,
follow-up from ER visits, medical management coordination with the VNA,
and Tufts Health Unify transportation logistics.
As of 2017, the member is living independently in her own apartment and
going to the methadone clinic daily. She has had no ER visits recently and
has been working collaboratively with her care team and the help of a
visiting nurse to manage medications and dietary needs. In addition, her
care manager helped her find a dentist, and she is now getting dental care.
She loves living independently and is looking for a part-time job. Her care
manager and interdisciplinary care team discuss her progress and make
adjustments with her as needed.
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Assessment drives care planning
Members receive the following assessments to help determine
their care plan:
 Tufts Health Unify comprehensive assessment
 Minimum Data Set-Home Care (MDS-HC), if applicable
 LTSS assessment for independent living, performed by an LTSS coordinator
 Reassessments take place annually, or more frequently with changes in
health status
The ICT creates a plan based on the comprehensive initial
assessment, LTSS assessment and the doctor’s treatment plan.
Plans include the member’s:
 Care plan with interventions and goals
 Support services
 Agreement on treatment plan
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What does inter-professionalism look like?
Inter-professional
collaboration
MCO care manager
Clinical view
•
Assessment
•
Care planning
•
Care coordination
• Providers
• Services
•
•
•
•
•
•
Shared strategy: assessment
and care planning
Collective action
Common goal
Interdependence
Negotiated agreement
Trusting relationships
LTSS coordinator
Social support view
• Assessment
• Care planning
• Social determinants
• Care coordination
•
Wellness
•
Independence
•
Recovery
The integrated model of care requires alignment between the MCO care
manager and LTSS coordinator. An inter-professional collaboration
framework can shift practice from individual contributions to shared goals
and mutual accountability for member outcomes.
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2017 care management overview driven by
complexity of care
Complex
• Care management outreach: At least weekly
• ICT meetings: At least every 6-8 weeks
High
• Care management outreach: At least every two weeks
• ICT meetings: At least every 6-8 weeks
Medium
• Care management outreach: At least every 6-8 weeks
• ICT meetings: At least one meeting quarterly
Low
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• Care management outreach: At least quarterly
• ICT meetings: At least semi-annually
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Quality measurement and performance
improvement programs
•
Quality management is designed to address population health
outcomes, utilization management priorities, disease management
opportunities and provider and member satisfaction
•
Performance improvement initiatives are prioritized based on
internal and external benchmarks and regulatory requirements,
including but not limited to:
•
•
•
•
•
•
•
Improving access to care
Affordable health service delivery
Coordination of care and care planning
Preventive services
Health care transitions
Operational work flows targeting efficiency and efficacy
Quality improvement initiatives promote PCP engagement
whenever feasible, including leveraging any existing programs
and/or population/member-specific focus areas
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PCP collaboration and care management
commitment
•
PCP engagement is encouraged whenever possible, and includes
the engagement of dedicated clinical and administrative staff, as
necessary
•
Shared strategies between the PCP and care management team
will drive positive member experiences and promote their
independence and compliance with medical and behavioral
treatment plans
•
Care management oversight, including effective and timely
coordination of all services, will strive to ensure member stability in
between office visits
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Tufts Health Unify:
Doing business with us
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Doing business with us
As a Tufts Health Public Plans contracted provider, you get:
 A comprehensive approach to care for your Tufts Health Unify
patients
 A dedicated provider relations team to provide support and keep
you informed
 Ability to check member eligibility, authorization status and claims
status through our secure and online self-service tool,
Tufts Health Provider Connect,* and by calling us at
888.257.1985.
 Educational materials for your patients (e.g., information about
benefits and services and displays for your office)
 A dedicated claims team to ensure you get prompt payment for
electronic and paper claims
 Multilingual, multicultural customer service for your patients
* To access Tufts Health Provider Connect go to: https://thpprovider.healthtrioconnect.com/app/index.page?
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What to do before patient care
Verify
patient
eligibility
Provide
equal
appointment
availability
Confirm
patient is
in your
panel
Check for
thirdparty
liability
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Request or
check
authorization
status
Request
or check
referral
status
How to verify eligibility on date of service
Check the Eligibility
Verification System
(EVS)
MassHealth’s EVS, 800.554.0042
Have your MassHealth provider number or
National Provider Identification (NPI)
number and password ready.
Go online
Tufts Health Provider Connect*
NEHEN
New England Healthcare Exchange Network
(NEHEN) or NEHENNet
Call us
Our 24/7 member eligibility line,
888.257.1985
Call MassHealth
24/7 automated line, 888.665.9993
* To access Tufts Health Provider Connect, go to: https://thpprovider.healthtrioconnect.com/app/index.page?
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What to do after patient care
1. Please file claims no later than 60 days after service
• Submit claims online using Tufts Health Provider Connect or on
paper by mailing them to:
Tufts Health Plan
P.O. Box 859
Park Ridge, IL 60068-0859
• You may submit claims through the EDI. Please contact the
EDI Operations Department with any questions or requests for
set up at 888.880.8699 ext. 54052 or email at
[email protected]
2. Check the claim’s status by going to Tufts Health Provider Connect
(thpprovider.healthtrioconnect.com/app/index.page?)
3. File a request for the claim’s review within 90 days of the EOP
(Explanation of Payment)
• You may find the Request for Claim Review form on our
website in the Provider Resource Center at
tuftshealthplan.com.
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Provider checklist
Have you taken the following actions?
 Register for Provider Update, our quarterly newsletter
Go to: tuftshealthplan.com/provider/provider-email-capture
 Register to access our secure provider portal,
Tufts Health Provider Connect, and enjoy one-stop access for member
eligibility clams, authorizations and panel reports
Go to: tuftshealthplan.com/provider/provider-register-for-secure-access
 Fill out the Medical or Behavioral Health Provider Information Form
available in the Provider Resource Center at tuftshealthplan.com/provider
 Set up direct deposit and get paid faster:
Go to emdeon.com to enroll or call Emdeon at 866.506.2830 for
instructions on how to enroll by mail or fax
 Review the Tufts Health Provider Manual available in the Provider
Resource Center at tuftshealthplan.com/provider
 Call Provider Services if you have any questions: 888.257.1985
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Provider resources
Provider Resource
Guide
A resource guide to help you get the information you need to do
business with us.
Read payment policies and coverage guidelines; use our
tuftshealthplan.com searchable preferred drug list; find a doctor, hospital, or
pharmacy; and download benefit summaries, coverage area maps,
forms and clinical practice guidelines.
Provider Update
Read our quarterly e-newsletter to get updates about pharmacy
policies and coverage guidelines, pharmacy and preferred drug list
changes, important business changes and regulatory
requirements. Go here to sign up for Provider Update.
Provider Manual
The annually updated Provider Manual is a tool to keep you
updated on policies and procedures, as well as information about
federal and state regulatory requirements that may affect
participating providers.
Provider Connect
Our secure online portal that allows you to check the status of a
claim, verify member eligibility, check panel assignments, get
remittance advice and view and download Explanations of
Payment.
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Please remember
•
•
Always bill Tufts Health Plan, not MassHealth or the member.
•
Be sure to register your email with us to receive important
updates. (https://tuftshealthplan.com/provider/provider-email-capture)
Quarterly, you will receive a notification from
Tufts Health Plan requesting that you verify whether your
information is accurate. Please take the time to update your
information if it is inaccurate.
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Thank you. Any questions?
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