aIPAM Fall Conference

Presented by: Lisa Fox & Maggie Goncerzewicz

Today’s Agenda

• Affordable Care Act

• Health Insurance

Marketplace(Exchange)

• Risk Adjustment

• ICD-10

• MMAI

Affordable Care Act

We Are Part Of The Largest Health Care Changes IN US HISTORY

Almost 50 million Americans without health insurance. The Affordable Care Act (ACA) will extend coverage to the uninsured Americans.

Affordable Care Act

• BCBS website • Sign up for email alerts

• Look for local seminars and

events

Stay Informed:

Internet Resources

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Health Insurance Marketplace

Marketplace

An online tool enabling a member to shop The statewide Marketplace

Cost of Product Health Insurance

Marketplace

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Provide toll-free hotline for assistance Help eligible

individuals get federal tax credits

& subsidies

Inform consumers about

individual mandate exemptions

Screen for Medicaid/CHIP eligibility and

enroll if eligible

Public Exchanges

Perform Risk Adjustment

Run state websites that allow consumers to shop for qualified

health plans

Help consumers and employers choose &

enroll in coverage

This presentation is a high-level summary and for general informational purposes only. The information in this presentation is not comprehensive and does not constitute legal, tax, compliance or other advice or guidance.

Marketplace

New online sites launch October 2013

Individual Small Group 2-50

Marketplace

Individuals who cannot afford

coverage

Taxpayers with income below the

filing threshold

Members of Indian tribes

Hardship

Individuals who experience short

coverage gaps

Who is Exempt?

Religious conscience

Members of a health care

sharing ministry

Incarcerated individuals

Individuals who are not lawfully

present

Marketplace

Platinum

Gold

Silver

Bronze

Expected Percentage of Medical Expenses Covered by the Health Plan

Expected Percentage of Medical Expenses Covered by the Member

90% (AV)

80% (AV)

70% (AV)

60% (AV)

The key difference between the “metallic” plans is the expected percentage of medical expenses shared between the health plan and the member.

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• 90% Actuarial Value (AV)

• 80% Actuarial Value (AV)

• 70% Actuarial Value (AV)

• 60% Actuarial Value (AV)

Platinum Gold Silver Bronze

Individual and insured small group plans, sold on and off the exchange, will have to meet one of four metallic levels that correspond to plan actuarial value.

Catastrophic coverage will be available on an exchange, for individuals under age 30 or individuals who received certification for lack of affordable coverage or financial hardship.

Actuarial Thresholds (Metallic Levels)

Marketplace

Essential Health Benefits

Ambulatory patient services

Emergency services

Hospitalization Maternity and newborn care

Mental health and substance

abuse services

Prescription drugs Habilitative and rehabilitative services and

devices

Laboratory services

Preventive and wellness services,

disease management

Pediatric care including oral and

vision care

Marketplace

www.bcbsil.com/reformandyou

www.becoveredillinois.org

Internet resources

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Risk Adjustment

What is Risk Adjustment?

Risk Adjustment is an ACA program designed to identify the differences in health care risk among specific patients, which results in the ability to compare care and cost performance fairly by,

analyzing different types of health care data with a variety of statistical models to explain an outcome, adjusting for the differences in such factors as member age, gender and diagnoses

Risk Score

Demographics Health status

female

Age 72

male

Age 38

Age 29 Anxiety

Diabetes Emphysema

Asthma

Hypertension

Eczema

Risk Adjustment

Risk Adjustment

Risk Marker Risk

Weight

Male, Age 32 0.22

Total Risk Score 0.22

Risk Marker Risk

Weight

Male, Age 32 0.22

Diabetes with significant co-morbidities

1.32

Asthma/COPD 0.96

Low cost dermatology 0.30

Total Risk Score 2.80

Risk Adjustment

Risk Score Cost of care

2.2 $$$

Risk Adjustment

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Currently used for Medicare Advantage and Medicaid

Transfer of money from health plans with low risk scores to those with high risk scores, to provide plans additional funding for the treatment of the highest risk scored members

Risk Adjustment

Risk Adjustment

Physician’s Role and Risk Score Drivers :

Ensure the medical records show conditions that are being monitored, evaluated, assessed or treated (MEAT) for each condition relating to a diagnosis code on the date of service.

Documentation should be clear, concise, consistent, complete and legible.

CLINICAL DOCUMENTATION

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ICD -10

Introducing ICD-10 141,000 new codes.

October 2014.

Will you be ready?

W56.42XA Struck by shark, initial encounter

V95.40XD Unspecified spacecraft accident

injuring occupant

V91.07XA Burn due to water-skis on fire

T63.122A Toxic effect of venom of other venomous lizard, intentional self-harm

ICD-10 Yeah, there’s a code for that!

THE END Or is it just the beginning?

Visit www.bcbsil.com/provider for more information and resources.

Get to know ICD-10 It changes everything!

35 February 2011: ANSI v5010 / ICD-10

ICD-9-CM ICD-10-CM

3-5 characters Approximately 14,000 codes 1st character may be alpha (E or V) or numeric Limited room for new codes Lacks detail Lacks laterality Non-specific codification issues Not interoperable with other countries (WHO has adopted ICD-10)

3-7 characters Approximately 140,000 codes 1st character alpha; characters 2-3 are numeric; 4-7 are alphanumeric Flexibility to add new codes Very specific Includes laterality Improved accuracy and richness of codification Interoperable with global community (adopted in 99 countries)

X99.99 X99.XXX

What You Need to Know

36 February 2011: ANSI v5010 / ICD-10

ICD-10-CM Structure (Diagnosis Volumes 1 & 2): 3 to 6 position code with leading alpha (+ extension)

Note: ICD-9-CM diagnosis was 3 to 5 position numeric except V and E

. X X X X X X X Category

Etiology, anatomic site, severity

Extension

What You Need to Know

What Does This Mean?

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Medicare Medicaid Alignment Initiative

MMAI Initiative

Medicare Medicaid Alignment Initiative (MMAI) is effective January 1, 2014 and administers Medicare and Medicaid benefits jointly so duals experience health coverage as a single integrated program. MMAI establishes a single point of accountability for the delivery and coordination of primary, acute,

behavioral health and long term care supports and services.

Targeted Counties

1. Cook

2. DuPage

3. Kane

4. Kankakee

5. Lake

6. Will

1 3

6 4

2

5

Potential Enrollment

Cook – 93,574

DuPage – 7,107

Kane - 5134

Kankakee – 1,889

Lake – 5,565

Will – 4,781

1 3

6 4

2

5

Contracted Providers

Federally Qualified Health Centers (FQHC’s)

Community Mental Health Centers (CMHC’s)

Hospitals

Ambulatory Surgery Centers (ASC’s) Independent Physicians

Ancillary Providers (SNF, Home Health, Hospice, DME)

IPA’s

Long Term Services & Support (LTSS)

Training

The Centers for Medicaid and Medicare Services (CMS) and the State of Illinois require that the Blue Cross and Blue Shield of Illinois Plan train MMAI contracted providers, prior to the program implementation date of

January 1, 2014, on the following topics: • Patient Centered Practice • Care Coordination • Cultural Competency • Disability Literacy • Compliance with the Americans with Disability Act • Independent Living and Recovery Health • Safety and Welfare (Abuse, Neglect and Financial Exploitation Recognition and Prevention) • Wellness Principles

Training Detail

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Providers can choose the seminar location they prefer to attend per their contract

Providers are required to attend a session

Held at contracted hospital facilities

October - December

LTSS training will be conducted at neighborhood locations/community centers