Ideas for Care Coordination Presented to the Kentucky Department for Medicaid Services April 7, 2004 In Response to The Request for Information

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Passport Advantage A Special Needs Plan for Dual
Eligibles April 20, 2006
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Organizational Structure
CMS
University Health Care, Inc. dba Passport
Advantage Larry N. Cook, M.D. President
Chairman of the Board
Region 3 Medicaid Partnership Council Bill
Wagner- Chairman
Robert Slaton, Ed.D. Executive Vice President
AmeriHealth Mercy Health Plan Joyce Hagen -
President, Passport Advantage
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Organization and Governance
University Health Care, HMORisk bearing
entitySection 501(c)(3) tax-exempt organization

• Original Funders
• University of Louisville Medical School Practice
  Association (51)
• Jewish Hospital St. Marys Healthcare (13)
• Norton Healthcare (13)
• University Medical Center, Inc. (13)
• Louisville-Jefferson County Primary Care
  Association(10)
• Family Health Center, Inc. (FQHC)
• Jefferson County Health Department
• Park DuValle Community Health Center, Inc.
  (FQHC)
• University of Louisville Primary Care Center

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Region 3 Partnership Council Committee Structure
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Why Develop a Special Needs Plan?

• As a result of the Medicare Modernization Act,
  Passport Health Plan applied to become a Medicare
  Advantage Special Needs Plan for its aged, blind,
  and disabled members who are also eligible for
  Medicare.
• Absent a CMS contract, Passport Health Plan would
  have lost the ability to manage pharmacy benefits
  and ultimately, quality and continuity of care,
  for these dual eligible members.

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Why Develop a Special Needs Plan?

• As a Medicare Advantage Special Needs Plan,
  Passport Advantage is able to manage both
  Medicare and Medicaid benefits, thereby providing
  better coordinated care for this vulnerable
  population.

Passport Health Plan was influential in achieving
passive enrollment process
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Members Eligible to Participate

• Only dually eligible beneficiaries currently
  enrolled in Passport Health Plan.
• All categories of beneficiaries (aged, disabled,
  and ESRD).
• Approximately 10,500 members.
• Passport Advantage provides Medicare Parts A, B
  D

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Members Eligible to Participate
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Dual Eligible Demographics
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Implementation Challenges

• New product organizational stress.
• CMS eligibility file delays.
• System set-up error.
• Original eligibility file received mid-January.
• (ID card contingency plan, interim payment).
• Still resolving last of January 1 eligibility
  issues.
• Confusion over Part D eligibility
  (reconciliation).

Eligibility and Part D confusion at retail
pharmacy caused greatest operational issues
during immediate go-live
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Part D Implementation

• Provided frequent written communications to
  inform/educate pharmacists about Part D benefit.
• Plan staff visited high volume pharmacies to
  explain Passport Advantage and Part D benefit.
• List of Passport Health Plan members sent to
  pharmacies where duals routinely had
  prescriptions filled to facilitate transition
  from Passport Health Plan to Passport Advantage.

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Part D Implementation

• Decision made on January 1 to cover prescriptions
  for Passport Health Plan duals when pharmacy
  could not confirm enrollment in any Part D plan.
• Worked closely with PBM (PerformRX) to assure
  access to prescriptions.
• Redirected some pharmacy calls from PBM to Plan
  due to unexpected call volume during first
  several weeks.

Passport Health Plan and Passport Advantage
recognized by local pharmacies and legislators
as plan with best Part D transition
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Continuity of Care Provider Network

• Non-contracted providers paid 100 of Medicare
  payment amount.
• Contracted providers receive higher
  reimbursement.

Minimize member disruption and maintain
continuity of care
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Medical Management
Shift in Approach
Care Coordination

• Progressive Proactive Approach
• Health Assessment
• Member Education
• Member Empowerment
• Preventive Health Management
• Wellness Awareness
• Disease Management
• Member Advocacy
• Predictive Modeling
• Member Safety

• Traditional Reactive Approach
• Utilization Management
• Case Management

Shift from reactive to proactive approach
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Health Management Solutions

• healthy Now (member educational articles)
• Preventive health outreach letters, postcards,
  phone calls, website
• Health risk assessment at enrollment
• 24/7 nurse advice line and audio library

Well Members
Low/ModerateRisk Members

• Utilization management
• Member outreach via letters, postcards, phone
  calls
• Case management

• Specialized Case Management
• i.e., Palliative Care, HIV, Transplant
• Disease Management
• Diabetes
• Asthma
• COPD
• CAD

High Risk Members
Targeted interventions based on member health risk
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Advocate Community Support

• Supported advocate education to address confusion
  over pharmacy benefits transitioning to Part D.
• Participation on new Medicare Advantage
  committees.

Support of advocates critical for member
recruitment and retention.
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Key Success Factors

• Provider sponsored.
• Partnership model.
• Extensive physician/clinician involvement in
  developing, implementing and managing the plan.
• Collaboration with community agencies and health
  departments.
• Extensive provider network and enhanced
  reimbursement.
• Member satisfaction and involvement.
• Proactive care coordination model.

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Questions and Answers