Statewide Legal Aid Conference October 17, 2017
Statewide Legal Aid Conference – October 17, 2017
The Role of the CCC Plus Advocate
Background
- The Office of the Long-Term Care Ombudsman was awarded the CMS grant in 2014 for Support for Demonstration Ombudsman Programs Serving Beneficiaries of Financial Alignment Models for Medicare-Medicaid Enrollees. Advocate assistance ends December 2017 when Duals CCC Members transition to CCC Plus.
- Beginning January 2019, Medicaid Managed Care Rules and Regulations requires every State offering a Managed Long-Term Services and Supports (MLTSS) program to provide enrollees of that program with an independent beneficiary support system to perform outreach to beneficiaries, serve as an access point for beneficiaries issuing complaints about the MLTSS Managed Care Organization (MCO) and assist beneficiaries navigate MCO grievance and appeals process and provide DMAS with guidance on the identification and remediation of systemic issues.
Commonwealth Coordinated Care Plus Managed CareAdvocate Program
The Virginia Department for Aging & Rehabilitative Services Long-Term Care Ombudsman Programworks to ensure individual beneficiaries have access to person-centered assistance in resolving problems related to their care and services underCCC Plus.
Managed Care Advocates will:
Provide beneficiary assistance in understanding member rights and responsibilities under the CCC Plus Program;
Assist members to resolve enrollment and disenrollment issues;
Assistance with access to needed health care services including behavioral health services, prescriptions and long-term services and supports;
Payments, claims and billing issues;
Access to Care Coordinator;
Self-determination and supported decision making issues;
Person centered assistance without conflict of interest;
Track problems reported and provide recommendations for quality improvement;
Provide assistance with Grievances and Appeals;
*Assistance with navigation, appealing adverse benefit determinations to a State fair hearing, and referrals to sources of legal representation
Managed Care (CCC) Top Issues by Reporting Categories
CCC Enrollment/Disenrollment Issues
Other Benefits/Access Issues (Authorization transition problems)
Pharmacy Issues (Part D)
Access to Care Coordinator
Payments/Claims
Access to Health Services
Supplies/Medical Equipment
Hospital/Physician/PCP Assignment
Self-Determination/Communication Issues
Quality of Care
Some Lessons Learned with CCC → CCC Plus
- Education, education, education
- Advocate information on letters and MCO notifications of adverse decisions
- Getting Help Toolkit information for Beneficiaries
- Information about grievances and appeals
- On-going reporting to DMAS and MCO’s
- More specific complaint categories – MCO’s, Regions,
- Member feedback - Take Listening sessions to the Members
A Couple of Coordinated Care Advocate Case Examples
Case Example 1
KF is a Transportation Coordinator with a nursing facility in the Valley Region. KF reported three residents
that experienced transportation issueswith two CCC Plus MCO Plans and their designated transportation
vendors.The residents did not receive timely and transportation services to needed therapies and
medicalappointments. KF had tried contacting the MCO’s but she was not receiving needed call-backs
from theMCO’s.
The Coordinated Care Advocate contacted the MCO Care Managers and also called additional MCO staff
to escalate the need for follow up communication with the nursing facility transportation director and
to re-schedule the members’ transportation right away. Both MCO’s followed up with KF. The
Coordinated Care Advocate followed up again with both MCO’s and KF to ensure resolution.
Case Example 2
At DMAS Member Town Hall meeting a Coordinated Care Advocate met a parent with multiple disabilities
and medical needs who was enrolled in CCC Plus September 1, 2017. There was extensive case work prior
to his enrollment due to the complexity of needs. The CCC Advocate assisted the parent in understanding
the options and how she could change plans for her child. There was a great deal of fear and concern
voiced to the Advocate because of the many services and supports needed to be in place – some of those
life-sustaining such as breathing treatments, highly specialized medications, DME, etc.
The Advocate contacted DMAS for intervention because of some denials for essential supplies prior
to CCC Plus enrollment. One of the more important aspects was to work with the Care Coordination
Supervisor to ensure that this member would be reached immediately upon enrollment with a specialized
Care Coordinator. Because of the urgency of need, the Advocate made sure there were no breaks in
Availability of life-sustaining equipment and checked to see that someone had been assigned and the
Case would be prioritized. If Care Coordination works well, this will be an example of how care
Coordination can truly be a resource and support for members with complex needs,
For more information, contact the Coordinated Care Advocate Manager, at the State Long-Term Care Ombudsman Office at 1-800-552-5019 or804-662-7162 or