Care Coordination between Medicare Advantage (MA) DSNPs,Managed Care Organizations and Long-term Care

Care Coordination

Requires collaboration between Medicare Advantage (MA) Dual Special Need Plans (DSNP), Managed Care Organizations (MCOs) and the Medicaid Long-term care (LTC) system. Collaborative care coordination increases the beneficiary’s ability to return to and remain in the community, by ensuring the right support(s) are in place. Many of Washington’s most vulnerable are dually eligible individuals who have both LTC and, are also enrolled in an MA DSNP making coordination between these two systems of care critical to avoid unnecessary inpatient stays or health complications. Utilizing a collaborative care coordination process between the DSNP, MCOs and the LTC case management system, including Area Agencies on Aging (AAA) and Home and Community Services (HCS), will lead to more efficient and timely transitions of care, support whole person health and achieve better integration of services at the local level.

When and How to Engage System Partners

Medicare Advantage (MA) Plans, MCOs and LTC system should coordinate with each other as they become aware of a client who would benefit from cross-system coordination.

MA Plans, MCOs and LTC system can initiate coordination via email or through established biweekly care coordination meetings. To add a client to the biweekly HCS/AAA/MA Plans, please send: client’s name, DOB and ProviderOne number via secure email to a HCS Managed Care Systems Consultant.

  •  HCA/AAAs can find the contact list of the MA health plans on the ALTSA Intranet
  • MA plans may find the HCS/AAA case manager listed in PRISM if the individual has LTSS authorized services.

Understanding Entities’ Roles

Individuals responsible for achieving successful transitions of care and care or case management should be well versed on the services available to clients/beneficiaries and how to access them. While we cannot all be experts in all the things, we can partner across the delivery systems to address gaps in care and achieve more efficient and cost-effective service delivery.

Area Agency on Aging (AAA):

  • Information and Assistance (no wrong door access to local community services and supports)
  • Case management of Medicaid LTC clients served in their home.
  •  Conduct ongoing functional assessments for LTC and service plans
  • Assist with transition to LTC services or settings
  • Case management for other programs like supportive housing, state funded family caregiver support programs, Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA)
  • Some AAAs have special programs like Health Homes or care transitions
  • Contract Medicaid LTC providers
  •  Other social support services (local expertise) e.g.:
    •  Transportation
    • Nutrition Services – congregate or home delivered meals
    • Family Care Giver Support
    • Information and Assistance
    • Environmental modifications

Home and Community Services (HCS)

  • Initial eligibility determination for referrals to the Medicaid LTC system.
  • Financial eligibility determination for some Medicaid clients
  • Conduct person centered initial and ongoing functional assessment and service plan
  • Residential and SNF case management
  • Assist with referrals as identified in the functional assessment
  • Assist with transitions of care from inpatient to community LTC and from different LTC settings.
  • Authorize Medicaid LTC services
  • Contract LTC residential settings and services

Medicare Advantage(MA) Dual Special Needs Plan (D SNP):

  • Responsible to conduct an Initial Health Risk Assessment and offer care management services if indicated.
  • Assist with transition planning and responsible to locate and assist with scheduling post discharge appointments with providers
  • Coordination with the BHSO (behavioral health plan) as appropriate
  • Reviews/approves authorization requests for Durable Medical Equipment (DME)
  • Timely Prior Authorizations for medically necessary care like SNF, Home Health or other care
  • Track in-patient stays and identify opportunities for early intervention, assist with transitions
  • Responsibility for Medicare-covered benefits and to coordinate Medicare benefits and services
  • Offer Supplemental Benefits (vary depending on the plan) could include:
    • Transportation
    •  PERS
    • Transitional Meals
    • Utilities, Over the Counter (vitamins, basic supplies), and Healthy Food Card

Not sure how to initiate care coordination or need further support?

MA Plans, MCOs and LTC case managers can reach out to the HCS Managed Care System Consultant:

Region Locations Contact
Region 1 North Central, Spokane, Greater Columbia and Klickitat County Sarah Rogala Managed Care Systems Consultant sarah.rogala2@dshs.wa.gov
Region 2 North Sound, King County Laura Botero Managed Care Systems Consultant laura.botero@dshs.wa.gov
Region 3 Salish, Thurston-Mason, Pierce, Great Rivers, Clark and Skamania Genevieve Boyle Managed Care Systems Consultant genevieve.boyle@dshs.wa.gov
View Regional Map    

​

Resources

Stakeholder Resources

Trainings

Success Stories

General Information

MA Plans can find a list of locations and general contact information for AAA and HCS Offices on the ALTSA resource webpage https://www.dshs.wa.gov/ALTSA/resources