MI Health Link

Table of Contents


    WHO ARE DUAL ELIGIBLES?

    “Dual eligibles” are people who are eligible for both Medicare and Medicaid.

     


    WHAT IS INTEGRATED CARE FOR DUAL ELIGIBLES?

    “Integrated Care for Dual Eligibles” is a way to improve the way that dual eligibles get their health care. 

     

    Medicare (a federal government for older adults and certain people with disabilities) and Medicaid (a joint state and federal program for low-income individuals) are large, complicated programs.  If you are enrolled in both, it can be hard to coordinate your health care under the two programs and make sure you’re getting the services you need and want.  It also means that you might have a lot of paperwork and administrative headaches.

     

    “Integrated care” means that Medicare and Medicaid will talk and work with each other to better coordinate the care that you’re getting and make the administrative process easier.  Not only should you notice improvements in the way you get your health care, but it should be more efficient and therefore save both the federal government and the state of Michigan money.

     

    The federal Centers for Medicare & Medicaid Services (CMS) has been working with several states, including Michigan, to create what are called “demonstrations” – test programs to integrate care for dual eligibles.  In Michigan, this demonstration project is called MI Health Link.

     


    WHAT IS MI HEALTH LINK?

    MI Health Link is Michigan’s program to integrate care for dual eligibles.  It is run by the Michigan Department of Health and Human Services (MDHHS).

     


    WHO CAN JOIN MI HEALTH LINK?[1]

    To join MI Health Link, you have to be:

    • At least 21 years old

    • Eligible for full benefits under Medicare Part A

    • Enrolled in Medicare Parts B and D

    • Receiving full Medicaid benefits

    • Live in certain areas of the state

    • Not enrolled in Hospice

     

    Only dual eligibles who live in certain areas of the state will be able to join MI Health Link, at least for right now.  These areas are:

    • The Upper Peninsula (Alger, Baraga, Chippewa, Delta, Dickinson, Gogebic, Houghton, Iron, Keweenaw, Luce, Mackinac, Marquette, Menominee, Ontonagon, and Schoolcraft counties)

    • Southwestern Michigan (Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph, and Van Buren counties)

    • Metro Detroit (Wayne and Macomb counties)

     

    You are not eligible for MI Health Link if:

    • You do not live in one of the regions listed above. 

    • You were previously disenrolled due to Special Disenrollment from Medicaid managed care

    • You have Additional Low Income Medicare Beneficiary/Qualified Individual (ALMB/QI)

    • You have Medicaid with a spend-down (but you are still eligible if you eligible for Medicaid through expanded financial eligibility limits under a 1915(c) waiver or live in a nursing home with a monthly patient pay amount)

    • You have Medicaid and live in a state psychiatric hospital

    • You have commercial HMO coverage

    • You have elected hospice services

    If you are in MI Choice, Money Follows the Person (MFP), or PACE, you can join MI Health Link but only if you disenroll from MI Choice, MFP, or PACE.

     


    HOW DOES MI HEALTH LINK WORK?[2]

     

    If you choose to enroll in MI Health Link, all of your health care will be handled and coordinated by a company called an Integrated Care Organization (ICO) You will deal just with the ICO for all of your health care benefits – not Original Medicare, a Medicare Advantage Plan, Medicaid, or a Medicaid Health Plan. However, if you currently have a Prepaid Inpatient Health Plan (PIHP), your ICO will work with your PIHP, so your PIHP will still be involved. The current health plans, by region, are listed below. 

    Upper Peninsula

    Souwest Michigan

    Wayne County

    Macomb County

    There are a number of ICOs and they all had to meet certain requirements and be approved by the state of Michigan before they became a part of MI Health Link.  Not all ICOs will operate in all geographic areas, but you can choose any ICO you want that operates where you live.

     

    Once you pick an ICO, you will be assigned a Care Coordinator, who will most likely be a nurse or a social worker.  (If you would prefer a different Care Coordinator after meeting the one whom you are assigned, you will be able to request a different Care Coordinator.)  You will also have an Integrated Care Team (ICT).  Your Integrated Care Team will include you, your family members or friends or others you want to be a part of your care team, your primary care doctor, your Care Coordinator, and maybe others (such as your Long-Term Services and Supports (LTSS) Coordinator or PIHP Supports Coordinator if you have them).  Your Care Coordinator will be the leader of your Integrated Care Team.

     

    Your Care Coordinator will assess you, work with you and your Integrated Care Team to prepare your plan of care (also called your Individual Integrated Care and Supports Plan (IICSP) or person-centered plan), and coordinate your care transitions. 

     

    Your Integrated Care Team will work with you to create and carry out your plan of care and coordinate how your services and benefits get to you.

     

    Your plan of care will include the following things:

    • The results of your assessments

    • A summary of your health

    • Your preferences for your care, supports, and services

    • A list of your concerns, goals, objectives, and strengths that indicates which of these things are most important to you

    • Details about the services you will get (like which services, how much, for how long, who will provide them, etc.)

    • The plan for addressing your concerns or goals

    • The person or people who are responsible for and their due dates for getting involved, monitoring you, and reassessing you

     

    The Care Bridge is the way that members of your team make sure you get all of the services and supports included in your plan of care.  The Care Bridge has an electronic tool (called the Integrated Care Bridge Record) that should include all of your records and documents so everyone on your team has the same information and can see everything quickly and efficiently.  If you prefer not to access your Integrated Care Bridge Record online, you can request to see it on paper.

     


    CAN I KEEP THE DOCTORS I HAVE NOW?[3]

    Each ICO has to have a wide network of providers, and you are allowed to choose any providers that are in your ICO’s network.  If you want to make sure that you can keep seeing your current doctors in the long-term, you may want to choose an ICO that includes your doctors in its provider network.

     

    When you first enroll in MI Health Link and sign up with an ICO, generally the ICO has to let you keep seeing your current doctors for 90 days.  But after that, the ICO may make you see different doctors if your current doctors are not in the ICO’s network.

     


    WHEN CAN I JOIN MI HEALTH LINK?[4]

    MI Health Link is now available in all 4 demonstration regions across the state. And there is no limited open enrollment period for MI Health Link; individuals can enroll at any time.

    The state has currently launched another wave of passive (automatic) enrollments for newly eligible enrollees across the state. This passive enrollment is set to go into effect on June 1, 2016. Individuals that are part of this passive enrollment should have received 60-day notices beginning on April 1, 2016, and 30-day notices on May 1, 2016. After this June enrollment, the state plans to do ongoing passive enrollments on the 1st of each month.

    If you are eligible for MI Health Link and haven’t already opted in, opted out, or disenrolled from MI Health Link, you will be passively enrolled.  If you are in MI Choice, PACE, or MFP (Money Follows the Person), or if you have an employer-sponsored Medicare Advantage Plan, you will not be passively enrolled.

    60 days before passive enrollment:

    • You will get a notice telling you about your options.  The notice will tell you which ICO you will have by default and how you can choose among ICOs, opt-out of MI Health Link, or disenroll after you are passively enrolled.  You can “Opt out” and disenroll from MI Health Link by contacting Michigan ENROLLS at 1-800-975-7630, TTY users may call 1-888-263-5897.

    ​30 days before passive enrollment

    • If you are eligible for MI Health Link and haven’t already opted in, opted out, or disenrolled from MI Health Link, you will get a second notice about “passive” or “auto” (automatic) enrollment.  You can “Opt out” and disenroll from MI Health Link by contacting Michigan ENROLLS at 1-800-975-7630, TTY users may call 1-888-263-5897.

    If you do not opt out and disenroll before the date listed on your passive enrollment letters, you will be automatically enrolled in the listed health plan. 

    At any time after you are enrolled in MI Health Link (either because you opted in or were passively enrolled):

    • You can change your ICO or disenroll from MI Health Link.  The change or disenrollment will take effect on the first day of the next month. 

     


    WHAT DO I DO IF I WANT MORE INFORMATION ABOUT MI HEALTH LINK OR I WANT TO ENROLL?[5]

    You can contact the Michigan Medicare/Medicaid Assistance Program (MMAP) at 1-800-803-7174.  They can answer your questions and counsel you about your ICO options.  MMAP isn’t affiliated with any ICO, so the information and help they give you shouldn’t be biased.

     

    If you want to enroll in MI Health Link, you can call Michigan ENROLLS at 1-800-975-7630. TTY users may call 1-888-263-5897.

     


    WHAT DO I DO IF I'M HAVING A PROBLEM WITH MI HEALTH LINK[6]

    The MI Health Link Ombudsman is an advocate for people who are enrolled in MI Health Link and is completely independent and confidential.  You are able to go to the MI Health Link Ombudsman with any problems you have with the MI Health Link program, including any problems with your ICO or your Care Coordinator.  The Ombudsman can help you with your individual problems, but will also look out for and try to help fix any problems that seem to be happening with a lot of MI Health Link participants or a lot of people enrolled with a certain ICO.

    The Ombudsman can be reached toll free at 1-888-746-MHLO (1-888-746-6456) Monday-Friday 8am-5pm. You can also email the ombudsman at help@MHLO.org or visit its website at MHLO.org

    If you are having a problem with your ICO (or PIHP), you have a right to file a grievance with the ICO (or PIHP).  The ICO (or PIHP) has to “track and resolve its grievances according to applicable Medicare and Medicaid rules, or if appropriate, re-route grievances to the coverage decision or appeals processes.”   You also have the right to file an external grievance through 1-800-MEDICARE.

     

    If your ICO or PIHP has denied coverage for something or plans to reduce, suspend, or terminate your benefits or services, you will get a notice that tells you about your right to appeal.  The process for appealing works differently depending on the benefits or services that are affected.

     

    If Medicare is the primary payer for the benefits or services:

    • You have 90 days from the date of the notice to file an appeal with your ICO

    • If you request an appeal within the timeframe for making the request or the date on which your change in benefits or services is supposed to take effect, your ICO must continue paying for your benefits or services (except Medicare Part D prescription drugs) until after it makes a decision on your appeal

    • Your ICO generally has to make a decision within 30 days when you request a standard appeal and within 72 hours if you request an expedited appeal

    • If the ICO rules against you, your appeal will be automatically forwarded to the Medicare Independent Review Entity (IRE)

    • If the IRE rules against you, you can request a hearing before an administrative law judge

     

    If Medicaid is the primary payer for the benefits or services:

    • You have 90 days from the date of the notice to file an appeal with your ICO and/or the Michigan Administrative Hearing System (MAHS) for the Department of Community Health

    • If you request an appeal within the timeframe for making the request, your ICO must continue paying for your benefits or services until after it or MAHS makes a decision on your appeal

    • If the ICO rules against you, you can appeal to MAHS

     

    If the services may be eligible for both Medicare and Medicaid coverage:

    • You can file an appeal through the Medicare appeals process, the Medicaid appeals process or both

    • If both MAHS and IRE make a ruling in your case, your ICO has to follow the ruling that is most favorable to you

     


    RESOURCES

     


    [1] Memorandum of Understanding (MOU) Between The Centers for Medicare & Medicaid Services (CMS) And The Michigan Department of Community Health. p. 6-7. http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/MIMOU.pdf

    [2] Memorandum of Understanding (MOU) Between The Centers for Medicare & Medicaid Services (CMS) And The Michigan Department of Community Health. p. 21-24. http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/MIMOU.pdf; MI Health Link Region 4 Implementation Forum (Questions and Answers). http://www.michigan.gov/documents/mdch/MI_Health_Link_Region_4_Implementation_Forum_Questions_5-2-14_455168_7.pdf

    [3] Memorandum of Understanding (MOU) Between The Centers for Medicare & Medicaid Services (CMS) And The Michigan Department of Community Health. p. 9, 82. http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/MIMOU.pdf

    [4] Memorandum of Understanding (MOU) Between The Centers for Medicare & Medicaid Services (CMS) And The Michigan Department of Community Health. p. 7, 58-60. http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/MIMOU.pdf; Centers for Medicare & Medicaid Services. Fact sheets: CMS and Michigan Partner to Coordinate Care for Medicare-Medicaid Enrollees. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-04-03.html

    [5] MI Health Link Region 4 Implementation Forum (Questions and Answers). http://www.michigan.gov/documents/mdch/MI_Health_Link_Region_4_Implementation_Forum_Questions_5-2-14_455168_7.pdf; MOU p. 61

    [6] Memorandum of Understanding (MOU) Between The Centers for Medicare & Medicaid Services (CMS) And The Michigan Department of Community Health. p. 10, 86-88. http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/MIMOU.pdf