Integrated Care Initiative – Continuity of Care

The Integrated Care Initiative is a program designed to improve care for Rhode Islanders eligible for both Medicaid and Medicare (dual eligibles).  Rhode Island’s Integrated Care Initiative is a joint effort between the State of Rhode Island, the Centers for Medicare and Medicaid Services (CMS), and Neighborhood Health Plan of Rhode Island. Phase 2 of the Integrated Care Initiative, sometimes called the Medicare-Medicaid Plan, launched in July of 2016 with a plan called Neighborhood INTEGRITY. Eligible individuals who enroll will receive all their covered benefits in Medicare and Medicaid plus additional services through a single integrated plan.

When an individual enrolls in Neighborhood INTEGRITY, they have rights and protections that allow them to maintain their current doctors, services, and medications for a certain period of time.  These rights are called continuity of care protections. This article explains which services are covered by these protections and for how long.

Health Care Professionals

An enrollee who has seen an out-of-network primary care doctor or specialist in the six months prior to enrolling can continue to see that provider for the first six months they are enrolled in Neighborhood INTEGRITY. After the first six months, they may be required to use providers in Neighborhood’s network.
X
During the transition period, Neighborhood is required to notify enrollees (and their health care professionals) if and when they have received care that would not otherwise be covered in-network. Neighborhood must also provide information on becoming an in-network provider to healthcare professionals who provide care during the transition period. Such providers must be offered single case agreements by Neighborhood should they choose not to become part of Neighborhood’s network.
X
Neighborhood may choose to transition an enrollee to an in-network primary care physician (PCP) earlier than six months only if all the following criteria are met:
X
  • The enrollee is assigned to a PCP that is capable of serving his/her needs appropriately
  • Neighborhood has completed an Initial Health Screen (IHS) and/or a Comprehensive Functional Needs Assessment (CFNA) for the enrollee
  • Neighborhood has consulted with the new PCP and determined that the PCP is accessible, competent, and can appropriately meet the enrollee’s needs
  • A transition plan is in place (to be updated and agreed to with the new PCP, as necessary)
  • The enrollee agrees to the transition and the transition plan prior to the expiration of the six month transition period
Neighborhood may choose to transition an enrollee to an in-network specialist earlier than six months only if all the following criteria are met:
X
  • An IHS and/or a CFNA, if necessary, is complete
  • A transition plan is in place (to be updated and agreed to with the new Health Care Professional, as necessary)
  • The enrollee agrees to the transition and the transition plan prior to the expiration of the six month transition period.

Long-Term Services and Supports

A enrollee who is currently receiving Long-Term Services and Supports (LTSS), will continue to receive the same number of authorized hours (for services including personal care, waiver nursing, home care, respite care, community living, adult day health, social work, counseling, and independent living assistance) for the first six months of enrollment in INTEGRITY, unless a significant change has occurred and is documented in a CFNA.
X
Neighborhood may choose to transition an enrollee to an in-network LTSS provider earlier than six months only if all the following criteria are met:
X
  • An IHS and/or a CFNA, if necessary, is complete
  • A transition plan is in place (to be updated and agreed to with the new Health Care Professional, as necessary)
  • The enrollee agrees to the transition and the transition plan prior to the expiration of the six month transition period.
Enrollees who are permanent residents of nursing facilities or assisted living facilities may remain in that nursing facility or assisted living facility, regardless of whether that nursing facility or assisted living facility is in Neighbohood’s network.
X

Drugs

Most prescription drugs covered under Medicare Part D or Medicaid are covered under Neighborhood INTEGRITY. If an individual is on a non-formulary prescription drug (i.e. a drug that is not covered under Neighborhood’s formula), the following rules apply:
X
For non-formulary Part D drugs (including drugs that are on Neighborhood’s formulary but require prior authorization or step therapy under the Utilization Management rules), Neighborhood must cover a temporary supply during the first 90 days of membership in the plan. This temporary coverage will be for up to a 30 day supply. If a prescription is written for fewer days, Neighborhood will allow multiple fills to provide up to a maximum of a 30 day supply of a Part D drug. Neighborhood is required to provide an appropriate transition process when an enrollee requests a refill during the first 90 days of coverage. The transition process needs to be consistent with federal requirements, including the required provision of a temporary supply of drugs.
X
For non-formulary drugs covered under Medicaid but not Part D (drugs not covered under Part D include drugs for weight loss or weight gain, fertility, cosmetic purposes or hair growth, relief of the cold symptoms, erectile dysfunction, prescription vitamins and minerals, and over-the-counter drugs), Neighborhood must provide a 90 day supply of drugs when an enrollee requests a refill during the first 90 days of coverage.
X
All prior approvals for non-Part D drugs, therapies, or other services existing in Medicare or Medicaid at the time of enrollment will be honored for 60 days after enrollment and will not be terminated at the end of 60 days without advance notice to the enrollee and transition to other services, if needed. For exceptions, see Appendix A of the Contract.
X

Contact Information

Neighborhood Health Plan, Member Services
(Call for information on providers and covered benefits)
1 (844) 812-6896 (TTY 711)
Hours: Mon – Fri 8:00am – 8:00 pm, Sat 8:00 am – 12 noon
X

Helpful Links

Three Way Contract Between CMS, EOHHS, and Neighborhood – Link
X
Contract Section on Continuity of Care (starting at p. 94) – Link
X
Contract Appendix A – Covered Services (starting at p. 289) – Link
X
Federal Rules on Access to Part D drugs – Link
X
Neighborhood INTEGRITY Member Handbook  – Link

Healthcare Rights E-News

Updates and more for Resource Hub users Join

And financial support from: