Integrated Care Initiative – Eligibility and Enrollment

The Integrated Care Initiative is a model 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. Rhode Island is one of thirteen states testing models for integrated care in Financial Alignment Initiative demonstrations.

Phase 1 of the Integrated Care Initiative, sometimes called Rhody Health Options, launched in November of 2013 with a plan called Neighborhood UNITY. UNITY is designed to manage just the Medicaid covered benefits for dual eligibles.  It doesn’t change a person’s Medicare, Medicare Advantage or Medicare Part D Prescription Drug Plan. Unlike Phase 2, UNITY is available to individuals with just Medicaid (not Medicare) who are receiving long-term services and supports in a nursing facility or the community. UNITY is still available following the roll out of Phase 2.

Phase 2 of the Integrated Care Initiative, sometimes called the Medicare-Medicaid Plan (MMP), 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.

This article describes who is eligible for Neighborhood INTEGRITY and how they should proceed if they would like to enroll.

 

Eligibility

In order to be eligible to enroll in Neighborhood INTEGRITY, individuals must:

  • Live in Rhode Island
  • Be at least 21 years of age
  • Have Medicare Part A and Part B and be eligible for Medicare Part D
  • Have full Medicaid benefits

Individuals must meet all four criteria to be eligible. Possible reasons for ineligibility include:

  • Having only Medicare Part A or Part B
  • Not having ‘full’ Medicaid benefits (i.e. having ‘spend down’ or ‘flex’ Medicaid benefits)
  • Participating in the Medicare Premium Payment Program (QMB, SLMB or QI), but not full Medicaid
  • Receiving hospice care at the time of enrollment
  • Being incarcerated
  • Living in an institution (Tavares or Eleanor Slater Hospital) or in an out-of-state hospital
  • Being enrolled in the Sherlock Plan (health coverage for adults with disabilities who are working)

The RI Executive Office of Health and Human Services (EOHHS) estimates that there are approximately 30,000 dual eligibles in Rhode Island who qualify for Neighborhood INTEGRITY.

 

Enrollment

There are two types of enrollment, Opt-In and Passive enrollment. Both types of enrollment are completely voluntary, as those scheduled for passive enrollment are free to cancel before being enrolled.

Individuals who are identified for the Opt-In enrollment group will be mailed an enrollment packet that includes an enrollment letter (blue), an application, and information on the plan. Individuals can either apply over the phone or send in a paper application. Once they have submitted an application, the State will verify their eligibility and mail a notice either verifying or denying their enrollment. No one in the Opt-In enrollment group will be automatically enrolled in INTEGRITY, they must affirmatively apply to be enrolled.

Individuals who are identified for the Passive enrollment group will be mailed two enrollment letters (yellow), one 60 days prior to their start date and a reminder letter 30 days prior to their start date. People in the Passive enrollment group need to call the Enrollment Line to stop the automatic enrollment if they do not want to be enrolled in Neighborhood INTEGRITY.

Who Must Opt In?

Individuals who are eligible for Opt-In enrollment include:
  • Those who are not already enrolled in Neighborhood UNITY.
  • Those who are enrolled in Neighborhood UNITY and meet one or more of the following criteria:
    • Also enrolled in a Medicare Advantage plan
    • Identified as having been auto-enrolled in a part D Prescription Drug Plan within the last calendar year
    • Identified as having comprehensive health insurance coverage through a private commercial plan or group health plan provided by an employer, union, or TRICARE (in addition to Medicare and Medicaid)

Who Will be Passively Enrolled?

Individuals are eligible for Passive enrollment if they meet all of the following criteria:

  • They are already enrolled in Neighborhood UNITY for their Medicaid benefits
  • They do not have any comprehensive commercial coverage, or employer or union sponsored insurance
  • They are not currently enrolled in a Medicare Advantage plan
  • They have not been passively enrolled in a Part D Prescription Drug plan within the last calendar year

Initial Enrollment Schedule

Initial enrollment for Neighborhood INTEGRITY was scheduled in waves, with different populations receiving enrollment notices over the course of nine months. Enrollment began on July 1, 2016 for Opt-In enrollees and October 1, 2016 for Passive enrollees.

LTSS – long-term services and supports

SPMI – severe and persistent mental illness

I/DD – intellectual and developmental disabilities

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EOHHS has indicated that it is still developing a protocol for enrollment after the initial waves have concluded.
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How to Enroll

Those who are passively enrolled don’t need to take any action to enroll.

Those in opt-in enrollment categories have to either complete and submit the paper application they receive in the mail, or call the Medicare-Medicaid Enrollment Line to enroll. The timing of an application is important. If an application is submitted by the tenth of the month, the individual is enrolled on the first day of the following month. If an application is submitted after the tenth of the month, the individual is enrolled the first day of the next month.

Example 1

If Jane applies on April 5 and her application is processed and approved, her effective date is May 1. If Jane waits until April 15 to apply and her application is processed and approved, her effective date is June 1.

Those who opt in and apply for coverage may have their applications denied. Individuals are most commonly denied coverage under Neighborhood INTEGRITY because they:

  • Are found not to meet all program eligibility criteria
  • Submit an incomplete application and do not respond to a request for additional information within 30 days
  • Are identified as having employer or union sponsored coverage and fail to confirm their decision to enroll

Unsuccessful applicants will receive a notice explaining the reasons for the decision, accompanied by instructions on how to request a hearing to appeal the denial. Those seeking additional information on their decision should call the Enrollment Line. Those who are unable to resolve their disputes and plan to file appeals may contact the RIPIN Healthcare Advocate, designated by EOHHS as the Integrated Care Initiative Ombudsman.

 

How to Opt Out or Disenroll

Those in opt-in enrollment categories will not be enrolled without affirmatively applying for coverage.

Those scheduled for passive enrollment may opt out or cancel their enrollment up until the last day of the month prior to their enrollment start date (listed on their enrollment letter). Call the Enrollment Line to opt out. You should then receive a notice confirming your decision to opt out.

If an individual who is already enrolled in Neighborhood INTEGRITY does not wish to be enrolled, they can disenroll at any time. Call the Enrollment Line to disenroll. In most cases, disenrollment will go into effect the first day of the following month. Individuals who successfully disenroll from Neighborhood INTEGRITY will receive a notice confirming their disenrollment. In cases where a disenrollment request is incomplete or made by an unauthorized individual, it may be denied.
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Individuals may become involuntarily disenrolled if they no longer meet the eligibility criteria (e.g. a covered individual loses Medicare Part A or Part B coverage, loses Medicaid coverage, or moves out of Rhode Island). Individuals will also be disenrolled if they enroll in a Medicare Part D plan or a Medicare Advantage Plan.

Effects of Disenrollment

Individuals who disenroll from Neighborhood INTEGRITY will continue to have all their Medicare and Medicaid benefits.
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If an individual disenrolls from INTEGRITY, they will be automatically enrolled in ‘Original’ Medicare (Part A and B) for their Medicare health benefits. These individuals can choose a Medicare Advantage or Part D plan  by calling 1 (800) MEDICARE. Help is also available from The Point (401-462-4444) and from Senior Health Insurance Program (SHIP) Counselors for in-person options counseling.
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If an individual does not choose a Part D plan quickly enough, then they will be auto-enrolled into a Part D plan.  Dual eligibles who are auto-enrolled can always change plans if they are not happy with the results of the auto-enrollment.
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If a member chooses to disenroll from Neighborhood INTEGRITY, they will be automatically enrolled in Neighborhood UNITY for their Medicaid benefits.
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Those who disenroll can re-enroll at any time.
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Contact Information

Medicare-Medicaid Enrollment Line
(Call to enroll, disenroll, or to get information on Neighborhood INTEGRITY)
1 (844) 602-3469 (TTY 711)
Hours: Mon – Fri 8:30am – 7:00pm, Sat 9:00am – 12 noon
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RIPIN Healthcare Advocate
(Call to resolve problems with enrollment, eligibility, or access to care)
1 (855) 747-3224
Hours:  Mon – Fri 8:00am – 5:00pm, extended to 7 p.m. on Thursdays
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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
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Helpful Links

EOHHS Integrated Care Initiative Regulations – Link

Three Way Contract Between CMS, EOHHS, and Neighborhood – Link

EOHHS Integrated Care Initiative Page – Link

EOHHS Integrated Care Initiative Resources Page (includes all notices) – Link

EOHHS Integrated Care Initiative Training Manual – Link

EOHHS Integrated Care Initiative Fact Sheet – Link

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