Medicare-Medicaid Plan Demonstrations - PowerPoint Presentation

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Medicare-Medicaid Plan Demonstrations

Chicago Regional OfficeCenters for Medicare Health Plan Operations

Yolanda Burge-Clark

August 19, 2014Slide2

10 million (aprox) individuals that are enrolled in both Medicare and Medicaid (or “dual eligibles”).

More likely to have mental illness, have limitations in activities of daily living, and multiple chronic conditions

.

Who are Medicare-Medicaid Enrollees?Slide3

Medicare-Medicaid Beneficiaries Account for Disproportionate Shares of Spending

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Medicare-Medicaid Coordination Office

Section 2602 of the Affordable Care Act

Purpose:

Improve quality, reduce costs and improve the beneficiary experience.

Ensure Medicare-Medicaid enrollees have full

access

to the services to which they are entitled.

Improve the

coordination

between the federal government and states.Identify and test innovative care coordination and integration models.Eliminate financial misalignments that lead to poor quality and cost shifting.

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Financial Alignment Initiative

Background:

In 2011, CMS announced new models to integrate the

service delivery and financing of both Medicare and Medicaid

through a Federal-State demonstration to better serve the population.

Goal:

Increase access to quality, seamlessly integrated programs for Medicare-Medicaid enrollees.

Demonstration Models:

Capitated Model:

Three-way contract among State, CMS and health plan to provide comprehensive, coordinated care in a more cost-effective way.Managed FFS Model: Agreement between State and CMS under which states would be eligible to benefit from savings resulting from initiatives to reduce costs in both Medicaid and Medicare.

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Demonstration Details

13

total demonstrations

10 states have approved capitated demonstrations: Massachusetts,

Ohio

, Illinois, California, Virginia, New York, South Carolina,

Michigan, Texas, and

Washington.

2 states have Managed fee for Service demonstrations: Washington and Colorado.

Minnesota approved for alternative model. RO V States include IL, OH, MI, and MN.6Slide7

Letter of Intent;

Meet CMS Standards and conditions; State procurement documents released;

CMS and State select qualified plans;

Sign Memorandum of Understanding; CMS and State conduct readiness reviews; Three-way contracts signed; and

Implementation, monitoring, and evaluation

Demonstration ProcessSlide8

Quality

CMS and States jointly conduct a consolidated, comprehensive quality management reporting process

Core set of CMS measures for all plans in all States

Focus on national, consensus-based measurement sets Relevant to broader Medicare-Medicaid enrollee populationsState-specific measuresTargeted to State-specific demonstration populationFocus on long-term supports and services measures that are underrepresented in national measures

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States can request passive enrollment of eligible beneficiaries in their proposals

Approval of passive enrollment is subject to robust beneficiary protections

Passive enrollment systems designed to maximize continuity of existing relationships and account for benefits and formularies

CMS/State may allow for facilitation of enrollment using independent third party

Enrollment Parameters

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Individuals not eligible for passive enrollment:

PACE Organization enrollees

Enrollees in employer sponsored insurance or whose employer/union is paid the Part D Retiree Drug Subsidy

Enrollees who have opted out of a demonstration planOthers as memorialized in the CMS-State Memorandum of Understanding

For 2014, individuals who were reassigned to a below-benchmark PDP effective January 1, 2014

Enrollment Parameters (cont.)

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CMS expects States to phase in enrollment over a period of time at program start-up

Examples: By geography or population groupsCMS/State may limit enrollment for a variety of reasons (e.g., quality, capacity)No phase-in to new counties or populations in Years 2 and 3 of the demonstration

Phasing In Enrollment

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Notification in advance of the enrollmentAbility to opt out at any time

Understandable beneficiary notificationResources to support beneficiariesChoice counselors and enrollment brokersState Health Insurance Programs

Aging and Disability Resource Centers

Enrollment-Related Beneficiary Protections

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Milestones based on criteria from the readiness reviews

Allows CMS and State to monitor demonstration plan as enrollments begin

System Capacity

Health Risk AssessmentsStaffing

Transitions

May delay future enrollment

Implementation Monitoring

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Ongoing Monitoring Elements based on Readiness Review

Care CoordinationHealth Risk AssessmentsProvider and Facility Network CapacityPart C and Part D data driven monitoring

Call Centers

Part D Appeals and GrievancesWeb SitesPart C and Part D Reporting RequirementsOngoing MonitoringSlide15

CMS-State contract management team, emphasis is on efficient coordination between the two entities

Part D oversight will continue to be a CMS responsibilityDemo plans will be subject to all existing Part C & D oversight.Oversight FrameworkSlide16

CMS contracted with independent evaluator (RTI)

State-specific evaluation plans

Mixed method approach (qualitative and quantitative)

Site visitsAnalysis of focus group data

Analysis of program data

Calculate savings attributable to the demonstration

Evaluation

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Key issues, include but are not limited to:

Beneficiary health status and outcomes

Quality of care provided across settings and care delivery models

Beneficiary access to and utilization of care across settingsBeneficiary satisfaction and experience

Administrative and systems changes and efficiencies

Overall costs or savings for Medicare and Medicaid

Evaluation

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MOU signed: February 22,

2013Contract signed: November 5, 2013Eligible population:Age 21 and olderReceiving full Medicaid benefits, and

Enrolled

in the Medicaid Aid to the Aged, Blind, and Disabled (AABD) category of assistance,IllinoisSlide19

In the following Medicaid 1915(c)

waivers:Persons who are Elderly; Persons with Disabilities;

Persons

with HIV/AIDS; Persons with Brain Injury and Persons residing in Supportive Living Facilities.Individuals with End Stage Renal Disease (ESRD) at the time of enrollment.

Illinois (continued)Slide20

Excluded from enrollment:

Under the age of 21; Receiving developmental disability institutional services or who participate in the HCBS waiver for Adults with Developmental Disabilities;

Medicaid

Spend-down population; Enrolled in the Illinois Medicaid Breast and Cervical Cancer program; Enrolled in partial benefit programs; and Those having comprehensive Third Party Insurance

Illinois (continued)Slide21

IllinoisSlide22

Opt-in enrollment: March 1, 2014

Passive enrollment: June 1, 2014

Illinois (continued)

Region

Medicare-Medicaid Plan

Central Illinois

Health Alliance, Molina

Greater Chicago

Aetna, BCBS, Cigna-Healthspring,

Humana, Illinicare, MeridianSlide23

Passive enrollment phased in over 6 month period.

No more that 5,000 per month in Chicago regionNo more than 3,000 per month in Central IL regionEligible members will receive notification of passive enrollment by the State at 60 days and 30 days prior to being enrolled.Members can opt out at any time.

Illinois (continued)Slide24

March Enrollment: 160July Enrollment: 37,000

Goal of 135,000 enrolleesTransition period for medical, behavioral, and LTSS is 180 daysMedicare Part D transition period unchanged.

Illinois ( continued)Slide25

Funding to support Options Counseling:

$394,932 (August, 2013)Funding to support Ombudsman Program:$267. 556 (December 2013) Enrollment Broker Contact Information: 1-877-912-8880 (TTY: 1-866-565-8576),

Monday

to Friday from 8 a.m. to 7 p.m. and Saturday from 9 a.m. to 3 p.m.Illinois (continued)Slide26

MOU signed: December 11,

2012Contract signed: February 11, 2014Eligible population includes Full-benefit

Medicare-Medicaid Enrollees only.

Individuals with serious and persistent mental illnessIntellectual Disabilities (ID) and other Developmental Disabilities (DD) who are not served through an IDD 1915(c) HCBS waiver or an ICF-IDD may opt into the ICDS program.

OhioSlide27

Excluded Individuals:

Only eligible for Medicare Savings Program benefits (QMB-only, SLMB-only, and QI-1) ID and other DD who are served through an IDD 1915(c)HCBS waiver or an ICF-IDDenrolled in PACE

have other third party insurance

under age of 8on a delayed Medicaid spend downOhio (continued)Slide28

OhioSlide29

Region

Medicare-Medicaid

Plans

Enrollment StartNortheastBuckeye, Caresource, United

May 1

st

Northwest

Aetna, Buckeye

June 1st Northeast CentralCaresource, UnitedJune 1st SouthwestAetna, MolinaJune 1st East-CentralCaresource, UnitedJuly 1stWest CentralBuckeye, MolinaJuly 1

st

Central

Aetna, Molina

July 1

st

Ohio (continued)Slide30

Medicare Opt-in enrollment and Medicaid passive enrollment:

May 1, 2014Medicare passive enrollment: January 1, 2015May Enrollment: 5,000

July Enrollment:

14,000Provider transition period of 90 days for enrollees identified for high risk care and 365 days for all others Transition period for all drugs follows Part D rules

Ohio (continued)

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Funding to support Ombudsman Program:

$272, 354 (March, 2014)Enrollment Broker Contact Information: 1-800-324-8680

Monday

through Friday from 7:00 am to 8:00 pm and Saturday from 8:00 am to 5:00 pm TTY users should call Ohio Relay Service at 7-1-1Ohio (continued)Slide32

MOU signed April 3, 2014Estimate 100,000 eligible beneficiaries

8 Medicare-Medicaid Plans4 PIHPs are responsible for all behavioral health services Eligible populationOver 21

Full Medicaid benefits

MichiganSlide33

Individuals excluded from demonstration

Under 21Previously disenrolled due to special disenrollment from Medicaid managed care defined in 42 CFR 438.56 Additional Low Income Medicare Beneficiary/Qualified Individuals (ALMB/QI)

Medicaid spend downs or deductibles

Medicaid who reside in a State psychiatric hospitalCommercial HMO coverageElected Hospice Services

Michigan (continued)Slide34

Michigan (continued)Slide35

Four regionsRegion 1- Upper

PeninsulaRegion 4- Southwest Michigan- Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph, and Van Buren counties Region 7- Wayne CountyRegion 9- Macomb County

Michigan (continued)Slide36

Region

Medicare-Medicaid Plan

Opt-in Enrollment

Passive EnrollmentUpper PeninsulaUpper Peninsula

Health Plan

1/1/15

4/1/15

Southwest

Coventry, Meridian

1/1/154/1/15MacombAmerihealth, Coventry, Fidelis, Midwest, Molina, United5/1/157/1/15WayneAmerihealth, Coventry, Fidelis, Midwest, Molina, United5/1/157/1/15Michigan (continued)Slide37

MOU signed September 12, 2013

Implemented in 2013Alternative design to Financial Alignment InitiativeUsing current MSHO DSNP plansDemonstration focused on:

Administrative

efficiencies, marketing, qualityMinnesotaSlide38

Medicare-Medicaid Coordination Office

http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-MedicaidCoordination.html Financial Alignment InitiativeIntegrated Care Resource Center

http://www.integratedcareresourcecenter.com/

Yolanda.Burge@cms.hhs.govAdditional Resources