Medicare-Medicaid Plan Demonstrations
Chicago Regional Office
Centers for Medicare
Health Plan Operations
Yolanda Burge-Clark
August 19, 2014
Who are Medicare-Medicaid Enrollees?
• 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.
Medicare-Medicaid Beneficiaries Account
for Disproportionate Shares of Spending
3
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 costeffective 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.
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Demonstration Process
1.
2.
3.
4.
5.
6.
7.
8.
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
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
populations
• State-specific measures
– Targeted to State-specific demonstration population
– Focus on long-term supports and services measures that
are underrepresented in national measures
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Enrollment Parameters
• 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
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Enrollment Parameters (cont.)
• 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
plan
– Others as memorialized in the CMS-State
Memorandum of Understanding
– For 2014, individuals who were reassigned to a
below-benchmark PDP effective January 1, 2014
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Phasing In Enrollment
• CMS expects States to phase in enrollment
over a period of time at program start-up
– Examples: By geography or population groups
• CMS/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
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Enrollment-Related Beneficiary
Protections
•
•
•
•
Notification in advance of the enrollment
Ability to opt out at any time
Understandable beneficiary notification
Resources to support beneficiaries
– Choice counselors and enrollment brokers
– State Health Insurance Programs
– Aging and Disability Resource Centers
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Implementation Monitoring
• Milestones based on criteria from the
readiness reviews
• Allows CMS and State to monitor
demonstration plan as enrollments begin
• System Capacity
• Health Risk Assessments
• Staffing
• Transitions
• May delay future enrollment
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Ongoing Monitoring
• Ongoing Monitoring
• Elements based on Readiness Review
– Care Coordination
– Health Risk Assessments
– Provider and Facility Network Capacity
• Part C and Part D data driven monitoring
– Call Centers
– Part D Appeals and Grievances
– Web Sites
• Part C and Part D Reporting Requirements
Oversight Framework
• CMS-State contract management team,
emphasis is on efficient coordination between
the two entities
• Part D oversight will continue to be a CMS
responsibility
• Demo plans will be subject to all existing Part
C & D oversight.
Evaluation
• CMS contracted with independent evaluator
(RTI)
• State-specific evaluation plans
• Mixed method approach (qualitative and
quantitative)
– Site visits
– Analysis of focus group data
– Analysis of program data
– Calculate savings attributable to the
demonstration
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Evaluation
• 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
settings
– Beneficiary satisfaction and experience
– Administrative and systems changes and
efficiencies
– Overall costs or savings for Medicare and
Medicaid
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Illinois
• MOU signed: February 22, 2013
• Contract signed: November 5, 2013
• Eligible population:
– Age 21 and older
– Receiving full Medicaid benefits, and
– Enrolled in the Medicaid Aid to the Aged, Blind,
and Disabled (AABD) category of assistance,
Illinois (continued)
• 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)
• 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
Illinois (continued)
Region
Medicare-Medicaid Plan
Central Illinois
Health Alliance, Molina
Greater Chicago
Aetna, BCBS, CignaHealthspring, Humana,
Illinicare, Meridian
• Opt-in enrollment: March 1, 2014
• Passive enrollment: June 1, 2014
Illinois (continued)
• Passive enrollment phased in over 6 month period.
– No more that 5,000 per month in Chicago region
– No more than 3,000 per month in Central IL region
• Eligible 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)
•
•
•
•
March Enrollment: 160
July Enrollment: 37,000
Goal of 135,000 enrollees
Transition period for medical, behavioral, and
LTSS is 180 days
• Medicare Part D transition period unchanged.
Illinois (continued)
• 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.
Ohio
• MOU signed: December 11, 2012
• Contract signed: February 11, 2014
• Eligible population includes
– Full-benefit Medicare-Medicaid Enrollees only.
– Individuals with serious and persistent mental illness
– Intellectual 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.
Ohio (continued)
• 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-IDD
– enrolled in PACE
– have other third party insurance
– under age of 8
– on a delayed Medicaid spend down
Ohio
Ohio (continued)
Region
Medicare-Medicaid Plans
Enrollment Start
Northeast
Buckeye, Caresource,
United
May 1st
Northwest
Aetna, Buckeye
June 1st
Northeast Central
Caresource, United
June 1st
Southwest
Aetna, Molina
June 1st
East-Central
Caresource, United
July 1st
West Central
Buckeye, Molina
July 1st
Central
Aetna, Molina
July 1st
Ohio (continued)
• Medicare Opt-in enrollment and Medicaid
passive enrollment: May 1, 2014
• Medicare passive enrollment: January 1, 2015
• May Enrollment: 5,000
• July Enrollment: 14,000
• Provider 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)
• 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 7-1-1
Michigan
•
•
•
•
MOU signed April 3, 2014
Estimate 100,000 eligible beneficiaries
8 Medicare-Medicaid Plans
4 PIHPs are responsible for all behavioral
health services
• Eligible population
– Over 21
– Full Medicaid benefits
Michigan (continued)
• Individuals excluded from demonstration
– Under 21
– Previously 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 hospital
– Commercial HMO coverage
– Elected Hospice Services
Michigan (continued)
Michigan (continued)
• Four regions
– Region 1- Upper Peninsula
– Region 4- Southwest Michigan- Barry, Berrien,
Branch, Calhoun, Cass, Kalamazoo, St. Joseph, and
Van Buren counties
– Region 7- Wayne County
– Region 9- Macomb County
Michigan (continued)
Region
Medicare-Medicaid
Plan
Opt-in Enrollment
Passive Enrollment
Upper Peninsula Upper Peninsula
Health Plan
1/1/15
4/1/15
Southwest
Coventry, Meridian
1/1/15
4/1/15
Macomb
Amerihealth, Coventry, 5/1/15
Fidelis, Midwest,
Molina, United
7/1/15
Wayne
Amerihealth, Coventry, 5/1/15
Fidelis, Midwest,
Molina, United
7/1/15
Minnesota
• MOU signed September 12, 2013
• Implemented in 2013
• Alternative design to Financial Alignment
Initiative
• Using current MSHO DSNP plans
• Demonstration focused on:
– Administrative efficiencies,
– marketing,
– quality
Additional Resources
• Medicare-Medicaid Coordination Office
http://www.cms.gov/Medicare-MedicaidCoordination/MedicareMedicaidCoordination.html
– Financial Alignment Initiative
• Integrated Care Resource Center
http://www.integratedcareresourcecenter.com/
• Yolanda.Burge@cms.hhs.gov