MedicaidMedicare Integration: Opportunities for States

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Medicaid/Medicare Integration Opportunities for
States Dual Eligibles
Integration of Acute and Long-Term Care in
Virginia September 7, 2006
Stephen Somers, PhD President Center for Health
Care Strategies
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What is Integration?

• States increasingly interested in integration
  of acute, long term, and behavioral services for
  dual eligibles. Particularly, the integration of
• Administrative requirements (e.g. marketing,
  quality reporting),
• Service delivery, and
• Financing.

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What is Integration? (contd)

• Multiple levels of integration
• Medicare premiums and beneficiary cost-sharing
• Non-covered Part D drugs
• Acute care services not covered/partially covered
  by Medicare
• Behavioral health services not covered/partially
  covered by Medicare
• Comprehensive case management and personal care
  services
• Medicaid long-term care services not covered by
  Medicare (nursing facility, home health, HCBS)

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Why Are States Interested?

• Improve coordination of care via enhanced care
  management, preventive services.
• Establish accountability for delivery,
  coordination, and management of quality care to
  high-risk dual eligibles.
• Increase number and duration of duals being
  served in their homes and communities.

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Why Are States Interested? (contd)

• An opportunity to do better with limited
  resources
• 36 of total Medicaid spending is for LTC
• 42 of total Medicaid spending is for the duals
• 24 of total Medicare spending is for the duals
• Approximately 7 million people

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State Experience with Medicaid/Medicare
Integration

• Medi-Medi demo states Massachusetts, Minnesota,
  Wisconsin
• Other models Arizona, Florida, New York, New
  Mexico, Texas, Washington
• Potential of Special Needs Plans (SNPs) created
  in the Medicare Modernization Act (MMA)

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CHCS Integrated Care Program (ICP)

• 2-year Initiative - Launched December 2005
• 5 Grantee States Florida, Minnesota, New Mexico,
  New York, Washington
• Objectives
• Provide technical assistance and training for the
  development and implementation of integrated care
  programs
• Facilitate and/or support the planning for state
  contracting with Medicare Advantage Special Needs
  Plans (SNPs) and
• Move the market toward fully integrated care by
  increasing awareness and buy-in, fostering
  innovation, evaluating models of integrated care,
  and disseminating best practices.

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State ICP Profiles
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State ICP Profiles (contd)
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Challenges

• Encouraging Enrollment Mandatory vs. voluntary
• Developing LTC Rates How to use MDS (nursing
  facility), OASIS (home health), measures of
  functional status, HCBS services, etc.
• Cost Shifting Financial misalignment between
  Medicare and Medicaid
• Building 3-Way Relationships Effective, timely
  communication among state, CMS, plans
• Maintaining Focus Superior care models and
  delivery for specialized populations
• Understanding Medicare World Regulatory
  expertise access to capital for Medicaid plans
• Future of SNPs Sunset in 2008?

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ICP Focus Areas (3 Sizes Fit All)

• Administrative Simplification
• Enrollment/Eligibility
• Marketing
• Monitoring Reporting
• Grievances Appeals
• Rate Setting/Risk Adjustment
• Performance Measures

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ICP Future Activities

• Engage 5-10 additional states in planning and
  technical assistance activities.
• Work with SNPs and other managed care entities to
  develop best practices in integrated care.
• Develop rate-setting/risk-adjustment methodology
  for long-term care services.

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CMS Resources

• Commitment to Promoting Integrated Care for Duals
• Fact Sheet http//www.cms.hhs.gov/apps/media/press
  /release.asp?Counter1912
• Integrated Care How To Guides http//www.cms.hhs.g
  ov/DualEligible/04_IntegratedMedicareandMedicaidMo
  dels.aspTopOfPage
• Enrollment
• Marketing
• Quality
• Dual Subsets Guidance http//www.cms.hhs.gov/DualE
  ligible/Downloads/specialneedsplanletter.pdf
• Regional Office Trainings

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Additional Resources

• CHCS
• Integrated Care Program Performance Measures
  Recommendations http//www.chcs.org/usr_doc/ICP_Re
  source_Paper.pdf
• Integrated Care Program Design, Rate Setting, and
  Risk Adjustment A Checklist for States
• http//www.chcs.org/usr_doc/ICP_TA_Tool.pdf
• Medicare Rate Setting Primer (Available in
  September)
• Congressional Research Service
• Integrating Medicare and Medicaid Services
  Through Managed Care