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Introduction of New

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Title: Introduction of New


1
Introduction of New Very Integrated
Programfor Dual-Eligible BeneficiariesTuesday,
January 10, 2011300 p.m. ET
2
Agenda
  • Introduction
  • Options for New Integrated Care Program for
    Persons Dually Eligible for Medicare and
    Medicaid
  • Jane Hyatt Thorpe, J.D. Katherine Jett Hayes,
    J.D. George Washington University School of
    Public Health and Health Services Department of
    Health Policy
  • Discussion

3
About ACAP
  • Our mission To represent and strengthen
    not-for-profit safety net health plans as they
    work with providers and caregivers in their
    communities to improve the health and well-being
    of vulnerable populations in a cost-effective
    manner.

4
ACAP Represents 57 Safety Net Health Plans
  • Arizona
  • University Physicians Health Plans
  • California
  • Alameda Alliance for Health
  • CalOptima
  • CenCal Health
  • Central California Alliance for Health
  • Community Health Group
  • Contra Costa Health Plan
  • Gold Coast Health Plan
  • Health Plan of San Mateo
  • Inland Empire Health Plan
  • L A. Care Health Plan
  • Partnership HealthPlan of California
  • Santa Clara Family Health Plan
  • San Francisco Health Plan
  • Colorado
  • Colorado Access
  • Denver Health

5
ACAP Represents 57 Safety Net Health Plans
  • Massachusetts
  • Boston Medical Center HealthNet Plan
  • Commonwealth Care Alliance
  • Neighborhood Health Plan
  • Network Health
  • Michigan
  • CareSource Michigan
  • Minnesota
  • Metropolitan Health Plan
  • New Jersey
  • Horizon NJ Health
  • New York
  • Affinity Health Plan
  • Amida Care
  • Elderplan Homefirst
  • Health Plus
  • Hudson Health Plan
  • New York (cont.)
  • Monroe Plan for Medical Care, Inc.

6
Key Provisions of Todays Proposal
  • Discusses barriers to clinical and financial
    integration in services for dual eligibles
  • Identifies models used by states to integrate
    care through contract and waiver authority, pre-
    and post-ACA
  • Introduces a new, permanent model for dual
    integration that is not a subset of Medicare
    Advantage

7
Integrated Care and Financing for Dual Eligibles
A New Permanent State Plan Option
  • Jane Hyatt Thorpe, J.D. and Katherine Jett Hayes,
    J.D.
  • Department of Health Policy
  • School of Public Health and Health Services
  • George Washington University
  • December 8, 2011

8
The Challenge
  • Dual Eligibles Nine million individuals
  • High Need
  • Sixty-six percent (66) with three or more
    chronic conditions
  • Sixty-one percent (61) considered cognitively or
    mentally impaired
  • High Cost
  • Two hundred and thirty billion (230b) federal
    and state spending in 2006
  • Thirty-six percent (36) of Medicare spending
  • Thirty-nine percent (39) of Medicaid spending
  • Reference Gretchen Jacobson, Tricia Neuman,
    Anthony Damico Barbara Lyons,, Kaiser Family
    Foundation, The Role of Medicare for the People
    Dually Eligible for Medicare and Medicaid (2011).
    Available at http//www.kff.org/medicare/upload/8
    138.pdf The Kaiser Commission on Medicaid Facts
    Dual Eligibles Medicaids Role for Low-Income
    Medicare Beneficiaries (2011) Available at
    http//www.kff.org/medicaid/upload/4091-08.pdf.

9
ACA New Opportunities
  • Historically, barriers to integration
  • Care for dual eligibles reimbursed separately by
    Medicare and Medicaid through fee-for-service and
    managed care models
  • Only PACE and Medicare Advantage Special Needs
    Plans (SNPs) provide opportunities to integrate
    care and financing, but limited in scope
  • ACA provided new authority
  • Federal Office of Coordinated Health Care
    (Medicare-Medicaid Coordination Office)
  • Center for Medicare and Medicaid Innovation
  • Expanded demonstration authority
  • Funded technical assistance for 15 states,
    opportunities for other states
  • Sense of impermanence remains, states interested
    in permanent model

10
New State Plan Option
  • Congress could pass legislation authorizing a new
    permanent program
  • provides an additional pathway for states
  • provides a sense of permanence not currently
    available through demonstrations or SNP model
  • Could borrow from structure of PACE
  • Elements

Structure Eligibility Benefits Enrollment Provider Network Adequacy Marketing and Enrollee Communications Grievances and Internal and External Appeals Setting Payment Rates Quality Beneficiary Protections
11
Structure
  • States and the federal government act as partners
    in establishing the framework
  • As is the case with PACE, treat as a separate
    program with a single set of requirements
    regarding eligibility, application procedures,
    administrative requirements, services, payment,
    participant rights, quality assurance, and
    marketing requirements.

12
Eligibility
  • All full-benefit dual eligibles eligible for full
    range of medically necessary Medicare and
    Medicaid services, as well as care coordination
    and non-medical benefits offered through a health
    plan as part of home- and community-based
    long-term care supports and services
  • Allow participating states to adopt 1-year of
    continuous eligibility for dual-eligible
    beneficiaries.

13
Benefits
  • Plans required to cover all Medicare benefits, as
    well as all Medicaid benefits offered under a
    Medicaid plan and home- and community-based
    waivers.
  • Plans required to offer coordination services and
    permitted to offer additional supplemental
    benefits

14
Enrollment
  • Passive Enrollment with Opt-out
  • To address low participation rates by dual
    eligible individuals and the need to assure a
    higher volume of beneficiary enrollment
  • Beneficiary education
  • Strong beneficiary protections

15
Provider Network Adequacy
  • Use an existing standard applicable to qualified
    health plans, such as the requirement to contract
    with essential community providers under the ACA
  • Plans should demonstrate adequate capacity for
    medical and behavioral health services, as well
    as long-term care services and supports

16
Marketing and Enrollee Communications
  • Integrated materials (one set)
  • outreach and education materials
  • enrollment and disenrollment materials
  • benefit coverage information
  • operational letters for enrollment,
    disenrollment, claims or service denials,
    complaints, internal and external appeals and
    provider terminations
  • Information accessible and understandable to the
    beneficiaries that enroll in the plan, including
    individuals with disabilities and limited English
    proficiency

17
Grievances and Internal and External Appeals
  • Single set of complaints and internal appeals
    processes based on Medicare Advantage, Medicare
    Part D, and Medicaid managed care requirements

18
Payment
  • Payment Model
  • Both the Medicare and Medicaid programs calculate
    and provide risk-adjusted prospective payments to
    a participating health plan
  • Health plan discretion to combine the payment
    streams as appropriate to manage and reimburse
    care for the eligible enrolled individuals
  • Use risk adjustment model that more accurately
    reflects the scope and usage levels of care
    needed for the dual eligibles
  • Include broader set of diagnoses that reflect
    care needs of dual eligibles, including
    comorbidities, complications associated with
    frailty, and behavioral health
  • Account for actual service utilization ideally
    over the course of the previous 12 months at the
    individual level, as well as functional status
    (using activities of daily living scale), and
    mortality of the dually eligible population
  • Include an opportunity for shared savings
  • Similar to PACE payment structure

19
Quality
  • States work closely with health plans and CMS to
    develop a new set of quality and access measures
    that are specific to the more vulnerable dual
    eligible population and focus on outcomes
    measures, including rates of emergency room use,
    long term care, hospital admission and
    readmission rates, and medication errors
  • Participate in 5 Star Quality Demonstration and
    Program

20
Beneficiary Protections
  • Use of passive enrollment for dual-eligible
    individuals with an opt-out, must include strong
    consumer protections to assure that individuals
    or their families have a meaningful process for
    opting-out of the program, including opting-in to
    other plans or back into fee-for-service Medicare
  • Protections
  • Network adequacy
  • Quality of care
  • Consumer representation on plan governing boards
  • Notice and explanations regarding enrollment and
    disenrollment
  • Assurances that all services are culturally and
    linguistically appropriate and physically
    accessible
  • Individualized care plans that maximize consumer
    choice in decisions relating to patient care

21
Discussion
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