Title: Introduction of New
1Introduction of New Very Integrated
Programfor Dual-Eligible BeneficiariesTuesday,
January 10, 2011300 p.m. ET
2Agenda
- 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
3About 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.
4ACAP 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
5ACAP 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.
6Key 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
7Integrated 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
8The 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.
9ACA 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
10New 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
11Structure
- 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.
12Eligibility
- 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.
13Benefits
- 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
14Enrollment
- 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
15Provider 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
16Marketing 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
17Grievances 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
18Payment
- 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
19Quality
- 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
20Beneficiary 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
21Discussion