Medicare-Medicaid Plan Demonstrations

1. Medicare-Medicaid Plan Demonstrations Chicago Regional Office Centers for Medicare Health Plan Operations Yolanda Burge-Clark August 19, 2014

2. 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.

3. Medicare-Medicaid Beneficiaries Account for Disproportionate Shares of Spending

4. 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.

5. 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.

6. 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.

7. Demonstration Process • 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

8. 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 8

9. 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 9

10. 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 10

11. 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 11

12. 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 12

13. 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 13

14. 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

15. 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.

16. 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 16

17. 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 17

18. 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,

19. 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.

20. 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

21. Illinois

22. Illinois (continued) • Opt-in enrollment: March 1, 2014 • Passive enrollment: June 1, 2014

23. 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.

24. 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.

25. 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.

26. 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.

27. 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

28. Ohio

29. Ohio (continued)

30. 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 periodof 90 days for enrollees identified for high risk care and 365 days for all others • Transition period for all drugs follows Part D rules

31. 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

32. 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

33. 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

34. Michigan (continued)

35. 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

36. Michigan (continued)

37. 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

38. Additional Resources • Medicare-Medicaid Coordination Office http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-MedicaidCoordination.html • Financial Alignment Initiative • Integrated Care Resource Center http://www.integratedcareresourcecenter.com/ • Yolanda.Burge@cms.hhs.gov