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Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS « » The Henry J. Kaiser Family Foundation

Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS

Issue Brief
  1. For background on the demonstrations, see Kaiser Commission on Medicaid and the Uninsured, Explaining the State Integrated Care and Financial Alignment Demonstrations for Dual Eligible Beneficiaries (Oct. 2012), available at http://www.kff.org/medicaid/issue-brief/explaining-the-state-integrated-care-and-financial/.

     

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  2. California revised its start date from October 2013 to January 2014 and then to April 2014. CalDuals, “Coordinated Care Initiative to begin no earlier than April 2014,” posted Aug. 16, 2013, available at http://www.calduals.org/2013/08/16/coordinated-care-initiative-to-begin-no-earlier-than-april-2014/; CalDuals, News & Updates, “Demo to start January 2014,” posted May 6, 2013, available at http://www.calduals.org/news-and-updates/.

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  3. CMS announced that Illinois’ demonstration start date has been revised from October 2013 to January 2014. Email from Daniel Farmer, Special Assistant to the Director, Medicare-Medicaid Coordination Office (May 31, 2013) (on file with author); subsequently, Illinois changed its start date to February 2014, and then to March 2014. See Medicare-Medicaid Alignment Initiative Implementation Status and County Plan Participation (March 1, 2014), available at http://www2.illinois.gov/hfs/PublicInvolvement/cc/mmai/Pages/MMAIImplementationStatus.aspx.

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  4. Although Massachusetts’ MOU with CMS provided for an April 1, 2013 start date, the state and CMS subsequently agreed to delay implementation until July 1, 2013, and again until October 1, 2013. Massachusetts Executive Office of Health and Human Services, One Care Timeline Update, accessed June 6, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/related-information.html.

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  5. Massachusetts Executive Office of Health and Human Services, One Care Timeline Update, accessed Sept. 9, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/related-information.html. Prior to announcing its revised enrollment effective dates, Massachusetts had decided to delay passive enrollment of beneficiaries in the high community need and community high behavioral health need categories until calendar year 2014. MassHealth presentation at slide 7, Open Meeting, May 17, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html; see also MassHealth Demonstration to Integrate Care for Dual Eligibles, Open Meeting presentation at slide 17 (Oct. 16, 2013), available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.

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  6. Massachusetts revised its 2013 savings to zero. MassHealth presentation at slide 5, Open Meeting, May 17, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html. Demonstration year one in Massachusetts lasts from 2013 through December 2014.

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  7. Massachusetts anticipates savings of greater than 4% in year 3 (approximately 4.2%) to make up for foregone savings in year one. Massachusetts Demonstration to Integrate Care for Dual Eligible Individuals, Updated Rate Report, May 15, 2013 at 18, available at http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/state-fed-comm/duals-demo-cy2013-payment-rates.pdf.

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  8. Ohio revised its demonstration start date from September 2013 to March 2014 and again to May 2014 for voluntary enrollment and Jan. 1, 2015 for passive enrollment. Emails from Daniel Farmer, Special Assistant to the Director, Medicare-Medicaid Coordination Office (May 31, 2013 and Jan. 23, 2014) (on file with author).

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  9. Virginia Medicare-Medicaid Financial Alignment Demonstration Regions, updated Jan. 11, 2013, available at http://www.dmas.virginia.gov/Content_atchs/altc/altc-anst6.pdf.

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  10. Although Washington’s MOU with CMS provided for an April 1, 2013 start date, the state and CMS subsequently agreed to delay implementation until July 1, 2013. Washington Health Care Authority Stakeholder Notice (Feb. 4, 2013), available at http://www.communitycatalyst.org/doc_store/publications/StakeholdernoticeHealth%20Homes.pdf; see also Final Demonstration Agreement between CMS and State of Washington Regarding a Federal-State Partnership to Test a Managed FFS Financial Alignment Model for Medicare-Medicaid Enrollees (June 28, 2013), available at http://www.adsa.dshs.wa.gov/duals/documents/WA%20Final%20Demonstration%20Agreement.pdf.

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  11. See Kaiser Commission on Medicaid and the Uninsured, Medicaid’s Role for Dual Eligible Beneficiaries (Aug. 2013), available at http://www.kff.org/medicaid/issue-brief/medicaids-role-for-dual-eligible-beneficiaries/; Kaiser Family Foundation, Medicare’s Role for Dual Eligible Beneficiaries (April 2012), available at http://www.kff.org/medicare/issue-brief/medicares-role-for-dual-eligible-beneficiaries/.

     

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  12. Kaiser Commission on Medicaid and the Uninsured, Development of the Financial Alignment Demonstrations for Dual Eligible Beneficiaries:  Perspectives from National and State Disability Stakeholders (July 2013), available at http://kff.org/medicaid/issue-brief/development-of-the-financial-alignment-demonstrations-for-dual-eligible-beneficiaries-perspectives-from-national-and-state-disability-stakeholders/.

     

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  13. CMS, Medicare and Medicaid Coordination Office, Financial Alignment Initiative, Funding to Support Options Counseling for Medicare-Medicaid Enrollees, http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FundingtoSupportOptionsCounselingforMedicare-MedicaidEnrollees-.html.

     

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  14. See, e.g., Virginia Commonwealth University Partnership for People with Disabilities, A Closer Look at the Centers’ for Medicare and Medicaid Services’ Definition of Person-Centered Planning, available at http://www.medicaid.gov/mltss/docs/PCP-CMSdefinition04-04.pdf.

     

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  15. State Medicaid spending qualifies for federal matching funds based upon the state’s Federal Medical Assistance Percentage (FMAP).  For more information about the FMAP, see Kaiser Commission on Medicaid and the Uninsured, Medicaid Financing:  An Overview of the Federal Medicaid Matching Rate (FMAP) (Sept. 2012), available at http://www.kff.org/health-reform/issue-brief/medicaid-financing-an-overview-of-the-federal/.

     

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  16. CMS, Medicare-Medicaid Coordination Office, Financial Alignment Initiative, Funding to Support Ombudsman Programs, http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.

     

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  17. MassHealth Demonstration to Integrate Care for Dual Eligibles, Open Meeting presentation at 17 (Oct. 16, 2013), available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html; Calduals Ombudsman Resources, available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/IllinoisContract.pdf.

     

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  18. California’s three-way contract templates are available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/California.html; Illinois’ three-way contract is available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/IllinoisContract.pdf; Massachusetts’ three-way contract is available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MassachusettsContract.pdf; Ohio’s three-way contract is available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/OhioContract.pdf; Virginia’s three-way contract is available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/OhioContract.pdf.

     

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  19. Washington’s final demonstration agreement is available at http://www.adsa.dshs.wa.gov/duals/documents/WA%20Final%20Demonstration%20Agreement.pdf.

     

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Appendix
  1. The states’ MOUs with CMS are available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html.  All information in the Appendix is from the states’ MOUs unless otherwise indicated.

     

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California
  1. Templates available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/California.html.

     

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  2. California revised its start date from October 2013 to January 2014 and then to April 2014.  CalDuals, “Coordinated Care Initiative to begin no earlier than April 2014,” posted Aug. 16, 2013, available at http://www.calduals.org/2013/08/16/coordinated-care-initiative-to-begin-no-earlier-than-april-2014/; CalDuals, News & Updates, “Demo to start January 2014,” posted May 6, 2013, available at http://www.calduals.org/news-and-updates/.

     

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  3. CCI Enrollment Timeline by County and Population (revised April 1, 2014), available at http://www.calduals.org/2014/04/02/revised-enrollment-chart-by-county-available-here/.

     

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  4. Cal Duals, Proposed LA County Enrollment – Draft Revised Version (Feb. 18, 2014), available at http://www.calduals.org/implementation/policy-topics/la-county-enrollment-strategy/.

     

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  5. Available at http://www.calduals.org/dhcs-cci-amendment-to-1115-waiver/.

     

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  6. California’s limited down-side risk corridor applies county-specific interim savings percentages to establish initial capitation rates; if plan costs exceed the initial capitation rates (excluding Part D), Medicare and Medicaid will reimburse the plan 67% of the costs above the initial capitation rates, provided that total federal and state payments to the plan cannot exceed the demonstration minimum savings percentage for the applicable year.  California’s limited up-side risk corridor is as follows:  difference between demonstration minimum savings percentage and county specific savings percentage, plans retain 100% (if county savings percentage is the same as the demonstration minimum savings percentage, this band is based on the difference between the minimum savings percentage and maximum demonstration savings percentages of 1.5% in year one, 3.5% in year two, and 5.5% in year three); from upper limit of first band applying the same number of percentage points, Medicare and Medicaid share in 50% of plan savings and plan shares in the other 50%; for all amounts above the upper limit of the second band, plans retain 100%.

     

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  7. In California’s demonstration, in calendar year 2014, CMS will apply “an appropriate Medicare Advantage coding intensity adjustment reflective of all prime contractor plan enrollees.”  In 2015 and 2016, CMS will apply “the prevailing Medicare Advantage coding intensity adjustment factor.”

     

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  8. California’s Medicaid rating categories include institutionalized (90 or more days), HCBS High (high utilizers), HCBS Low (low utilizers), and Community Well (no HCBS).

     

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  9. In Phase I, California’s risk adjustment methodology will be applied monthly and retroactively to match actual plan enrollment, continuing through each county’s enrollment phase-in period (except San Mateo) for a minimum of one year, ending at the start of the next fiscal quarter.  Phase II will last for one fiscal quarter (except two quarters in San Mateo) in which the risk adjustment methodology will be applied prospectively at the start of the quarter and risk category weighting will be based on enrollment in the month preceding the quarter and applied retroactively.  In Phase III, plan rates will be based on a targeted relative mix of the population (based on plan enrollment leading up to the start of Phase III and including an assumed shift in population mix based on assumptions about the plan’s ability to promote community services and prevent or delay institutional placement) and will not be adjusted during the year (however, if the population mix results in greater than 2.5% impact on the Medicaid rate paid as compared to the rate that would have been paid based on the actual mix, then the plan and Medicaid will share equally in any cost increases or decreases beyond 2.5%, regardless of actual plan gain or loss).

     

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  10. http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.

     

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  11. Calduals Ombudsman Resources, available at http://www.calduals.org/implementation/policy-topics/ombudsman-resources/.

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Illinois
  1. Available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/IllinoisContract.pdf.

     

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  2. CMS announced that Illinois’ demonstration start date has been revised from October 2013 to January 2014.  Email from Daniel Farmer, Special Assistant to the Director, Medicare-Medicaid Coordination Office (May 31, 2013) (on file with author); subsequently, Illinois changed its start date to February 2014, and then to March 2014.  See Medicare-Medicaid Alignment Initiative Implementation Status and County Plan Participation (March 1, 2014), available at http://www2.illinois.gov/hfs/PublicInvolvement/cc/mmai/Pages/MMAIImplementationStatus.aspx.

     

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  3. Illinois beneficiaries enrolled in a Medicare Advantage plan operated by the same parent organization as a demonstration plan will be passively enrolled into that demonstration plan.

     

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  4. Medicare-Medicaid Alignment Initiative Implementation Status and County Plan Participation (March 1, 2014), available at http://www2.illinois.gov/hfs/PublicInvolvement/cc/mmai/Pages/MMAIImplementationStatus.aspx.

     

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  5. MMAI April 18, 2013, Stakeholders Meeting, Questions and Answers, items 61 and 62, available at http://www2.illinois.gov/hfs/SiteCollectionDocuments/MMAI_QA_041813.pdf. Beneficiaries required to enroll in a Medicaid managed care plan will be locked in for one year, after an initial 90 day change period, with an annual open enrollment period.

     

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  6. IL Dep’t of Healthcare and Family Services, Path to Transformation IL § 1115 waiver proposal, available at http://www2.illinois.gov/hfs/publicinvolvement/1115/pages/1115.aspx#toc379811249.

     

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  7. Illinois’ Medicaid rating categories will be stratified by age (21-64 and 65+), geographic region, and care setting, including nursing facility (except that the HCBS waiver rate applies for the first three months after transition from waiver to nursing facility), HCBS waiver, waiver plus (for the first three months for beneficiaries moving from a nursing facility to a HCBS waiver), and community (do not meet nursing home level of care, reside in a nursing facility or qualify for an HCBS waiver).

     

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  8. MMAI County Plan Participation, http://www2.illinois.gov/hfs/PublicInvolvement/cc/mmai/Pages/MMAIImplementationStatus.aspx.

     

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  9. Available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.

     

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Massachusetts
  1. Available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/related-information.html.

     

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  2. Although Massachusetts’ MOU with CMS provided for an April 1, 2013 start date, the state and CMS subsequently agreed to delay implementation until July 1, 2013, and again until October 1, 2013.  Massachusetts Executive Office of Health and Human Services, One Care Timeline Update, accessed June 6, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/related-information.html.

     

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  3. MassHealth presentation at slide 7, Open Meeting, July 29, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.

     

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  4. Id. 

     

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  5. MassHealth Demonstration to Integrate Care for Dual Eligibles, Open Meeting presentation at slide 12 (Oct. 16, 2013), available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.

     

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  6. MassHealth presentation, Open Meeting, Feb. 21, 2014, available at http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/prev-meetings/140221-masshealth-presentation.pdf.

     

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  7. Massachusetts Executive Office of Health and Human Services, One Care Timeline Update, accessed Sept. 9, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/related-information.html.  Prior to announcing its revised enrollment effective dates, Massachusetts had decided to delay passive enrollment of beneficiaries in the high community need and community high behavioral health need categories until calendar year 2014.  MassHealth presentation at slide 7, Open Meeting, May 17, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html; see also MassHealth Demonstration to Integrate Care for Dual Eligibles, Open Meeting presentation at slide 17 (Oct. 16, 2013), available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.

     

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  8. Massachusetts revised its 2013 savings to zero.  MassHealth presentation at slide 5, Open Meeting, May 17, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.  Demonstration year one in Massachusetts lasts from 2013 through December 2014.

     

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  9. Massachusetts anticipates savings of greater than 4% in year 3 (approximately 4.2%) to make up for foregone savings in year one.  Massachusetts Demonstration to Integrate Care for Dual Eligible Individuals, Updated Rate Report, May 15, 2013 at 18, available at http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/state-fed-comm/duals-demo-cy2013-payment-rates.pdf.

     

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  10. Massachusetts’ Medicaid rating categories initially included facility-based care (long-term stay of more than 90 days), high community needs (skilled need seven days a week; 2 or more ADL limitations and need for skilled nursing 3 or more days a week; or 4 or more ADL limitations), community high behavioral health (based on specific diagnosis of ongoing chronic condition), and community other.  Massachusetts subsequently refined its rating categories so that the high community needs and community high behavioral health categories each will be split to separate beneficiaries with certain chronic diagnoses that lead to costs considerably above average for the overall rating category, with the result that the high community needs group will be divided into highest community need (for beneficiaries with certain diagnoses such as quadriplegia, ALS, and respirator dependence, that lead to costs considerably above average for this rating category) and medium/high community need, and the community high behavioral health group will be divided into community highest behavioral health (for beneficiaries with co-occurring substance abuse and serious mental illness) and community medium/high behavioral health.  MassHealth presentation at slide 7, Open Meeting, Feb. 21, 2014, available at http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/prev-meetings/140221-masshealth-presentation.pdf.

     

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  11. Massachusetts’ high cost risk pools apply to the facility-based care and high community needs rating categories.  A portion of the base Medicaid capitation rate for each of these rating categories will be withheld from all ICOs and placed into a risk pool that will be divided among ICOs based on their percent of total costs above a threshold amount for select Medicaid LTSS.

     

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  12. Massachusetts’ risk corridor tiers have been revised as follows:  greater than 20% gain or loss, plans bear entire risk/reward; 3%-20% gain or loss, plans bear 50% of risk/reward and state and CMS share in other 50%; 1% to 3% gain or loss, plans bear 10% of risk/reward and state and CMS share in other 90%; 0 to 1% gain or loss, plans bear entire risk/reward.  MassHealth presentation at slide 3, Open Meeting, June 28, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.

     

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  13. Dental Services in One Care (Nov. 2013), available at http://www.communitycatalyst.org/initiatives-and-issues/initiatives/voices-for-better-health/dual-agenda-newsletter/the-dual-agenda-december-4-2013/body/Dental-Services-in-One-Care_Nov-2013.pdf.

     

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  14. MassHealth Demonstration to Integrate Care for Dual Eligibles, Open Meeting presentation at slide 17 (Oct. 16, 2013), available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.

     

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Michigan
  1. In 2015, CMS will apply an appropriate adjustment based on expected proportion of target population with prior Medicare Advantage experience on a county-specific basis; in 2016, CMS will apply an appropriate adjustment reflective of all demonstration enrollees; after 2016, CMS will apply the prevailing adjustment to all enrollees.

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  2. Michigan’s rating categories are tier 1 (meet NF LOC and occupy a NF bed certified for Medicare and Medicaid; separate rates for publicly owned and privately owned NFs); tier 2 (meet NF LOC, do not live in NF, and enrolled in 1915(c) ICO waiver); tier 3 (do not meet tier 1 or tier 2 criteria); rates may vary by age and will vary by geographic region.  For up to 3 months following the transition of a tier 2 or 3 enrollee to a NF, payment will be based on the tier 2 or 3 rate.  A transition case rate will be paid after transition of a tier 1 enrollee to the community if the ICO received 3 consecutive tier 1 payments for the enrollee and provided transition services.

     

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  3. Michigan’s year 1 risk corridor bands are net income before taxes as % of revenue less than or equal to 3% or greater than 9%, ICO bears entire risk/reward; greater than 3% and less than or equal to 9%, ICO bears 50%, Medicare bears percentage based on Medicare share of combined capitation payments excluding Part D, Medicaid bears percentage based on Medicaid share of combined capitation payments excluding Part D.

     

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  4. MI Dep’t of Comm’y Health, MI Health Link Region 4 Implementation Forum presentation (April 8, 2014), available at http://www.michigan.gov/documents/mdch/MI_Health_Link__Forum_Presentation_4.08.14__452964_7.pdf.

     

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New York
  1. While the MOU provided for a July 1, 2014 start date, CMS and the state subsequently modified the state date to October 2014 (email from Daniel Farmer, CMS, Jan. 23, 2014, on file with author) and again to February 2015 (email from NY Medicaid Redesign Team, July 2, 2014, on file with author).

     

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  2. Id.

     

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  3. MOU provided for Sept. 1, 2014, but CMS and the state subsequently modified to Jan. 1, 2015.  Id. 

     

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  4. Centers for Medicare and Medicaid Services, Special Terms and Conditions, New York State Dep’t of Health, Federal-State Health Reform Partnership Medicaid Section 1115 Demonstration (April 1, 2013), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ny/ny-f-shrp-ca.pdf.

     

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  5. In NY’s demonstration, in CY 2014 and 2015, CMS will apply “an appropriate coding intensity adjustment based on the proportion of the target population with prior Medicare Advantage experience on a county-specific basis.”  After CY 2015, CMS will apply “the prevailing Medicare Advantage coding intensity adjustment to all FIDA Plan Participants.”

     

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  6. NY’s rating categories include community non-nursing home certifiable (more than 120 days community-based LTSS but do not require nursing home level of care) and nursing home certifiable.

     

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  7. NY Fully Integrated Duals Advantage Demonstration Frequently Asked Questions, Question 6 (Sept. 2013), available at http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm.

     

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Ohio
  1. Available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/OhioContract.pdf.

     

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  2. Ohio revised its demonstration start date from September 2013 to March 2014 and again to May 2014 for voluntary enrollment and Jan. 1, 2015 for passive enrollment.  Emails from Daniel Farmer, Special Assistant to the Director, Medicare-Medicaid Coordination Office (May 31, 2013 and Jan. 23, 2014) (on file with author).

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  3. MyCare Ohio, Enrollment Update (Jan. 2014), available at http://medicaid.ohio.gov/Portals/0/For%20Ohioans/Programs/MyCareOhio/EnrollmentUpdate012014.pdf.

     

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  4. Ohio’s rating categories include community well (varies by age group (18-44, 45-64, 65+) and geographic region) and nursing facility level of care (waiver enrollment or 100 or more days in nursing facility, single rate for each region, plan continues to receive nursing facility rate for three months after a beneficiary is determined to no longer meet this level of care).

     

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  5. http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.

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South Carolina
  1. In CY 2014, CMS will apply an “appropriate coding intensity adjustment based on the expected proportion of the target population with prior Medicare Advantage experience on a county-specific basis.”  In CY 2015, CMS will apply “the prevailing Medicare Advantage coding intensity adjustment proportional to the anticipated proportion of Demonstration Enrollees in CY 2015 with prior Medicare Advantage experience and/or Demonstration experience based on the Demonstration’s enrollment phase-in as of September 30, 2014.”  After CY 2015, CMS will apply “the prevailing Medicare Advantage coding intensity adjustment for all Enrollees.”

     

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  2. South Carolina’s rating categories include nursing facility based care (stay of more than 100 days); HCBS (meets level of care requirement for nursing facility and/or HCBS waiver); HCBS plus (moving from nursing facility to waiver for first 3 months of transition); and community (do not meet criteria for another category).

     

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  3. South Carolina Medicaid Healthy Connections Prime, Health Plan Announcement, available at https://msp.scdhhs.gov/SCDue2/.

     

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Texas
  1. Year 1(a) is March, 2015-Dec. 2105.  Year 1(b) is Jan. 2016-Dec. 2016.

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  2. In CY 2015, CMS will apply an “appropriate coding intensity adjustment based on the expected proportion of the target population with prior Medicare Advantage experience on a county-specific basis.”  In CY 2016, CMS will apply “the prevailing Medicare Advantage coding intensity adjustment proportionate to the anticipated percent of enrollees in CY 2016 with prior Medicare Advantage experience and/or Demonstration experience based on the Demonstration’s enrollment phase-in as of September 30, 2015.”  After CY 2016, CMS will apply “the prevailing Medicare Advantage coding intensity adjustment” to all enrollees.

     

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  3. Texas’s rating categories include HCBS (includes those who receive HCBS waiver services and seniors and adults with disabilities who qualify for NF LOC but do not reside in a NF), Other Community Care (receive Medicaid state plan services only and do not reside in NF), and Nursing Facility (receive state plan services only and reside in NF).  Rating categories may be updated to be consistent with the § 1115 demonstration, subject to CMS approval.  For the first 3 months after a beneficiary transitions to a NF, the plan will be paid the HCBS rate.  For the first 3 months after a beneficiary transitions out of a NF to the community, the plan will be paid the NF rate.

     

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  4. Plans retain 100% of net income before taxes equal to or less than 3% of total plan revenues; the experience rebates that plans must pay are 20% for the portion of net income before taxes greater than 3% and less than or equal to 5% of total plan revenues, 40% for the portion greater than 5% and less than or equal to 7%, 60% for the portion greater than 7% and less than or equal to 9%, 80% for the portion greater than 9% and less than or equal to 12%, and 100% for the portion greater than 12%.  Net income before taxes is an aggregate excess of revenues over allowable expenses.

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  5. Texas Health and Human Services Commission, Medicaid and CHIP, Dual Eligible Integrated Care Project, Geographic Area, Participating Counties with number of clients covered and health plans, available at http://www.hhsc.state.tx.us/medicaid/managed-care/dual-eligible/.

     

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Virginia
  1. Available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/OhioContract.pdf.

     

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  2. Email from Daniel Farmer, Special Assistant to the Director, Medicare-Medicaid Coordination Office (Jan. 23, 2014) (on file with author).

     

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  3. Virginia Medicare-Medicaid Financial Alignment Demonstration Regions, updated Jan. 11, 2013, available at http://www.dmas.virginia.gov/Content_atchs/altc/altc-anst6.pdf.

     

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  4. The MOU provides for voluntary enrollment effective Feb. 2014, but the state and CMS subsequently revised the effective date.  Email from Daniel Farmer (Jan. 23, 2014) (on file with author).

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  5. Id.

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  6. Virginia state plan amendment 13-03 (approved June 12, 2013), available at http://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/VA/VA-13-03-Att.pdf.

     

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  7. Demonstration year one in Virginia encompasses February 2014 through December 2015.

     

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  8. In Virginia’s demonstration, in calendar year 2014, CMS will apply “an appropriate coding intensity adjustment based on the proportion of the target population with prior Medicare Advantage experience on a county-specific basis.”  After calendar year 2014, CMS will apply “the prevailing Medicare Advantage coding intensity adjustment for all [e]nrollees.”

     

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  9. Virginia’s rating categories include community well ages 21-64, community well age 65+, nursing facility level of care ages 21-64, and nursing facility age 65+.  Beneficiaries are eligible for the nursing facility categories if they are enrolled in an HCBS waiver or spend 20 or more consecutive days in a nursing facility.  Plans will continue to receive the nursing facility rate for two months after a beneficiary is determined to no longer meet that level of care.  Rates within each category will vary by region.

     

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  10. http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.

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Washington (managed FFS model)
  1. Washington’s final demonstration agreement is available at http://www.adsa.dshs.wa.gov/duals/documents/WA%20Final%20Demonstration%20Agreement.pdf.

     

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  2. Although Washington’s MOU with CMS provided for an April 1, 2013 start date, the state and CMS subsequently agreed to delay implementation until July 1, 2013.  Washington Health Care Authority Stakeholder Notice (Feb. 4, 2013), available at http://www.communitycatalyst.org/doc_store/publications/StakeholdernoticeHealth%20Homes.pdf; see also Final Demonstration Agreement between CMS and State of Washington Regarding a Federal-State Partnership to Test a Managed FFS Financial Alignment Model for Medicare-Medicaid Enrollees (June 28, 2013), available at http://www.adsa.dshs.wa.gov/duals/documents/WA%20Final%20Demonstration%20Agreement.pdf.

     

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  3. Chronic conditions included in WA’s health homes eligibility criteria include mental health conditions, substance use disorder, asthma, diabetes, heart disease, cancer, cerebrovascular disease, coronary artery disease, dementia or Alzheimer’s disease, intellectual disability, HIV/AIDS, renal failure, chronic respiratory conditions, neurological disease, gastrointestinal, hematological, and musculoskeletal conditions.  CMS/WA Final Demonstration Agreement at 5.

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  4. WA state plan amendment 13-08 (June 28, 2013), available at http://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/WA/WA-13-08-Ltr.pdf.

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  5. WA state plan amendment 13-17 (Dec. 11, 2013), available at http://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/WA/WA-13-17-HHSPA.pdf.

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  6. Washington State Health Care Authority, RFA #12-005 Qualified Health Homes Release C (Aug. 9, 2013), http://www.hca.wa.gov/Documents/health_homes/ASAAnnouncement_1_2_6.pdf.

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  7. Id.

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  8. Washington State Health Care Authority, RFA #12-005 Release A (Feb. 1, 2013), http://www.hca.wa.gov/Documents/health_homes/coveragearea4_asa_announcement.pdf.

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  9. Washington State Heath Care Authority, RFA #12-005 Release B (April 30, 2013), http://www.hca.wa.gov/Documents/health_homes/ASAAnnouncementReleaseB.pdf.

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  10. Washington State Health Care Authority, RFA #12-005 Qualified Health Homes Release C (Aug. 9, 2013), http://www.hca.wa.gov/Documents/health_homes/ASAAnnouncement_1_2_6.pdf.

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  11. Washington State Heath Care Authority, RFA #12-005 Release B (April 30, 2013), http://www.hca.wa.gov/Documents/health_homes/ASAAnnouncementReleaseB.pdf.

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Washington (capitated model)
  1. The MOU originally called for enrollment in July 2014, but Washington subsequently amended its earliest effective enrollment date to February 1, 2015 (www.altsa.dshs.wa.gov/duals).

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  2. Demonstration year 1 in Washington is July 1, 2014 to Dec. 31, 2015.

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  3. In calendar year 2014, CMS will apply an “appropriate” coding intensity adjustment based on the proportion of the target population with prior Medicare Advantage experience on a county-specific basis.  In calendar year 2015, CMS will apply an appropriate coding intensity adjustment reflective of all demonstration enrollees.  After calendar year 2015, CMS will apply the prevailing Medicare Advantage coding intensity adjustment.

     

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  4. Washington’s rating categories are medical and chemical dependency (institutional LOC and non-institutional LOC), mental health (disabled according to SSI definition and non-disabled), and LTSS (institutional LOC, HCBS institutional level of care, non-institutional LOC).  In July and August 2014, rates will be based on an average mix of acuity with adjustments for geography, age and gender and will be paid at the non-institutional rate (to the extent that beneficiaries who meet an institutional level of care enroll, institutional rates will be applied retroactively).  The mental health component of the rate will be risk adjusted based on historical claims and encounter data, using age, gender, diagnosis and medication data.  The LTSS component of the rate will be risk adjusted based on age, gender, and functional assessment level.  The medical/chemical dependency rate will not be risk adjusted by diagnosis.  Rates will vary by county as determined by the state and by age, and gender as determined necessary by the state and reviewed by CMS.

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  5. WA State Health Care Authority, “Health Care Authority, DSHS announce apparently successful bidders for HealthPath Washington” (June 6, 2013), available at http://www.altsa.dshs.wa.gov/duals/documents/Bidder%20awards%20on%20Strategy%20II%20duals%20project.pdf.

     

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