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


MOU Signed:
March 27, 2013
3-way contract issued1
Demonstration Duration:
3 years
April 1, 20142 to Dec. 31, 2016
Target Group:
Includes:  an estimated 456,000 full benefit dual eligible beneficiaries age 21 and older in 8 counties are eligible to enroll; enrollment is capped at 200,000 in Los Angeles county; PACE, AIDS Healthcare Foundation, and enrollees in certain § 1915(c) HCBS waivers may participate if they disenroll from their existing program
Excludes:  dual eligible beneficiaries with other comprehensive coverage, those who receive services from a regional center, state developmental center or ICF/DD, certain long-term care beneficiaries with a Medicaid share of cost, veterans’ home residents, residents in certain rural zip codes, and beneficiaries with end stage renal disease in certain counties unless already enrolled in a separate plan operated by a demonstration prime contractor
Geographic Area: 8 counties:  Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara
California’s revised enrollment timeline is as follows:3
April 2014:  all beneficiaries currently in Medicare FFS and Medicaid managed care in San Mateo county and those in MSSP in San Mateo county will be passively enrolled in one month; voluntary enrollment period begins for beneficiaries currently in Medicare FFS in Los Angeles, Riverside, San Bernardino, and San Diego counties
May 2014:  all beneficiaries currently in Medicare FFS and Medicaid managed care in Riverside, San Bernardino and San Diego counties are passively enrolled in one month; passive enrollment begins by birth month for beneficiaries currently in Medicare FFS and Medicaid FFS in Riverside, San Bernardino, and San Diego counties (except that April birthdays enroll in May 2014)
July 2014:  all beneficiaries currently in Medicare FFS and Medicaid managed care in Los Angeles county are passively enrolled in one month (passive enrollment will be in CareMore, Care First, Molina, and Health Net plans only; L.A. Care will be eligible for passive enrollment once it improves its Medicare quality rating);4 12 month passive enrollment period by birth month begins for beneficiaries currently in Medicare FFS and Medicaid FFS in Los Angeles county
August 2014:  all beneficiaries currently in MSSP in Los Angeles, Riverside, San Bernardino, and San Diego counties are passively enrolled in one month
Jan. 2015:  all beneficiaries in Medicare FFS and Medicaid managed care in Alameda and Santa Clara counties, MSSP beneficiaries in Alameda, Orange, and Santa Clara counties, and beneficiaries in Medicare Advantage plans in all 8 demonstration counties are passively enrolled in one month; start of 12 month passive enrollment period by birth month for beneficiaries in Medicare FFS and Medicaid managed care in Orange county and for beneficiaries in Medicare FFS and Medicaid FFS in Alameda and Santa Clara counties
L.A. County enrollment is capped at 200,000, and a waiting list will be maintained.
Notices will be sent 90, 60, and 30 days prior to passive enrollment.
Beneficiaries in certain rural zip codes where only one demonstration plan operates and those in certain non-profit prepaid health plans are exempt from passive enrollment
Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter on a monthly basis
CMS approved the amendment to California’s existing § 1115 waiver,5 which requires beneficiaries to enroll in a Medicaid managed care plan if they opt out of the financial alignment demonstration
Passive enrollment intelligent assignment process based on 12 months of Medicare and Medicaid claims history data to identify most frequently used providers and to ensure that beneficiaries in long-term care facilities will not need to change facilities
Capitated with minimum savings percentage (1% in year one, 2% in year two, and 4% in year three) applied upfront to baseline Medicare and Medicaid contributions; for purposes of California’s risk corridors,6 the MOU also specifies county-specific interim savings percentages and demonstration-wise maximum savings percentages of 1.5% in year one, 3.5% in year two, and 5.5% in year three; capitation rate withhold (1% in year one, 2% in year two, 3% in year three) which plans earn back by meeting specified quality measures
Plans must provide incentive payments from quality withhold funds to county behavioral health agencies based on achievement of service coordination measures
Medicare baseline for capitated payments: Parts A and B = blend of Medicare Advantage benchmarks (including quality bonus payments) and Medicare FFS standardized county rates weighted by whether beneficiaries who are expected to transition to the demonstration are enrolled in Medicare Advantage or Medicare FFS in the prior year; Medicare Advantage risk score coding intensity adjustment factor will apply after calendar year 2013;7 Part D = national average monthly bid amount plus average projected low income cost sharing subsidy and average projected federal reinsurance amounts
Medicare risk adjustment: CMS Hierarchical Condition Categories model used for Medicare Advantage plans
Medicaid baseline for capitated payments: Medicaid capitation rates under § 1115 waiver that would apply to beneficiaries who are in target population but not enrolled in the demonstration (excluding specialty behavioral health services financed and managed by county behavioral health agencies and costs for county administration of In Home Supportive Services)
Medicaid risk adjustment: Rating categories with financial incentives for HCBS  over institutional care8 to be implemented in each county in 3 phases9
Risk sharing: Limited risk corridors in all years6
Care Delivery Model:
Cal MediConnect plans will provide person-centered medical homes, care coordination and integrated medical, behavioral health, and LTSS
Requires behavioral health MOU with county mental health and substance use agency and MOU with county social services agency to coordinate In Home Supportive Services
Prime contractor plans may subcontract with other Medicare Advantage plans to offer multiple plan benefit packages
Participating Health Plans:
-Alameda County (2 plan model county):  Alameda Alliance Complete Care and Anthem Blue Cross
-Los Angeles County (2 plan model county):  Health Net and L.A. Care (L.A. Care partner plans include CareMore, Care First Health Plan, and Kaiser Permanente)
-Orange County (county organized health system): CalOptima OneCare-Riverside County (2 plan model county):  Inland Empire Health Plan and Molina Dual Options
-San Bernardino County (2 plan model county):  Inland Empire Health Plan and Molina Dual Options
-San Diego County (geographic managed care):  Care First Health Plan, Community Health Group Communicare Advantage, Health Net, and Molina Dual Options
-San Mateo County (county organized health system): Health Plan of San Mateo Care Advantage
-Santa Clara County (2 plan model county): Anthem Blue Cross and Santa Clara Family Health Plan
Benefits: Includes all Medicare and Medicaid services except Medicare hospice and certain § 1915(b) specialty mental health and substance use services that will continue to be financed and administered by county behavioral health agencies; includes In Home Supportive Services although counties will continue to assess and authorize the need for these services and enroll providers; plans may provide additional HCBS and behavioral health services to prevent institutionalization as appropriate to beneficiary needs; adds dental, vision, and non-emergency medical transportation services
Continuity of Care: Beneficiaries must maintain current providers and service authorizations for up to 6 months for Medicare services and up to 12 months for Medicaid services except for IHSS providers, DME, medical supplies, transportation, and other ancillary services
Ombuds Program: California’s state Medicaid managed care ombuds office will support individual advocacy and independent systemic oversight for the demonstration with an emphasis on community integration, independent living and person-centered care.  California has been awarded CMS funding to support its ombuds program10 and has selected Legal Aid Society of San Diego as the primary contractor for the ombuds program.11
Stakeholder Engagement: Plans must establish at least one consumer advisory committee that provides input to the governing board and include beneficiaries with disabilities in the plan governance structure
Notice:  single integrated notice
Timeframe to request initial appeal:  60 days for Medicare-covered service; 90 days for Medicaid-covered serviceInternal health plan appeal:  appeals for services traditionally covered by Medicare and by Medicaid are to be integrated over time; for demonstration year 1 and until a new system is established, current Medicare and Medicaid managed care appeals processes continue: initial Medicare appeal is filed with health plan; initial Medicaid appeal is filed with health plan or beneficiary may directly request fair hearing; California will work with CMS and stakeholders to create a more integrated appeals process in future years, with 90 days to request an appeal and a requirement that beneficiaries exhaust health plan and external reviews before requesting a fair hearing
External Medicare appeals:  health plan automatically sends appeal to Medicare Independent Review Entity (IRE) if initial denial upheld; beneficiary may then request Office of Medicare Hearing and Appeals review
External Medicaid appeals:  beneficiary may request fair hearing directly or after internal health plan appeal; beneficiaries may request Independent Medical Review for certain Medicaid appeals if a fair hearing has not already been requested
Appeals where Medicare and Medicaid services overlap:  to be determined in 3-way contract; beneficiaries will retain right to Medicaid fair hearing
Continued benefits pending appeal:  current rules continue to apply (available for Medicaid services but not for Medicare services)
Medicare Part D appeals:  existing Medicare Part D appeals process continues
Existing appeals process for county-authorized IHSS and behavioral health services also remains unchanged.


Appendix Colorado