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Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – Colorado – 8426-06 « » The Henry J. Kaiser Family Foundation

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


MOU Signed:
Feb. 28, 2014
Final demonstration agreement not yet available
Demonstration Duration:
3 years
Aug. or Sept., 2014 to Dec. 31, 2017
Target Group:
Includes:  an estimated 48,000 full benefit dual eligible beneficiaries without other public or private health insurance are eligible to enroll
Excludes:  beneficiaries residing in an ICF/DD; beneficiaries enrolled in Medicare Advantage, PACE, Denver Health Medicaid Choice Plan or Rocky Mountain Health Plan and those participating in the CO House Bill 12-1281 ACC Program Payment Reform pilot may participate if they disenroll from their existing program
Geographic Area:
Statewide, divided into 7 regions:
Region 1:  Archuleta, Delta, Dolores, Eagle, Garfield, Grand, Gunnison, Hinsdale, Jackson, La Plata, Larimer, Mesa, Moffat, Montezuma, Montrose, Ouray, Pitkin, Rio Blanco, Routt, San Juan, San Miguel, and Summit counties
Region 2:  Cheyenne, Kit Carson, Lincoln, Logan, Morgan, Phillips, Sedgwick, Washington, Weld, and Yuma counties
Region 3:  Adams, Arapahoe, and Douglas counties
Region 4:  Alamosa, Baca, Bent, Chaffee, Conejos, Costilla, Crowley, Custer, Fremont, Huerfano, Kiowa, Lake, Las Animas, Mineral, Otero, Prowers, Pueblo, Rio Grande, and Saguache counties
Region 5:  Denver
Region 6:  Boulder, Broomfield, Clear Creek, Gilpin, and Jefferson counties
Region 7:  El Paso, Elbert, Park, and Teller counties
Beneficiaries will be passively enrolled in the Regional Care Collaborative Organization (RCCO) serving their geographic area and to a primary care medical provider (PCMP) based on existing beneficiary-provider relationships.
Enrollment will be phased-in over 6 months with no more than 7,500 beneficiaries enrolled per month.  Beneficiaries will be categorized by RCCO, county, delivery system (community relatively well, waiver, high waiver, skilled nursing facility), and provider type (based on Medicare and Medicaid claims history:  existing PCMP in Accountable Care Collaborative (ACC) program, Medicare-Medicaid primary care providers not yet in ACC program, Medicare primary care providers without Medicaid billing id number).
Enrollment is as follows:
Month 1:  community relatively well with ACC PCMPs
Month 2:  remainder of community relatively well with ACC PCMPs; community relatively well with Medicare-Medicaid providers not yet in ACC
Month 3:  remainder of community relatively well with Medicare-Medicaid providers not yet in ACC; those receiving waiver services with ACC PCMPs
Month 4:  remainder of community relatively well and those receiving waiver services with Medicare-Medicaid providers not yet in ACC
Month 5:  remainder of those receiving waiver services and those receiving high waiver services with Medicare-Medicaid providers not yet in ACC or with Medicare primary care provider with no Medicaid billing id number
Month 6:  those in skilled nursing facilities
Month 7:  remainder of skilled nursing facilities
Newly eligible beneficiaries will be assigned on a monthly basis
For purposes of calculating shared savings, beneficiaries must be assigned to the demonstration within 9 months of implementation (except for newly eligible beneficiaries)
Beneficiaries can opt out of the demonstration at any time.
CMS must approve Colorado’s § 1932 Medicaid state plan amendment to expand the ACC program to dual eligible beneficiaries
Financing: Managed FFS; providers continue to receive FFS reimbursement; state eligible for retrospective performance payment if savings targets and quality standards met
Medicare baseline for capitated payments: N/A
Medicare risk adjustment: N/A
Medicaid baseline for capitated payments: N/A
Medicaid risk adjustment: N/A
Risk sharing: N/A
Care Delivery Model:
Colorado will expand its existing ACC Medicaid managed FFS program to include dual eligible beneficiaries.  In the ACC, RCCOs offer care coordination through RCCO staff or arrangements with local providers; develop a network of participating PCMPs; and will establish informal arrangements with ancillary providers.  PCMPs receive per member per month payments and must offer increased access to beneficiaries, such as extended office hours or same-day appointments.  RCCOs and PCMPs will work together with the state to integrate and coordinate primary, acute, prescription drug, behavioral health, and LTSS.
For beneficiaries attributed to a PCMP, RCCO will perform in-person screening and develop care plan to coordinate services.
For beneficiaries whose primary care provider is not currently participating in the ACC program, the RCCO will conduct outreach to involve the provider.  If outreach efforts are unsuccessful, and the beneficiary would like greater benefit from the ACC Program, the state and RCCO will assist the beneficiary with finding a participating PCMP.
Participating Health Plans:
Region 1:  Rocky Mountain Health Plan
Regions 2, 3, and 5:  Colorado Access
Region 4:  Integrated Community Health Partners
Region 6:  Colorado Community Health Alliance
Region 7:  Community Care of Central Colorado
Benefits: No changes to existing Medicare and Medicaid benefits
Continuity of Care: Beneficiaries are not required to change providers and retain access to their current choice of Medicare and Medicaid providers
Ombuds Program: A beneficiary rights and protections alliance will provide beneficiary education, assistance, and advocacy.  Alliance members include the state Medicaid agency, the 7 RCCOs, LTC ombudsman, Medicaid managed care ombudsman, SHIP, CO Center on Law and Policy, and CO Cross-Disability Coalition.  Permanently invited alliance participants and guests include CMS regional office, CO Legal Services, Demonstration Advisory Subcommittee beneficiaries, and Medicare Quality Improvement Organization.
Stakeholder Engagement: State will provide opportunities for beneficiaries to provide input and participate in the CO Medicare-Medicaid Enrollees Advisory Subcommittee, the ACC Program Improvement Advisory Committee, the Community Living Advisory Group, and the Nursing Facility Culture Change Accountability Board.
No changes from existing Medicare and Medicaid appeals systems.
Demonstration enrollees also can access the ACC complaint process, which includes addressing service complaints with a primary care provider or RCCO, contacting the Medicaid Managed Care Ombudsman about unresolved complaints, and requesting a state fair hearing if beneficiary believes that services are wrongfully denied.
The state, RCCOs and other beneficiary rights and protections alliance members will provide beneficiary education about enrollee rights and assist enrollees in exercising grievance and appeal rights.
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