Filling the need for trusted information on national health issues…

Trending on kff Medicare & Medicaid at 50 Individual Market Medicaid Expansion

Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – Michigan – 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: April 3, 2014
3-way contract not yet available
Demonstration Duration: 3 years
Jan. 1, 2015 to Dec. 31, 2017
Target Group: Includes:  an estimated 100,000 full benefit dual eligible beneficiaries age 21 and older are eligible to enroll; those enrolled in the MI Choice § 1915(c) HCBS wavier, Money Follows the Person, PACE, or an employer-sponsored Medicare Advantage plan may participate if they disenroll from their existing program

dual eligible beneficiaries previously disenrolled from Medicaid managed care due to uncooperative or disruptive behavior, those who are eligible as Additional Low Income Medicare Beneficiaries/Qualified Individuals or through a Medicaid spend down, state psychiatric hospital residents, those with commercial HMO coverage, and those who elect hospice services
Geographic Area:
25 counties, grouped into 4 regions:
Region 1 (Upper Peninsula):  Alger, Baraga, Chippewa, Delta, Dickinson, Gogebic, Houghton, Iron, Keweenaw, Luce, Mackinac, Marquette, Menominee, Ontonagon, and Schoolcraft counties
Region 4 (Southwest):  Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph and Van Buren counties
Region 7:  Wayne county
Region 9:  Macomb county
Enrollment: Initial enrollment period is voluntary, followed by passive enrollment periods in which the remaining beneficiaries in the target population will be automatically enrolled

Phase 1 voluntary enrollment:  beneficiaries in regions 1 and 4 can opt into the demonstration no earlier than Oct. 1, 2014, with enrollment effective Jan. 1, 2015.  Phase 2 voluntary enrollment:  beneficiaries in regions 7 and 9 can opt into the demonstration no earlier than March 1, 2015 with enrollment effective May 1, 2015.

Phase 1 passive enrollment effective date April 1, 2015 for regions 1 and 4.  Phase 2 passive enrollment effective date July 1, 2015 for regions 7 and 9.  Beneficiaries will receive notices no later than 60 and 30 days prior to passive enrollment.

Beneficiaries subject to Medicare reassignment effective Jan. 1, 2015 will not be passively enrolled in the demonstration in 2015, but will be eligible for passive enrollment no earlier than Jan. 1, 2016.

Plans designated by CMS as a past performance outlier or identified as consistently low performing based on parent/sibling organization performance will not receive passive enrollment.Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter on a monthly basis

Michigan’s demonstration is contingent upon CMS approval of a § 1915(b) Medicaid managed care waiver and concurrent § 1915(c) authority

Intelligent assignment for passive enrollment will consider previous managed care enrollment and historic provider utilization

SHIP in partnership with AAAs and working with senior centers and CILs will provide options counseling to beneficiaries.
Financing: Capitated with savings percentage (1% in year one, 2% in year two, 4% in year three, except that if at least 1/3 of ICOs have year one losses exceeding 3% of revenue, the year three savings percentage will be 3%) applied upfront to baseline Medicare and Medicaid contributions; capitation rate quality withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3); all ICO subcontracts with PIHPs must reward the PIHP when ICO achieves withheld amounts; state will phase-in separate quality withhold process specific to PIHP performance after year one
Medicare baseline for capitated payments: Same as California except that Medicare Advantage risk score coding intensity adjustment factor will apply beginning in 20151
Medicare risk adjustment: Same as California
Medicaid baseline for capitated payments: Blend of Medicaid FFS claims for services covered in demonstration and capitation payments for demonstration eligible beneficiaries in Medicaid managed care today
Medicaid risk adjustment: Rating categories based on level of care2 with financial incentives for HCBS over institutional care
Risk sharing: Risk corridors in year 1;3 MLR of 85% in years 2 and 3; risk sharing does not apply to services separately funded by direct payment from state to PIHPs
Care Delivery Model: Integrated care organizations (ICOs) provide care coordination and integrated medical, behavioral health, and LTSS directly or through subcontracts or partnership with local Prepaid Inpatient Health Plans (PIHPs).

State will continue to contract directly with PIHPs for delivery of Medicaid behavioral health services.  ICOs must contract with regional PIHP for Medicare-funded behavioral health services and to jointly coordinate care for enrollees with behavioral health, substance use disorder and I/DD needs.

Enrollees have choice of ICO care coordinator.  PIHP supports coordinators will be offered to enrollees with behavioral health, substance use, or I/DD needs.

ICOs must provide LTSS supports coordination services. LTSS Supports Coordinators will be offered to all enrollees who meet the NF LOC.
Participating Health Plans: Region 1:  Upper Peninsula Health Plan

Region 4:  CoventryCares of MI and Meridian Health Plan

Regions 7 and 9:  AmeriHealth, CoventryCares of MI, Fidelis SecureCare, Midwest Health Plan, Molina Healthcare, and United Healthcare4

Participation is subject to plans meeting readiness review requirements.
Benefits: Includes all Medicare and Medicaid state plan services except Medicare hospice.  Includes § 1915(c) home and community-based waiver services for enrollees who meet NF LOC; also includes supplemental benefits not currently available under Medicaid state plan:  adaptive medical equipment and supplies, community transition services, fiscal intermediary (to support self-direction), personal emergency response system, respite; ICOs can offer flexible benefits as appropriate to enrollee needs; enrollees must be offered option to choose own LTSS providers with an established individualized budget maintained by enrollee with support from fiscal intermediary
Continuity of Care: For enrollees in habilitation supports waiver and those receiving PIHP services:  maintain current provider for 180 days or continue with single case agreement; existing care plans and prior authorizations continue until authorization ends or 180 days from enrollment, whichever is sooner except that home health and state plan PCS level of services and providers continue for 180 days; current waiver service providers and service level continue unless changed through person-centered planning process.

For other enrollees:  maintain current provider for 90 days or continue with single case agreement; existing care plans and prior authorizations continue until authorization ends or 180 days, whichever is sooner, except that home health and state plan PCS continue for 90 days; enrollees in NFs may remain in that facility through ICO contract or single case agreement or on out-of-network basis for duration of demonstration or until enrollee chooses to relocate; MI Choices HCBS waiver services and providers continue for 90 days unless changed during person-centered planning.
Ombuds Program: State will establish ombuds program to provide individual advocacy and systemic oversight
Stakeholder Engagement: Each ICO must establish at least one advisory board that meets at least quarterly and a process for that board to provide input to the HMO governing board.  The advisory board should include a mix of enrollees, caregivers and key community stakeholders, with 1/3 of the board composed of enrollees.  ICOs must accommodate and support the advisory board members by arranging necessary transportation, appropriate communications, and other measures to ensure and encourage their full participation.  Advisory board members will be elected.
Notice:  same as California (single integrated notice)

Timeframe to request initial appeal:
  90 days
Internal health plan appeal:  initial Medicare appeals to ICO; initial Medicaid appeals to ICO or state; ICOs must resolve standard appeals within 30 days and expedited appeals within 72 hours

External Medicare appeals:
  appeals automatically forwarded to IRE, then enrollee can request ALJ hearing
External Medicaid appeals:  enrollee may request state fair hearing after ICO appeal or enrollee may bypass ICO appeal and immediately request state fair hearing

Appeals where Medicare and Medicaid services overlap:
  enrollees may file appeal through Medicare or Medicaid appeals process or both

Continued benefits pending appeal: 
Medicare and Medicaid benefits continue pending internal ICO appeal

Medicare Part D appeals:
  remain unchanged


Massachusetts Minnesota