Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS
|MOU Signed:||Sept. 12, 2013|
Sept. 13, 2013 to Dec. 31, 2016
|Target Group:||Includes: an estimated 36,000 full benefit dual eligible beneficiaries age 65 and older who are enrolled in Minnesota’s Senior Health Options Program|
|Enrollment:||Voluntary; the demonstration does not involve passive enrollment. The demonstration will use an integrated enrollment system in which beneficiaries enroll and disenroll from Medicare and Medicaid managed care simultaneously using an integrated form, notice, and process.|
|Financing:||Minnesota’s demonstration will not test one of CMS’s financial alignment models. Instead, the state will maintain its existing integrated capitated payment and delivery system involving Medicaid MCOs that also qualify as Medicare Advantage D-SNPs|
|Medicare baseline for capitated payments:||The demonstration maintains the state’s existing capitated financing arrangements through separate plan contracts with CMS and with the state. Plans will continue to comply with Medicare Advantage and Medicare Part D bid rules.|
|Medicare risk adjustment:||Same as above.|
|Medicaid baseline for capitated payments:||Same as above. Plan contracts with the state as Medicaid MCOs continue to apply.|
|Medicaid risk adjustment:||Same as above.|
|Risk sharing:||Same as above.|
|Care Delivery Model:||Benefits provided through Medicaid MCOs that contract with the state and that also qualify as Medicare Advantage D-SNPs that contract with CMS. Plans may process an integrated set of claims instead of differentiating between Medicare and Medicaid covered services.
Plans will be allowed to integrate Medicare and Medicaid primary care payments to facilitate Health Care Homes (HCHs) through Integrated Care System Partnerships (ICSPs) between plans and providers to improve Medicare and Medicaid service coordination, improve health outcomes, and help beneficiaries to remain in home or community-based settings. HCHs will receive an additional payment for care coordination. ICSPs will allow plans to use alternative payment approaches to integrate the HCH model with primary and specialty care coordination arrangements for beneficiaries.
There are 3 ICSP models:
(1) HCH-Based Virtual ICSPs, which provide payments to primary care providers to incentivize better care coordination;
(2) HCH or HCH alternative-based primary, acute, and/or LTC ICSPs, which build on the health care home approach to further integrate primary and LTC coordination and delivery; and
(3) Integration of Physical and Behavioral Health ICSPs, which allows further integration of Medicaid mental health targeted case management services with the care coordination required under Medicare and Medicaid HCHs and/or newly developing Medicaid behavioral health homes to focus on reducing emergency room visits.
|Participating Health Plans:||Blue Plus, HealthPartners, Itasca Medical Care, Medica Health Plans, Metropolitan Health Plan, PrimeWest Health, South Country Health Alliance, and UCare Minnesota|
|Benefits:||Medicare benefits will continue to be at least equivalent to those provided under Medicare Parts A, B, and D. CMS and the state will explore options to reduce Part D co-pays for all enrollees to test whether this will improve health outcomes and reduce overall health care expenditures through improved medication adherence. Plans may provide additional benefits to enrollees; the state will be involved in coordinating additional benefits to ensure that these benefits are not included in the Medicaid capitation payment.
Medicaid benefits will continue to be provided per the Medicaid MCO contracts with plans.
|Continuity of Care:||N/A – demonstration will not change existing plan provider network arrangements.|
|Ombuds Program:||The Minnesota Ombudsman for Managed Care will provide input on plan and system-wide performance. No further detail specified.|
|Stakeholder Engagement:||The CMS-state contract management team will review stakeholder input. No further detail specified.|
|Appeals:||CMS and the state already have integrated elements of the appeals process in the Senior Health Options program. The demonstration will add an integrated notice and appeal timeframes.
Notice: same as California (single integrated notice)
Timeframe to request initial appeal: same as Michigan (90 days)
Internal health plan appeal: not specified in MOU
Integrated external appeals process: not specified in MOU
Appeals where Medicare and Medicaid services overlap: not specified in MOU
Continued benefits pending appeal: not specified in MOU
Medicare Part D: same as California (existing Medicare Part D appeals process continues)