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Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – Ohio – 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: Dec. 11, 2012
3-way contract issued Feb. 11, 20141
Demonstration Duration: 3 years
May 1, 20142 to Dec. 31, 2016
Target Group: Includes:  an estimated 115,000 full benefit dual eligible beneficiaries age 18 and older in 29 counties grouped into 7 regions are eligible to enroll

dual eligible beneficiaries with other comprehensive coverage, those with developmental disabilities who are served through an ICF/DD or  § 1915(c) HCBS waiver, those on a Medicaid spend down, and PACE or Independence at Home enrollees
Geographic Area: 29 counties grouped into 7 regions:

-Central: Delaware, Franklin, Madison, Pickaway and Union counties

-East Central:  Portage, Stark, Summit and Wayne counties

-Northeast:  Cuyahoga, Geauga, Lake, Lorain, and Medina counties

-Northeast Central: Columbiana, Mahoning and Trumbull counties

-Northwest:  Fulton, Lucas, Ottawa and Wood counties

-Southwest:  Butler, Clermont, Clinton, Hamilton and Warren counties

-West Central:  Clark, Greene and Montgomery counties
Initial enrollment period is voluntary, followed by three passive enrollment periods in which the remaining beneficiaries in the target population will be automatically enrolled
Beneficiaries first will be passively enrolled in a Medicaid managed care plan, with enrollment effective May 1, 2014 in the Northeast region, June 1, 2014 in the Northwest, Northeast Central, and Southwest regions; and July 1, 2014 in the East Central, Central, and West Central regions.  Beneficiaries also will be able to voluntarily enroll in the demonstration for their Medicare benefits between May and Dec. 2014.  Beneficiaries who do not voluntarily enroll in the demonstration for their Medicare benefits will be passively enrolled beginning in Jan. 2015.3  The MOU provides that beneficiaries will receive notices 60 days prior to passive enrollment.

Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter on a monthly basis

Ohio may separately apply for a § 1915(b)/(c) waiver to require beneficiaries to enroll in a Medicaid managed care plan if they opt out of the financial alignment demonstration

Intelligent assignment for passive enrollment will consider previous managed care enrollment and historic provider utilization
Financing: Capitated with savings percentage (1% in year one, 2% in year two, and 4% in year three) 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)
Medicare baseline for capitated payments: Same as California
Medicare risk adjustment: Same as California
Medicaid baseline for capitated payments: Medicaid capitation rates under § 1915(b) waiver that would apply to beneficiaries who are in target population but not enrolled in demonstration
Medicaid risk adjustment: Rating categories with financial incentives for HCBS over institutional care4 and member enrollment mix adjustment to account for plans with greater proportion of high risk/high cost beneficiaries
Risk sharing: Required minimum medical loss ratio of 90%
Care Delivery Model:
Integrated Care Delivery System Plans will offer care management  services to coordinate medical, behavioral health, LTSS and social needs
Requires contracts with Area Agencies on Aging to coordinate home and community-based waiver services for beneficiaries over age 60
Participating Health Plans:
-Central and Southwest regions:  Aetna and Molina
-East Central and Northeast Central regions:  CareSource and United

-Northeast region:  Buckeye/Centene, CareSource, and United

-Northwest region:  Aetna and Buckeye/Centene

-West Central region:  Buckeye/Centene and Molina
Benefits: Includes all Medicare and Medicaid services, except Medicare hospice and Medicaid habilitation services and targeted case management for beneficiaries with developmental disabilities; includes Medicaid home and community-based waiver services  except for beneficiaries with developmental disabilities, with services to be defined in Ohio’s expected § 1915(b)/(c) waiver application; plans have discretion to offer flexible benefits as appropriate to beneficiary needs
Continuity of Care: Beneficiaries identified for high risk care management have a 90 day transition period for maintaining current physician services; other beneficiaries have one year.  HCBS waiver enrollees maintain current waiver service levels for one year and providers for either one year or 90 days, depending on the type of service
Ombuds Program: Ohio’s existing Office of the State Long-term Care Ombudsman will offer individual advocacy and independent systemic oversight in the demonstration.  Ohio has been awarded CMS funding to support its ombuds program.5
Stakeholder Engagement: Same as California
Notice:  same as California (single integrated notice)
Timeframe to request initial appeal:  same as Michigan (90 days)

Internal health plan appeal: 
initial appeals for Medicare Parts A and B services must be filed with health plan; initial appeals for Medicaid services may be filed with health plan or beneficiary may directly request fair hearing; health plan to resolve appeals within 15 days (standard) or 72 hours (expedited)

External Medicare appeals:
  same as California (health plan automatically sends appeal to Medicare IRE if initial denial upheld; beneficiary may then request Office of Medicare Hearings and Appeals review)

External Medicaid appeals:
  beneficiary may request fair hearing initially or after health plan appeal; fair hearings to be resolved within 90 days in year 1, 60 days in year 2 and 30 days in year 3

Appeals where Medicare and Medicaid services overlap:
  plan to be bound by decision most favorable to beneficiary

Continued benefits pending appeal: 
benefits continue pending internal health plan appeals and Medicaid fair hearings; payments for continued benefits while appeals are pending are not recouped based on appeal outcome

Medicare Part D:
  same as California (existing Medicare Part D appeals process continues to apply)


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