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Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – Washington (capitated model) – 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

Washington (capitated model)

WASHINGTON (capitated model):
MOU Signed:
Nov. 25, 2013
3-way contract not yet finalized
Demonstration Duration: 3 years
Feb. 1, 2015 to Dec. 31, 20171
Target Group:
Includes:  an estimated 27,000 full benefit adult dual eligible beneficiaries ages 21 and older in 2 urban counties are eligible to enroll in the capitated demonstration; includes Aging and Long-Term Support Administration  Community Options Program Entry System (COPES) § 1915(c) HCBS waiver enrollees; beneficiaries who receive Medicaid personal care services, including those with developmental disabilities; and those in a Medicare Advantage plan operated by the same organization as a demonstration plan; PACE participants and beneficiaries in a Medicare Advantage plan operated by a parent company that is not offering a demonstration plan may enroll in the demonstration if they disenroll from their current program
Excludes: dual eligible beneficiaries with developmental disabilities who receive institutional care or DD HCBS waiver services; Money Follows the Person participants; those receiving hospice services at the time of enrollment; Medicaid spend down SLMB Plus beneficiaries; and those with other comprehensive coverage
Geographic Area: King and Snohomish counties
Voluntary enrollment effective no earlier than July 2014, with plan marketing no earlier than June 2014
Three phases of passive enrollment effective no earlier than Sept. 2014 (phase 1), Nov. 2014 (phase 2), and Jan. 2015 (phase 3); enrollment of newly eligible beneficiaries will be monthly as of Feb. 2015; notices will be sent 60 and 30 days prior to passive enrollment.  Beneficiaries will be randomly assigned to a passive enrollment phase, considering the number of voluntary enrollments prior to phase 2 and the disenrollment rate for each plan.
American Indians and Alaska Natives are exempt from passive enrollment.  Beneficiaries subject to Medicare plan reassignment effective Jan. 2014 will not be subject to passive enrollment in 2014.  Beneficiaries eligible for Medicare plan reassignment effective Jan. 2015 who are eligible for the demonstration will be eligible for passive enrollment no earlier than Jan. 2015.
Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter on a monthly basis
The state must amend its § 1915(c) waiver by April 1, 2014 and submit a § 1932(a) state plan amendment.
Passive enrollment plan assignments will consider the number of voluntary enrollments prior to phase 2 and each plan’s disenrollment rate
ADRCs, operated by the AAAs, will provide independent enrollment assistance and options counseling
Financing: Capitated with savings percentage (1% in year one,2 2% in year two, and 3% 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 except that Medicare Advantage risk score coding intensity adjustment factor will apply beginning in calendar year 20143
Medicare risk adjustment: Same as California
Medicaid baseline for capitated payments: Historical state FFS and encounter data trended forward
Medicaid risk adjustment: Rating categories4
Risk sharing: Minimum medical-loss ratio of 85-90%
Care Delivery Model:
HealthPath Washington Medicare-Medicaid Integration Plans will provide health screenings and risk assessments, care coordination, and intensive care management and integrate medical, behavioral health, and LTSS.
Beneficiaries will be assigned to 1 of 3 tier levels based on screening, assessment, and utilization data:  Tier 1 (supported self-intervention – have care manager, care plan, and interdisciplinary care team and receive referral assistance when appropriate); Tier 2 (disease/episodic care management – receive care management services dedicated to problem-solving interventions and prevention and wellness messaging and condition-specific educational materials and have care plan and care team); Tier 3 (intensive care management for enrollees with special health care needs – have intensive care coordinator, care plan, access to high touch intensive care management care team with face to face interactions, and health action plan that identifies what the enrollee plans to do to improve or self-manage health conditions and actions of the intensive care coordinator)
Care manager/intensive care coordinator shall make referral to state within 5 days of identifying through the care coordination process or by the enrollee that there are unmet LTSS needs.  For beneficiaries newly eligible for HCBS waiver services, the demonstration plan will be responsible for waiver service planning.  For beneficiaries already eligible for HCBS waiver services, the demonstration plan will maintain the existing HCBS waiver service plan and providers through the authorization or continuity of care period, whichever is later.
Participating Health Plans: Regence Blue Shield and United Health Care5
Includes all Medicare Parts A, B, and D services (except hospice), Medicaid state plan services (except those listed below) and HCBS COPES waiver services
Services that remain FFS:  24 hour crisis intervention, involuntary treatment act-related transportation for judicial review, abortion, transportation other than ambulance or HCBS wavier, dental, child care/infant case management/maternity support, neurodevelopmental center services, health department or family planning clinic services when client self-refers, pharmaceuticals related to services under separate contract with state, weight loss or reduction surgery, urinalysis for drug screening for pregnant or parenting women and those received opiate substitution treatment, and prenatal diagnosis genetic counseling
Plans have discretion to offer flexible benefits as appropriate to address beneficiary needs
Plans may waive beneficiary Medicaid prescription drug and HCBS waiver service cost-sharing amounts
Beneficiaries shall decide what LTSS to receive to maintain independence and quality of life, subject to coverage rules, and be able to hire, fire, and supervise personal care workers
Continuity of Care: Beneficiaries must maintain current providers and service authorizations for 180 days or until completion of care plan whichever is later, unless enrollee agrees to earlier transition, for ESRD services, nursing facilities, adult family homes, and ALFs; and for 90 days or after completion of a care plan whichever is later, unless enrollee agrees to earlier transition, for all other services; plans will maintain LTSS providers (including home and community-based waiver services and PCS) for the duration of the existing authorization period or the demonstration continuity of care period, whichever is later (except 180 days for adult family homes and ALFs); plans may choose to pay established out-of-network providers indefinitely
Ombuds Program: State Office of Insurance Commissioner, Statewide Health Insurance Benefits Advisors, and Consumer Advocacy Unit will provide individual advocacy and systemic oversight by phone, online and through state health analysts
Stakeholder Engagement: Plans must establish an independent enrollee advisory committee that meets at least quarterly and includes beneficiaries, caregivers, and key community stakeholders
Notice:  same as California (single integrated notice)
Timeframe to request initial appeal:  same as Michigan (90 days)
Internal health plan appeal:  same as Illinois (initial appeals must be filed with plan); standard appeals to be resolved within 14 calendar days of plan receipt of appeal unless plan notifies enrollee that extension is necessary and in enrollee’s best interest; appeals must be resolved within a maximum of 45 calendar days from plan receipt of appeal; expedited appeals to be resolved no later than 72 hours of plan receipt of appeal
External Medicare appeals:  same as California (health plan automatically sends appeal to Medicare IRE if initial denial upheld; existing Medicare timeframes for appeal resolution apply; beneficiary may then request ALJ, appeals board, and judicial review)
External Medicaid appeals:  health plan automatically sends appeal to state Medicaid Independent Review Organization if initial denial upheld; existing Medicaid timeframes for appeal resolution apply; beneficiary may then request state administrative hearing; beneficiary or plan may appeal to state Board of Appeals; beneficiary may then seek judicial review in state court.
Appeals where Medicare and Medicaid services overlap:  default to Medicare appeals process, with further detail to be specified in 3-way contract; beneficiaries may choose to request state IRO review concurrently with automatic IRE review; plan bound by ruling most favorable to beneficiary.
Continued benefits pending appeal:  Medicare and Medicaid benefits continue pending appeal at plan level; for subsequent appeal levels, existing Medicaid rules apply to Medicaid service appeals
Medicare Part D appeals:  same as California (existing Medicare Part D appeals process continues)


Washington (managed FFS model)