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

WASHINGTON (managed FFS model):
MOU Signed: Oct. 24, 2012;
final demonstration agreement signed June 28, 20131
Demonstration Duration: 3 years
July 1, 20132 to Dec. 31, 2016
Target Group:
Includes:  an estimated 21,000 full benefit dual eligible beneficiaries who are considered high cost/high risk and eligible for Medicaid health home services3 statewide, except in 2 urban counties  where the state proposes testing a capitated model, are eligible to enroll in the managed FFS demonstration; Medicare Advantage and PACE enrollees and beneficiaries receiving hospice services may participate if they disenroll from their existing program
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Excludes: dual eligible beneficiaries with other comprehensive coverage
Geographic Area:
Statewide except in 2 urban counties (King and Snohomish), divided into the following coverage areas:
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-Coverage Area 1:  Clallam, Grays Harbor, Jefferson, Kitsap, Lewis, Mason, Pacific, and Thurston counties
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-Coverage Area 2:  Island, San Juan, Skagit, and Whatcom counties
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-Coverage Area 4: Pierce County
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-Coverage Area 5:  Clark, Cowlitz, Klickitat, Skamania, and Wahkiakum counties
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-Coverage Area 6:  Adams, Chelan, Douglas, Ferry, Grant, Lincoln, Okanogan, Pend Oreille, Stevens, Spokane, and Whitman counties
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-Coverage Area 7:  Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walla and Yakima counties
Enrollment:
Eligible beneficiaries are automatically enrolled in a health home network with beneficiaries retaining the choice about whether to receive health home services
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State is identifying eligible beneficiaries on a monthly basis and sending outreach materials one month prior to passive enrollment; earliest effective enrollment date was July 2013 for beneficiaries in coverage areas 4, 5, and 7 and Oct. 2013 for beneficiaries in coverage areas 1, 2, and 6
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CMS approved Washington’s Medicaid health home state plan amendment in June 2013 for counties in coverage areas 4, 5, and 74 and in Dec. 2013 for counties in coverage areas 1, 2, and 65
Financing: Managed FFS; providers continue to receive FFS reimbursement (except existing capitated behavioral health plans continue); 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: Health home care coordination organizations coordinate all Medicare and Medicaid services among existing primary, acute, specialist, behavioral health, and LTSS providers
Participating Health Plans:
-Coverage Area 1:  Molina Healthcare of Washington; provisional designation to Community Health Plan of Washington, Coordinated Care Corporation, United Behavioral Health, and UnitedHealthcare of Washington6
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-Coverage Area 2:  provisional designation to Community Health Plan of Washington, Coordinated Care Corporation, Molina Healthcare of Washington, Northwest Regional Council, and UnitedHealthcare of Washington7
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-Coverage Area 4:  Community Health Plan of Washington, United Behavioral Health (Optum Pierce), and UnitedHealthcare of Washington8
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-Coverage Area 5:  Community Health Plan of Washington, Coordinated Care Corporation, United Behavioral Health, and United Healthcare of Washington9
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-Coverage Area 6:  Molina Healthcare of Washington; provisional designation to Community Choice Healthcare Network, Community Health Plan of Washington, Coordinated Care Corporation, and UnitedHealthcare of Washington10
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-Coverage Area 7:  Community Health Plan of Washington, Coordinated Care Corporation, Southeast Washington Aging and Long-Term Care (Yakima County), United Behavioral Health, and United Healthcare of Washington11
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Provisional designation is conditioned on satisfactory submission of a corrective action plan and implementation timeline
Benefits: Adds Medicaid health home services but otherwise does not change Medicare and Medicaid benefits packages
Continuity of Care: Beneficiaries will retain access to their current choice of Medicare and Medicaid providers
Ombuds Program: Not addressed in MOU
Stakeholder Engagement: Health home networks must ensure meaningful beneficiary input, with specifics to be determined in the state’s health home network qualification process. State will include beneficiaries on its advisory team.
Appeals: No changes from existing Medicare and Medicaid appeals systems.  State and health home providers are to assist beneficiaries with exercising appeal rights.

 

Virginia Washington (capitated model)