1 Providing Effective Community- Based LTC in a Managed Care Environment Mary Guthrie, MBA

2 The Medicare Advantage Program The Medicare Prescription Drug, Improvement, & Modernization Act of 2003 (MMA) introduced a number of changes to the program of private plans in Medicare & created the Medicare Advantage (MA) program. New types of plans were introduced, plan quality requirements were altered, & payment policies were modified. Since 1982, Medicare beneficiaries in many areas of the country have been able to choose between whether to receive care under the traditional FFS program or through private plans. Increased emphasis by CMS to “manage” FFS enrollees. Medicare enrollment in private health plans paid on an at- risk capitated basis is at an all time high at 8 million enrollees (18% of beneficiaries).

3 Section 231 of Medicare Modernization Act authorizes Medicare contracting with Special Needs Plans (SNPs) to care for three distinct population: –Institutionalized beneficiaries (2.5 M beneficiaries; 75% DE) –Dual eligibles, people who are eligible for both Medicaid and Medicare (7.2 M) –Severely chronically ill & disabled (90% maybe DE) SNPs paid on same basis as Medicare Advantage plans, with risk adjustment. SNPs offer Part D since SNPs existed as CMS demonstration programs: Over 602,000 enrollees reported by CMS, 9/2006. Specialized Needs Plans (SNPs) – Social HMOs– ESRD– PACE – Evercare– DE Plans

4 Specialized Needs Plans (SNPs) SNPs can specialize in serving nursing facility residents, dual eligibles, and others with severe or disabling chronic conditions (SSA, Sec. 1859(b)(6)) –SNPs are Medicare plans and cover only Medicare services –Can contract with Medicaid to cover Medicaid services for duals 217 SNPs approved by CMS for –135 for dual eligibles –44 for those in institutions –38 for those with chronic conditions 40 states, DC, and PR have approved SNPs –Most have little enrollment unless duals were “passively enrolled” from existing Medicaid managed care plans

5 SNPs are Not Medicaid Managed Care Plans... Not required to participate in Medicaid managed care. Not required to cover Medicaid benefits. Not guaranteed any payment from Medicaid. Not regulated by the state (beyond licensure & solvency) However, CMS is implementing an action plan to facilitate better care for dual eligibles through SNPs: –“How To” Guides –Targeted enrollment –Model three-way agreement –Quality measures SNP populations.

6 AoA ICM Program Overview Awards to support the design, implementation, and dissemination of innovative models and approaches that demonstrate how Community Aging Services Providers (CASPs) and Area Agencies on Aging (AAAs) can either build capacity to adopt capitated financing approaches, or partner with Medicare and/or Medicaid managed care organizations, to improve the delivery of services that maximize the health and quality of life for older persons. –Replication of existing practice; –Program enhancement; or –New models or approaches Funded fourteen projects in FY 2004 and ten projects in FY 2005.

7 Major Accomplishments Programs disseminated information to older people, including low- income, rural and limited English speaking older people, to help them access health and social supports. Two programs specifically focus on cultural-competency in targeted populations. Partnering Medicare Advantage plans represent a mix of national, regional and local, for profit and not-for-profit plans Medicare participating providers include: Blue Cross & Blue Shield’s Anthem and Excellus Plans; two Evercare Plans; two Kaiser Permanente Plans; Group Health Cooperative; Health Alliance Plan; SummaCare Health Plan; Humana; and Independent Health Plan. In Boston, the Senior Care Options providers are both Medicare and Medicaid providers under a CMS integrated model.

8 Major Accomplishments Programs are also partnering with other organizations such as: AAAs; AoA funded service provides (meals, senior centers, care management); home care agencies; medical centers; universities; Michigan Association of Health Plans and the National ADRDA. Programs include disease prevention and chronic disease self- management programs indicative of the movement within the aging network to implement evidence-based programs & to promote integration of social supports with health.

9 Chronic Care Components Related to Integrated Care Management Grantees FY 05

10 Chronic Care Components Related to Integrated Care Management Grantees FY 04

11 Challenges Faced Time – strong agreement among partners that they spent more time than they expected, particularly the first year, establishing the partnership, setting expectations and getting logistics squared away. Geographic concerns – hampered many partnerships. Physical distance constrained their ability to meet face-to-face and made some communication more challenging. Also, catchment areas of the CBOs and MCOs did not always align. Strong reliance on “champions” within the organizations to ensure success.