Introduction of New “Very Integrated Program” for Dual-Eligible Beneficiaries Tuesday, January 10, :00 p.m. ET 1

Agenda  Introduction  Options for New Integrated Care Program for Persons Dually Eligible for Medicare and Medicaid  Jane Hyatt Thorpe, J.D. Katherine Jett Hayes, J.D. George Washington University School of Public Health and Health Services – Department of Health Policy  Discussion 2

About ACAP  Our mission: To represent and strengthen not-for-profit safety net health plans as they work with providers and caregivers in their communities to improve the health and well-being of vulnerable populations in a cost-effective manner. 3

ACAP Represents 57 Safety Net Health Plans 4 Arizona University Physicians Health Plans California Alameda Alliance for Health CalOptima CenCal Health Central California Alliance for Health Community Health Group Contra Costa Health Plan Gold Coast Health Plan Health Plan of San Mateo Inland Empire Health Plan L A. Care Health Plan Partnership HealthPlan of California Santa Clara Family Health Plan San Francisco Health Plan Colorado Colorado Access Denver Health Connecticut Community Health Network of Connecticut District of Columbia Health Care Services for Children With Special Needs Florida Prestige Health Choice Hawaii AlohaCare Illinois Family Health Network Indiana MDwise Kentucky Passport Health Plan Maine Maine Primary Care Association * Maryland Maryland Community Health System Priority Partners *Incubator plan.

ACAP Represents 57 Safety Net Health Plans 5 Massachusetts Boston Medical Center HealthNet Plan Commonwealth Care Alliance Neighborhood Health Plan Network Health Michigan CareSource Michigan Minnesota Metropolitan Health Plan New Jersey Horizon NJ Health New York Affinity Health Plan Amida Care Elderplan & Homefirst Health Plus Hudson Health Plan New York (con’t.) Monroe Plan for Medical Care, Inc. Total Care Univera Community Health VNSNY CHOICE Ohio CareSource Oregon CareOregon Pennslyvania AmeriHealth Mercy UPMC for You Rhode Island Neighborhood Health Plan of Rhode Island Texas Community Health Choice Cook Children’s Health Plan Driscoll Children’s Health Plan El Paso First Health Plans Sendero Health Plan Texas Children’s Health Plan Utah Association for Utah Community Health * Virginia Virginia Premier Washington Community Health Plan of Washington Wisconsin Children’s Community Health Plan *Incubator plan.

Key Provisions of Today’s Proposal  Discusses barriers to clinical and financial integration in services for dual eligibles  Identifies models used by states to integrate care through contract and waiver authority, pre- and post-ACA  Introduces a new, permanent model for dual integration that is not a subset of Medicare Advantage 6

Integrated Care and Financing for Dual Eligibles: A New Permanent State Plan Option Jane Hyatt Thorpe, J.D. and Katherine Jett Hayes, J.D. Department of Health Policy School of Public Health and Health Services George Washington University December 8, 2011

The Challenge Dual Eligibles: Nine million individuals High Need –Sixty-six percent (66%) with three or more chronic conditions –Sixty-one percent (61%) considered cognitively or mentally impaired High Cost –Two hundred and thirty billion ($230b) federal and state spending in 2006 –Thirty-six percent (36%) of Medicare spending –Thirty-nine percent (39%) of Medicaid spending Reference: Gretchen Jacobson, Tricia Neuman, Anthony Damico & Barbara Lyons,, Kaiser Family Foundation, The Role of Medicare for the People Dually Eligible for Medicare and Medicaid (2011). Available at The Kaiser Commission on Medicaid Facts: Dual Eligibles: Medicaid’s Role for Low-Income Medicare Beneficiaries (2011) Available at

ACA: New Opportunities Historically, barriers to integration –Care for dual eligibles reimbursed separately by Medicare and Medicaid through fee-for-service and managed care models –Only PACE and Medicare Advantage Special Needs Plans (SNPs) provide opportunities to integrate care and financing, but limited in scope ACA provided new authority –Federal Office of Coordinated Health Care (Medicare-Medicaid Coordination Office) –Center for Medicare and Medicaid Innovation –Expanded demonstration authority –Funded technical assistance for 15 states, opportunities for other states Sense of impermanence remains, states interested in permanent model

New State Plan Option Congress could pass legislation authorizing a new permanent program –provides an additional pathway for states –provides a sense of permanence not currently available through demonstrations or SNP model –Could borrow from structure of PACE –Elements Structure Eligibility Benefits Enrollment Provider Network Adequacy Marketing and Enrollee Communications Grievances and Internal and External Appeals Setting Payment Rates Quality Beneficiary Protections

Structure States and the federal government act as partners in establishing the framework As is the case with PACE, treat as a separate program with a single set of requirements regarding eligibility, application procedures, administrative requirements, services, payment, participant rights, quality assurance, and marketing requirements.

Eligibility All full-benefit dual eligibles eligible for full range of medically necessary Medicare and Medicaid services, as well as care coordination and non-medical benefits offered through a health plan as part of home- and community-based long-term care supports and services Allow participating states to adopt 1-year of continuous eligibility for dual-eligible beneficiaries.

Benefits Plans required to cover all Medicare benefits, as well as all Medicaid benefits offered under a Medicaid plan and home- and community- based waivers. Plans required to offer coordination services and permitted to offer additional supplemental benefits

Enrollment Passive Enrollment with Opt-out –To address low participation rates by dual eligible individuals and the need to assure a higher volume of beneficiary enrollment –Beneficiary education –Strong beneficiary protections

Provider Network Adequacy Use an existing standard applicable to qualified health plans, such as the requirement to contract with essential community providers under the ACA Plans should demonstrate adequate capacity for medical and behavioral health services, as well as long-term care services and supports

Marketing and Enrollee Communications Integrated materials (one set) –outreach and education materials –enrollment and disenrollment materials –benefit coverage information –operational letters for enrollment, disenrollment, claims or service denials, complaints, internal and external appeals and provider terminations Information accessible and understandable to the beneficiaries that enroll in the plan, including individuals with disabilities and limited English proficiency

Grievances and Internal and External Appeals Single set of complaints and internal appeals processes based on Medicare Advantage, Medicare Part D, and Medicaid managed care requirements

Payment Payment Model –Both the Medicare and Medicaid programs calculate and provide risk- adjusted prospective payments to a participating health plan –Health plan discretion to combine the payment streams as appropriate to manage and reimburse care for the eligible enrolled individuals –Use risk adjustment model that more accurately reflects the scope and usage levels of care needed for the dual eligibles Include broader set of diagnoses that reflect care needs of dual eligibles, including comorbidities, complications associated with frailty, and behavioral health Account for actual service utilization ideally over the course of the previous 12 months at the individual level, as well as functional status (using activities of daily living scale), and mortality of the dually eligible population –Include an opportunity for shared savings –Similar to PACE payment structure

Quality States work closely with health plans and CMS to develop a new set of quality and access measures that are specific to the more vulnerable dual eligible population and focus on outcomes measures, including rates of emergency room use, long term care, hospital admission and readmission rates, and medication errors Participate in 5 Star Quality Demonstration and Program

Beneficiary Protections Use of passive enrollment for dual-eligible individuals with an opt- out, must include strong consumer protections to assure that individuals or their families have a meaningful process for opting- out of the program, including opting-in to other plans or back into fee-for-service Medicare Protections –Network adequacy –Quality of care –Consumer representation on plan governing boards –Notice and explanations regarding enrollment and disenrollment –Assurances that all services are culturally and linguistically appropriate and physically accessible –Individualized care plans that maximize consumer choice in decisions relating to patient care

21 Discussion