Positioning for Integration Building Plan Capacity SNP Alliance Leadership Forum November 2, 2012 Catherine Anderson, MPA National Vice President, Strategy and Development Medicare-Medicaid Enrollees

Embracing the opportunity States have unprecedented interest in addressing the needs of their most complex populations Fiscal realities balancing political opposition Political interest is expanding Specialty and complex populations no longer off the table Timing may be tiered to address unique populations Comprehensive solutions seem to be gaining interest Reduces administrative burden Creates comprehensive incentives Demonstration authority re-energizing states Removal of historic barriers provides incentives 2

Creating an integrated health plan Few plans have comprehensive experience in managing Medicare-Medicaid Enrollees Most plans are likely to be challenged by developing certain capabilities to support integrated solutions Many plans are still learning what it means to be integrated

The competencies of integrated plans Medicare Medicaid LTSS

Medicare develops to Medicaid Medicare plans are well positioned to meet the CMS filing requirements Medicare plans are well positioned to deliver acute networks SNPs may be better positioned based on more intimate relationships with providers Growth Opportunities Establishing Medicaid regulatory infrastructure and oversight Interacting with Medicaid agencies is much more direct than Medicare oversight Reporting requirements are often more onerous and state-specific May need to adjust provider networks to incorporate historic Medicaid providers Likely more challenging for non-SNP Medicare plans

Medicaid develops to Medicare Medicaid plans have established processes for interacting with state regulators Medicaid plans understand Medicaid delivery models and safety net systems Multi-state Medicaid plans understand state variances Growth Opportunities Understanding and maneuvering through Medicare filing requirements Managing Medicare benefits and medical necessity Part D (filing, formulary development, MTMP, reporting) Reconciling provider networks to address historic Medicare provider use

Developing LTSS competencies LTSS competencies vital to comprehensively managing the population Developing LTSS networks unlike traditional Medicare and Medicaid networks Payment terms Codes Credentialing Community based organizations\ Provider relations Assessing for functional and social needs unique from physical and behavioral health Aligning LTSS benefits directly to needs vital to ensuring viability Intimacy in care coordination High volume of staff

Stretching overall plan competencies to match trends Person Centeredness Active participation of individuals and/or family Consumer Engagement Learning new language Meaningful member advisory involvement Delivery Flexibility Leveraging Community Based Organizations Multi-entity inter-disciplinary care teams Primary Care Supporting expansion of role of primary care Filling gaps for primary care case management Payment Flexibility Meaningful incentives Up and down stream engagement Non-traditional providers

Additional considerations for plans Risk stratification Vital to resource allocation Needs breadth to uncover hidden risks/opportunities Assessments Comprehensive tools are necessity Physical, behavioral, functional, and social indicators must be adequately reviewed Linking need to benefits/services key to managing LTSS, preparing for Fair Hearing and avoiding overturn decisions Transition monitoring System-wide transition planning essential Quality monitoring Non-traditional measures

Additional considerations for plans Care coordination Monitoring and inter-rater reliability Comprehensive care planning tools Interfaces to systems/providers outside of plan Provider payment Clear appreciation for total payments and historic trends Addressing cross over payments Increased access Moves beyond finding another physician for network Rapid member engagement Passive enrollment + opt-out ability requires need to have timely member touch points Real-time monitoring and adjustment Trigger events key due to comprehensive risk

Preparing for the populations In many instances the populations targeted for integrated models have been historically unmanaged Requires plans to develop engagement strategies to demonstrate value of managed care Requires engagement with stakeholders, providers, and CBOs to serve as influencers on value proposition Complexities of population and delivery systems have to be assessed Specialty populations such as DD or AIDS generally access the system in unique ways Managed care must demonstrate flexibility and sensitivity Interaction with waiver services and non-waiver services vital to comprehensive approach to care

Network and provider considerations Blurring the lines between Medicare and Medicaid delivery systems Community Health Traditional Medicare/Commercial providers Increasing expectations of provider engagement PCMH HH Increasing health plan oversight for providers ADA Primary care impacts on LTSS Expanding the view of quality in incentive structures Moving beyond acute utilization to address comprehensive concerns

Ensuring the success of integration Demonstrations and other integration activity is unique and unprecedented opportunities for complex populations Failure of demonstrations to improve quality, create community access and increase community placement, aligning incentives, and creating sustainability will lead to long-term consequences Plans have significant responsibility to understand the complexities and ensure an ability to support the needs of the population