Medicare-Medicaid Integration: Achieving Higher Quality and More Cost-Effective Care SNP Alliance Executive Roundtable March 19, 2012 Suzanne Gore, JD, MSW Center for Health Care Strategies sgore@chcs.org 20 min

Integrated Care: New Opportunities & Attitudes Affordable Care Act (ACA) established the Medicare-Medicaid Coordination Office, which is helping states to design integrated care programs. Federal funding to support state design and infrastructure development. Opportunity to combine Medicare and Medicaid funding streams. Beneficiaries and advocates are beginning to see that they have a lot to gain from integrated care.

Medicare-Medicaid Coordination Office (MMCO) Created by Section 2602 of the ACA Improve coordination between the Federal government and states for Medicare-Medicaid enrollees Focuses on: Program alignment, Data and analytics, and Models and demonstrations

Medicare-Medicaid Coordination Office (MMCO) State Demonstrations and Financial Alignment models Partnered with the Center for Medicare and Medicaid Innovation (CMMI) to competitively select 15 states for $1M design contracts www.innovations.cms.gov Three-year demonstrations

15 State Design Contracts Awarded April 2011 State Demonstrations $1 million contracts to support integrated care program design 15 State Design Contracts Awarded April 2011 California Oklahoma Colorado Oregon Connecticut South Carolina Massachusetts Tennessee Michigan Vermont Minnesota Washington New York Wisconsin North Carolina

Financial Alignment Models State Medicaid Director Letter July 8, 2011 Offers states two paths (aka “Financial Alignment Models”): Open to all interested states – but must pursue one of the two models State letter of intent was due October 1, 2011 22 states responded Some have subsequently retracted LOIs Capitated Model Financial Alignment Models Managed Fee-for-Service Model

New Financial Alignment Model: Capitated Three-way contract (state, CMS, health plan) Prospective, blended payment with “aggressive savings” built in Single set of rules for appeals, marketing, and audits Joint procurement of “selected high-performing health plans” Voluntary Enrollment: passive enrollment but opt-out provisions Example states: AZ, CA, MA, MI, MN, VA

New Financial Alignment Model: Managed Fee for Service Improve coordination of care through fee-for-service providers, including Medicaid health homes or Accountable Care Organizations Must exceed quality thresholds and meet a target for savings Program will provide seamless integration and access to all necessary services based on an individual’s needs Example states: CO, CT, and OK

Financial Alignment Participation (as of March 13, 2012) State Model Posted? Alaska FFS No Indiana Capitated Arizona Iowa California Kansas Colorado Maine Connecticut Maryland Both Retracted Florida Massachusetts State/CMS Hawaii Michigan Idaho Missouri Illinois Both?

Financial Alignment Participation continued (as of March 13, 2012) State Model Posted? Montana FFS Retracted Rhode Island Capitated No Nebraska South Carolina TBD New Mexico Tennessee New York Texas North Carolina Vermont Ohio Virginia Oklahoma Washington Oregon Wisconsin Both Pennsylvania

Requirements and Benefits for All Participating States States must: Participate in evaluation Collect and report data: Individual-level quality, cost, enrollment, and utilization data for participants and non-participants If using capitated model, health plans required to submit encounter data and quality indicators States may: Request technical assistance Have access to Medicare data

Stakeholder Involvement is Crucial! During design phase (April 2011 – May 2012) A robust stakeholder engagement process is required by CMS Two public notice requirements for design proposals (30 days by state, 30 days by CMS) CMS will post proposals on http://www.integratedcareresourcecenter.com/ During implementation (May 2012 – January 2013) stakeholders contribute to outreach and real-time feedback Post implementation, stakeholders contribute to monitoring and evaluation

State Operational Hurdles Rates Risk mitigation Joint development process Benefits Continuation of supplemental benefits Carve-outs due to stakeholder resistance Delivery options: Self-direction

State Operational Hurdles Quality Assurance Quality measure development Plan monitoring process Plan Selection Criteria Enrollment Voluntary, passive enrollment Flow of enrollment process (CMS vs. State)

Your Input is Requested What design or financial incentives can states use to promote community-based care? How important is inclusion of a risk mitigation strategy in the integrated care plan rates?

State Example: Oregon Integration initiative is part of overall health reform approach for all Medicaid-eligible individuals. Oregon is building a new model, the Coordinated Care Organization. Benefits will integrate most services, but by Oregon law, long-term services and supports are excluded. Health plans will have the opportunity to bid but may not be the only provider of CCO services. Website at http://health.oregon.gov/OHA/OHPB/health-reform/workgroups/medicare-medicaid-integration.shtml .

State Example: California California is building its integrated model off its existing managed care platform. A Request for Solutions has already been issued; 22 organizations in 10 counties responded. Benefits include medical and LTSS; behavioral health may be coordinated to start. Website www.calduals.org.

State Example: Massachusetts Massachusetts is creating new entity, the Integrated Care Organization, to initially serve Medicare-Medicaid eligible adults age 21- 65. Key element is the inclusion of person-centered medical home. First state to submit a design proposal to CMS. Procurement expected in April 2012. http://www.mass.gov/masshealth/duals.

Resources www.integratedcareresourcecenter.com. The Integrated Care Resource Center was established by CMS to help states develop and implement integrated care models for Medicaid beneficiaries with high-cost, chronic needs; Focus on integrating care for: (1) individuals who are dually eligible for Medicare and Medicaid; and (2) high-need, high-cost Medicaid populations via the Health Homes state plan option as well as other emerging models; Individual and group TA coordinated by Mathematica Policy Research and CHCS; and For more information, visit: www.integratedcareresourcecenter.com.

Thank you!