Protecting the Rights of Low-Income Older Adults

Dual Eligible Demonstrations Families USA Health Action Conference Fay Gordon, National Senior Citizens Law Center January 25,

The National Senior Citizens Law Center is a non-profit organization whose principal mission is to protect the rights of low-income older adults. Through advocacy, litigation, and the education and counseling of local advocates, we seek to ensure the health and economic security of those with limited income and resources, and access to the courts for all. For more information, visit our Web site at

Today Overview Recent Guidance and Common Features Across the States Advocacy Takeaways

Demonstration map continues to change 5

The Dual Eligible Demonstration is Live in Several States State Proposals: 26 states MOUs: 9 states Three-way contract: Mass., IL, VA Readiness Review Enrollment: Notices sent to Mass and CA Ongoing monitoring and evaluation

Passive enrollment began in January StateLatest enrollment timeline CaliforniaApril, 2014 (passive for all counties, except LA) April-July, 2014 (voluntary for LA county) IllinoisMarch, 2014 (voluntary) May, 2014 (passive) MassachusettsVoluntary enrollment went live on October 1 Passive enrollment went live on January 1 New YorkCommunity LTSS: July, 2014 (voluntary), September, 2014 (passive) Institutional LTSS: October, 2014 (voluntary), Jan (passive) Ohio*March, 2014 (voluntary) May, 2014 (passive) VirginiaFebruary, 2014 (voluntary) May, 2014 (passive) WashingtonMFFS went live on July 1 July, 2014 (voluntary, capitated) September, 2014 (passive, capitated) 7

Recent Guidance 8

MMCO: Website updated with new guidance MOUs Three-way contracts Marketing Guidance Enrollment Guidance Plan reporting requirements RTI Evaluation Plan Readiness reviews Joint rate setting guidance 9

Three-way contract details the specifics of state demonstration Basic structure: Starting point to understand other state contracts See: Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.htmlf for more informationhttp:// Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.htmlf 10 Medicare Advantage State: Medicaid statute and managed care contracts MCOs CMS: Medicare Advantage Contract & Guidance Three way contract

All states include an initial voluntary enrollment period All states* include at least 60 day initial voluntary enrollment. States will send individuals a notice informing them of their right to “opt-in” to demonstration. Passive enrollment will be phased. *California will only have voluntary enrollment in Los Angeles County. 11

CMS is requiring all states include an independent ombudsman MOUs include include similar language: – “The ombudsman will support individual advocacy and independent systematic oversight….with a focus on compliance with principles of community integration, independent living, and person-centered care in the home and community-based care context.” So far, California and Virginia received ombudsman funding. 12

All state demonstrations include upfront savings reductions VANYSCWA cap Year 11% Year 22%1.5%2% Year 34%3%4%3% 13

Care continuity differences VANYSCMAOHCAWA cap NF residents May stay thru demo N/ALater of 90D or initial assess* May stay through demo. 12 months ** 180D or care plan Medicare providers and services 180D or prior auth* 90D or care assess 180DLater of 90D or initial assess* 90D for high risk, 365D for all others 6 months ** Later of 90 D or care plan* Rx drugs Part D 14 * Earlier only with enrollee consent. **If certain conditions are met

Appeals- Most states 15 Plan appeal APP Plan appeal APP IRE State Hearing APP State Hearing APP MAC ALJ Fed Ct. If overlap External Medical Review Denial Available in OH, CA Medicare Services Medicaid Services Court

Advocacy Takeaways 16

Ombudsman Takeaways Consider clarifying in MOU and 3-way: – Best entity(s) in your state to maintain ombuds independence – Providing oversight of the demonstration as well as plan – Securing funding from CMS grant – Explicit assistance with all levels of appeal – Client is always the dual eligible; not state or plan 17

Appeals Takeaways Consider the following issues for MOU: – Aid paid pending Prohibit recoupment for aid paid pending – Shorten Fair Hearing decision timelines – Test for reasonableness of appeals route: can it be described in an intelligible consumer notice? 18

Questions for early implementation stages Information—Getting accurate information out to consumers, providers, advocates. Enough lead time? Adequate outreach? Care continuity—will it be robust? State organization and capacity for oversight and problem-solving—Staffing levels? Coordination? Systems readiness? 19

Broad takeaways Some, but limited, standardization is appearing in the MOUs around enrollment, savings, and ombuds. No straight line progression in consumer protections. State protections vary widely among recent MOUs. Most are the result of vigorous advocacy and state initiatives. CMS is open to state innovation if carefully thought out. 20

Duals Demo: Enrollment timelines Informational webinars Analysis and comparison of state demonstrations 21

Contact: Fay Gordon, 22