Scott Leitz Assistant Commissioner for Health Care Minnesota Department of Human Services Minnesotas Approach: Integrated Medicare & Medicaid Programs Alliance for Health Reform Briefing on Dual Eligibles June 3, 2011

MNs Dually Eligible Population 106,600 Minnesotans are fully eligible for both Medicare and Medicaid 97% of seniors and 50% of people with disabilities on Medicaid are dually eligible About 40% of MNs total Medicaid spending is for duals 68% of seniors and 41% of people with disabilities in MN Medicaid receive long-term care services Most seniors served through managed care Minnesota SeniorCare Plus (MSC+) Minnesota Senior Health Options (MSHO): SNP program, voluntary alternative to MSC+ Most people with disabilities served through FFS Special Needs BasicCare (SNBC): SNP program, voluntary alternative to FFS

Key Service Needs of Duals Aligned financial incentives between payers (Medicare and Medicaid) and providers Primary and chronic care management strategies implemented across care settings Improved coordination between primary, acute and long-term care services Aligned networks across Medicare and Medicaid providers Navigation assistance to get to right providers at the right time Simplified paperwork and member materials that explain Medicare and Medicaid services and how they fit together Coordination with behavioral and housing needs

Distinct Population Issues For seniors: Many opportunities for reducing hospitalization but savings accrue to Medicare Diversion strategies from nursing homes and high costs community settings (assisted living) For people with disabilities: High use of specialty care but lack of access to basic primary and preventive care Many primary care providers unwilling or lack expertise to serve people with disabilities Majority have co-occurring mental health diagnoses Not a static population: people with disabilities constantly becoming dual after Medicare waiting period results in continuity of care issues

Primary Issues Facing States Medicare-paid providers drive primary and acute care. If poorly managed, Medicaid pays for the result (Higher need for long-term care services) Increased pressure on State budgets due to high growth in dual eligible populations; need to prepare for both fiscal and care delivery challenges Lack of financial equity for States for investment in aligned/integrated options (immediate savings accrue to Medicare) Lack of stable scale-able platforms for alignment of Medicaid and Medicare for the future Access to Medicare data for total cost of care requires State resource investment

Minnesotas Approach First state to integrate Medicare and Medicaid primary, acute and long-term care for seniors Transitioned from Medicare demo to SNP status in 2005 No complex waivers needed; we use existing state plan and home and community based service authorities under 1915 (a) and (c ). Close working relationship and ongoing understanding and support from CMS (both Medicare and Medicaid) have been very important Stakeholder involvement key in acceptance of managed care approach for people with disabilities

Where Weve Succeeded SNPs aligned with State long-term care goals for improved access and cost management Majority of seniors now served in community 98% of seniors on MSHO now receive annual primary/preventive care visits State has leveraged integrated Medicare data and coverage of additional care coordination through contracts with Medicare SNPs Continued enrollment growth in current integrated program for people with disabilities (SNBC) despite loss of some SNPs Creative environment has produced some total cost of care models (virtual) that manage across payers and domains of care

Not Without Challenges Limited opportunity for State to share any Medicare and Medicare SNP savings under current models SNP bid process has resulted in premiums that duals cannot pay and thus lack of stability in SNP participation in integrated programs Need to stabilize current SNP platform for integration and make it more attractive to States Need for improvement in Medicare risk adjustment for frail seniors and people with disabilities Integration of administrative processes: devil is in details, requires expertise and diligence

Moving Forward Working to bring up PACE in Minnesota Implementing statewide All Payer Health Care Home including CMS Medicare APC demo Care Delivery System Payment Demo RFP will be issued soon; future steps expected to include FFS and MCO duals Duals Demonstration Planning Contract with CMS Development of performance metrics, risk adjustment, total cost of care payment models and provider feedback mechanisms specific to dual eligibles, consistent across managed care and FFS Pursuing improvements in current SNP and/or new platforms for integrated financing and service delivery

Contact Information Scott Leitz Assistant Commissioner for Health Care Minnesota Department of Human Services (651) Pam Parker Special Needs Purchasing Minnesota Department of Human Services (651)

Seniors MSHO (Statewide) 1915 (a)(c) MSC+ (Statewide) 1915(b)(c ) Enrollment 65+Voluntary 37,000 (5/11)Mandatory 11,500 (5/11) Medicare Services All Medicare services including Part D drugs through Medicare Special Needs Plan (SNP) Medicare A/B services through Medicare FFS. Part D drugs through separate Medicare drug plan Medicaid Basic Care Services Medicaid state plan services (includes PCA) and remaining drugs through same SNP Medicaid only plan provides state plan (includes PCA) and remaining drugs Medicaid Long- Term Care Services Elderly Waiver (EW) through SNP plus 180 days of nursing home care EW through same plan plus 180 days of nursing home care

Fee For Service (46,600 enrollees) Special NeedsBasicCare (Managed Care) (6,000 enrollees) Authority: 1915(a) Enrollment Age Voluntary, open to both duals and non duals with disabilities in 78 counties (new legislation pending to expand with opt out enrollment process) Medicare Services Medicare A/B through FFS Separate Part D Plan enrollment All Medicare services including Part D drugs through 4 Medicare Advantage SNPs, One SNBC MCO does not offer SNP Medicaid Basic Care Services Most Medicaid state plan services provided through same SNP plan including remaining drugs except PCA and PDN which remain Fee for Service, provides platform for integration of all behavioral services including MH-TCM. Medicaid Long-Term Care Services Includes first 100 days of nursing home care and remaining home health care, Medicaid HCBS waivers and long term care services remain Fee for Service People with Disabilities