1. 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
20 min

2. 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.

3. 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

4. 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
Three-year demonstrations

5. 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

6. 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

7. 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

8. 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

9. 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?

10. 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

11. 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

12. 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
During implementation (May 2012 – January 2013) stakeholders contribute to outreach and real-time feedback
Post implementation, stakeholders contribute to monitoring and evaluation

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

14. 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)

15. 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?

16. 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 .

17. 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

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

19. 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:

20. Thank you!