1. SNP Alliance 13th Annual Leadership Forum Washington, DC
The State of Integration:
Next Phase and Opportunities for Working with States
SNP Alliance 13th Annual Leadership Forum
Washington, DC
November 2, 2017
James M. Verdier
Senior Fellow
Mathematica Policy Research

2. Overview Enrollment in integrated care plans
Potential for growth in integrated care
Challenges for states and health plans
ICRC and other resources

3. Enrollment in Integrated Care Plans

4. D-SNP Enrollment by State, October 2017
Number of D-SNP Plans
Total D-SNP Enrollment
Puerto Rico 14
283,949
Florida 64
281,884
New York 32
250,830
Texas 28
155,874
California 30
133,439
Pennsylvania 13
125,356
Tennessee 7
94,870
Arizona 19
89,795
Georgia 12
62,087
Alabama 4
52,776
Massachusetts
46,179
Louisiana 10
41,497
Minnesota
40,951
Washington 6
33,352
New Jersey 5
29,918
Ohio
27,928
Wisconsin
27,918
South Carolina
27,882
North Carolina
24,493
Connecticut 2
23,622
Oregon 8
22,761
Hawaii
21,805
SOURCE: CMS SNP Comprehensive Report, October Available at:

5. D-SNP Enrollment by State, October 2017 Total D-SNP Enrollment
Number of D-SNP Plans
Total D-SNP Enrollment
New Mexico 6
21,130
Arkansas 5
18,355
Mississippi
18,110
Missouri 3
15,369
Michigan 4
13,720
Colorado
11,025
Kentucky 9
10,584
Illinois
8,812
Utah 2
8,191
Indiana
7,385
Washington D.C.
7,267
Maryland
5,087
Maine
4,258
Virginia 8
3,094
Delaware
2,563
Idaho 1
2,315
Kansas
1,865
Rhode Island
1,491
West Virginia
643
Montana
299
Nebraska 88
TOTAL1
383
2,060,815
1 Five plans spanned across multiple states. In this table, we divided the number of enrollees in those plans evenly across the states and added the plan to each state’s total number of D-SNP Plans. The total excludes 10 enrollees in plans with fewer than 11 enrollees. This table includes FIDE SNPs.

6. D-SNP Enrollment by State, October 2017 Total D-SNP Enrollment
Number of D-SNP Plans
Total D-SNP Enrollment
New Mexico 6
21,130
Arkansas 5
18,355
Mississippi
18,110
Missouri 3
15,369
Michigan 4
13,720
Colorado
11,025
Kentucky 9
10,584
Illinois
8,812
Utah 2
8,191
Indiana
7,385
Washington D.C.
7,267
Maryland
5,087
Maine
4,258
Virginia 8
3,094
Delaware
2,563
Idaho 1
2,315
Kansas
1,865
Rhode Island
1,491
West Virginia
643
Montana
299
Nebraska 88
TOTAL1
383
2,060,815
1 Five plans spanned across multiple states. In this table, we divided the number of enrollees in those plans evenly across the states and added the plan to each state’s total number of D-SNP Plans. The total excludes 10 enrollees in plans with fewer than 11 enrollees. This table includes FIDE SNPs.

7. FIDE SNP Enrollment by State, October 2017
Number of FIDE SNP Plans
Total FIDE SNP Enrollment
Massachusetts 7
46,179
Minnesota 9
39,555
New Jersey 5
29,918
California 4
13,450
Arizona 3
9,125
New York 6
8,497
Wisconsin
2,398
Idaho 1
2,315
TOTAL 39
151,437
SOURCE: CMS SNP Comprehensive Report, October Available at:

8. Growth in Integrated Care Enrollment
Integration Platform
Enrollment
States
June
June
Financial Alignment Initiative Demonstrations
397,697
10 states
Capitated: CA, IL, MA, MI, NY, OH, RI, SC, TX, VA
D-SNPs
1,036,712
1,997,869
41 states, DC and PR
Two-thirds of enrollment in 11 states: (FL, NY, TX, CA, PA, TN, AZ, GA, AL, MA, MN)
FIDE-SNPs
144,207
8 states
AZ, CA, ID, MA, MN, NJ, NY, WI
PACE
20,792
38,879
32 states
Sources: Integrated Care Resource Center. Monthly Enrollment in Medicare-Medicaid Plans by Plan and by State, June 2016 to June and Centers for Medicare & Medicaid Services. SNP Comprehensive Report, June 2011 and 2017.

9. States at the Forefront of Integration in 2017WY WI WV WA VA VT UT TX TN SD SC RI PR PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL
KEY
Both Financial Alignment Demonstration and Integrated D-SNPs
Financial Alignment Demonstration
Integrated D-SNP*
* These states have aligned D-SNP/MLTSS plans and/or FIDE-SNPs as of mid-2017.

10. Potential for Growth in Integrated Care

11. New and Departing D-SNPs in 2018
There will be at least 22 new D-SNPs in 2018 in 14 states
AL, AZ, FL, GA, ID, MI, MS, NC, NE, NY, OK, PA, SC, and VA
There will be 11 departures in 6 states
AZ, CA, IL, MI, NY, and VA
ICRC is preparing a detailed state-by-state table showing 2018 new entries, departures, and service area reductions by company
Will be posted soon on the ICRC web site

12. CHRONIC Care Act
Passed Senate unanimously on September 26; now pending in the House
Senate version (S. 870) would extend D-SNP authorization permanently and House version (H.R. 3168) would extend it for five years
Both bills would require that D-SNPs meet “one or more” of the following requirements by 2021 (Senate) or 2022 (House):
Qualify as a FIDE SNP (but without the requirement for a PACE average level of frailty)
Have a capitated contract with the state for Medicaid LTSS or behavioral health services, or both
If a state does not require or allow capitated coverage for these services, another type of integration arrangement with the state approved by CMS that includes requirements such as timely notice of Medicare hospitalizations, emergency room visits, and hospital and nursing facility discharges and sharing of data on service use to assist in care coordination

13. Some Implications of the CHRONIC Care Act
If it is enacted:
States will have an additional incentive to:
Limit D-SNP/MIPPA contracts to D-SNPs with companion Medicaid MLTSS plans
Establish Medicaid MLTSS programs that include dually eligible beneficiaries, or include duals in existing MLTSS programs
D-SNPs with limited Medicaid experience, capacity, or opportunities will have to begin closing down Medicare-only D-SNPs or converting them to non-D-SNP Medicare Advantage plans
States that want D-SNPs to operate companion Medicaid MLTSS plans will have to give them an opportunity to obtain Medicaid contracts

14. State Requirements for Companion D-SNP and Medicaid MLTSS Plans
AZ, HI, NJ, TN, and VA
Require dually eligible beneficiaries to obtain their Medicaid benefits from Medicaid MLTSS plans
Require Medicaid MLTSS plans and D-SNPs to operate companion plans that enable dually eligible beneficiaries to obtain their Medicare and Medicaid benefits from plans operated by the same entity in the same geographic area
Do not contract with any D-SNPs that do not operate companion Medicaid MLTSS plans
Do not contract with any MLTSS plans that do not have companion D-SNPs
PA and TX
Require new Medicaid MLTSS plans to have companion D-SNPs
Existing D-SNPs not required to have companion Medicaid MLTSS plans

15. Financial Alignment Initiative Demonstrations
Currently scheduled capitated model demonstration end dates
California: 12/31/2019
Illinois: 12/31/2019
Massachusetts: 12/31/2018
Michigan: 12/31/2020
New York: 12/31/2019 (FIDA); 12/31/2020 (FIDA-IDD)
Ohio: 12/31/2019
Rhode Island: 12/31/2020
South Carolina: 12/31/2018
Texas: 12/31/2020
Virginia: 12/31/2017

16. Challenges for States and Health Plans

17. Major Integrated Care Challenges for States and Health Plans
For Medicaid health plans and state staff
Developing needed expertise in Medicare and Medicare Advantage
For D-SNPs
Developing needed expertise in each state’s Medicaid program
LTSS presents special challenges; programs vary by state and services are not covered by Medicare

18. Major Integrated Care Challenges (Cont.)
For states designing and operating integrated programs
Designing programs that fit with each state’s history, context, and Medicaid and Medicare delivery systems
Working with health plans to implement integrated programs that attract and retain enrollees
Enrollment in health plans for Medicare services is always voluntary
Monitoring and reporting on health plan performance and quality to encourage continuing improvement
For integrated health plans
Demonstrating to enrollees and potential enrollees that integrated plans are better for enrollees than non-integrated plans or Medicare FFS
Delivering on the promise of integrated care
Better coordination, information exchange, access, enrollee satisfaction, and outcomes

19. ICRC and Other Resources

20. ICRC and Other Resources
Websites
Integrated Care Resource Center
CMS Medicare-Medicaid Coordination Office
CMS Monthly Enrollment Reports
Resources
Integrated Care Resource Center. “State Contracting with Medicare Advantage Dual Eligible Special Needs Plans: Issues and Options.” November
Integrated Care Resource Center. “State and Health Plan Strategies to Grow Enrollment in Integrated Managed Care Plans for Dually Eligible Beneficiaries.” June
Integrated Care Resource Center. “Medicare Basics: An Overview for States Seeking to Integrate Care for Medicare-Medicaid Enrollees.” Updated June
Medicare Payment Advisory Commission (MedPAC) and Medicaid and CHIP Payment and Access Commission (MACPAC). “Beneficiaries Dually Eligible for Medicare and Medicaid: Data Book.” January

21. Mathematica Policy Research E-Mail: jverdier@mathematica-mpr.com
Contact Information
James M. Verdier
Senior Fellow
Mathematica Policy Research
1100 1st Street, NE, 12th Floor
Washington, DC
Phone: (202)