1. 1 Guidance for Organizations Interested in Offering Capitated Financial Alignment Demonstration Plans Medicare-Medicaid Coordination Office Vanessa Duran, Senior Technical Advisor Marla Rothouse, Senior Technical Advisor April 2012

2. 2 Overview Capitated Financial Alignment Demonstration Background – Vanessa Duran Overview of March 29, 2012 Plan Guidance Memorandum – Vanessa Duran Overview of Demonstration Plan Application – Marla Rothouse Next Steps and Resources for Additional Information – Marla Rothouse

3. 3 Capitated Financial Alignment Demonstration Background Medicare-Medicaid Coordination Office Section 2602 of the Affordable Care Act Purpose: Improve quality, reduce costs, and improve the beneficiary experience Ensure dually eligible individuals have full access to the services to which they are entitled Improve the coordination between the federal government and states Develop innovative care coordination and integration models Eliminate financial misalignments that lead to poor quality and cost shifting

4. 4 Capitated Financial Alignment Demonstration Background Goal: To increase access to seamless, fully integrated care programs for Medicare-Medicaid enrollees Capitated Model: Three-way contract among State, CMS and health plan to provide comprehensive, coordinated care in a more cost-effective way Information about the Financial Alignment Initiative: http://cms.gov/Medicare-Medicaid-Coordination/Medicare-and- Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/FinancialModelstoSupportStatesEffortsinCareCoordination. html July 8, 2011 CMS State Medicaid Director Letter January 25, 2012 CMS Memorandum March 29, 2012 CMS Memorandum Capitated Financial Alignment Demonstration Plan Application

5. 5 Overview of Plan Guidance - Medicare Past Performance Information Organization is ineligible for participation if under Medicare sanction Conditions on enrollment will be applied to demonstration applicants affiliated with a current Medicare contractor that is considered a past performance outlier using two CMS methodologies: Past Performance Review Methodology “Low performing icon” on Medicare Plan Finder

6. 6 Overview of Plan Guidance - Medicare Past Performance Information Conditions on enrollment apply until organization is no longer a Medicare past performance outlier A past performance outlier can: Retain current enrollees from a Medicare or Medicaid managed care plan Enroll beneficiaries who voluntarily elect a demonstration plan A past performance outlier cannot: Accept new passively enrolled beneficiaries

7. 7 Overview of Plan Guidance - Joint Plan Selection Process Joint CMS/State plan selection process using State-based selection vehicles The following detail the process of establishing qualifications to participate from a Medicare perspective: January 25, 2012 guidance memorandum March 29, 2012 guidance memorandum Capitated Financial Alignment Demonstration Application States will have HPMS access to plan selection documentation submitted by demonstration plan applicants

8. 8 Overview of Plan Guidance - Medicare Components of the Plan Selection Process CMS’ plan selection process includes approval of: Integrated formulary April 30 – New formulary submissions May 14 – Formulary crosswalk requests June 8 and June 15 – Supplemental formulary file submissions Demonstration application: May 24, 2012 Unified model of care: May 24, 2012 Medication therapy management program: May 25, 2012 Integrated plan benefit package: June 4, 2012

9. 9 Overview of Plan Guidance - Integrated Formulary Submission Formulary must be consistent with Part D and Medicaid drug coverage requirements Base formulary submission Supplemental formulary files: CMS required supplemental files, including for excluded Part D drugs and Part D OTC drugs: June 8, 2012 Additional Demonstration Plan Drug File: June 15, 2012

10. 10 Overview of Plan Guidance - Demonstration Plan Application Components of the application: Part D requirements Part D and Medicare medical service network adequacy requirements Model of care Documentation demonstrating State licensure and solvency, and CMS fiscal soundness requirements Administrative and management information

11. 11 Overview of Plan Guidance - Model of Care (MOC) Submission MOC narrative will be: A unified document and reviewed by both CMS and States MOC narrative must address: 11 required elements of the Medicare Advantage Special Needs Plan (SNP) MOC framework Additional State-required elements

12. 12 Overview of Plan Guidance - Model of Care (MOC) Submission CMS review of 11 MOC elements consistent with review of SNP MOC elements CMS will coordinate joint CMS-State review process Both CMS and the State must approve the final MOC

13. 13 Overview of Plan Guidance - Integrated Plan Benefit Package (PBP) Submission PBP must be consistent with: Minimum coverage requirements under Medicare Parts A, B and D, and Medicaid Any State-required demonstration-specific supplemental benefits Cost sharing for Parts A and B-covered services must be $0 Standard PBP software for MA plans has been modified to allow data entry for Medicaid-covered services Both CMS and the States must approve final PBP

14. 14 Overview of Plan Guidance - Key Training Dates

15. 15 Overview of Demonstration Plan Application - General Information Applications are only accepted through the CMS Health Plan Management System Organizations will get a confirmation number as receipt of their submission Technical assistance in the completion of the application is available at: MMCOcapsmodel@cms.hhs.govMMCOcapsmodel@cms.hhs.gov

16. 16 Overview of Demonstration Application Process - Key Dates Application available in HPMS: April 12, 2012 Application Training: April 17, 2012 Applications Due: May 24, 2012 Deficiency Notice Emails: Mid-June 2012 Deadline to Request HSD Criteria Exception: July 2, 2012 Application Determination Notices: July 30, 2012

17. 17 Overview of Demonstration Application Process - Key Areas Medicare Prescription Drug Plan Attestations Pharmacy Networks Medical Provider Networks Administrative Contracts Pharmacy and Medical Provider Contract Templates Compliance Plan Licensure and Solvency Model of Care

18. 18 Overview of Demonstration Application Process - Attestations Prescription Drug Attestations: Includes prescription drug benefit attestations If Applicant believes an attestation is not applicable for purposes of the demonstration, the Applicant may provide a NO response (i.e., Bids, Premium Billing) Medical Medicare Benefit Attestations: Not included because many requirements in 42 CFR 422 may be modified based on the specifics of each State’s MOU with CMS

19. 19 Overview of Demonstration Application Process - Pharmacy Networks Applicants submit pharmacy lists for: Retail pharmacy Home Infusion Mail Order Long-Term Care Indian Tribe and Tribal Organization, and Urban Indian Organization CMS will automatically determine if Medicare network adequacy standards are met

20. 20 Overview of Demonstration Application Process - Medical Provider Networks Use of access criteria standardized by provider/facility type and geographic designation Largely automated review Maps are not required Applicant will be able to request exceptions to access standard under limited circumstances (joint review with State)

21. 21 Overview of Demonstration Application Process - Contracts and Templates Administrative contracts - executed agreements for key Medicare functions identified in HPMS (i.e., claims adjudication, enrollment, credentialing) Templates for distinct Medical Providers and distinct Pharmacy Providers Must include required provisions provided in the Application appendices

22. 22 Overview of Demonstration Application Process - Compliance Plan Application is specific to Medicare Part D Applicants should also refer to: Draft of Chapter 9 of the Prescription Drug Benefit Manual and; Chapter 21 of the Medicare Managed Care Manual

23. 23 Overview of Demonstration Application Process - Licensure and Solvency Applicants will be required to provide evidence of State licensure Applicants will be required to provide evidence of fiscal soundness Audited financial statements

24. 24 Overview of Demonstration Application Process - Application Determinations Letters will include the instructions for submitting a sampling of signature pages to validate the medical provider network as part of the Readiness Review Readiness Reviews are scheduled to begin in early August 2012

25. 25 Next Steps Organizations should continue to monitor State activity on their demonstration proposals, including posting for public comment and stakeholder input processes Additional bid-related guidance for non-demonstration MA and PDP contracts to be provided separately

26. 26 Resources for More Information Financial Alignment Initiative: http://cms.gov/Medicare-Medicaid-Coordination/Medicare- and-Medicaid-Coordination/Medicare-Medicaid- Coordination- Office/FinancialModelstoSupportStatesEffortsinCareCoordin ation.html http://cms.gov/Medicare-Medicaid-Coordination/Medicare- and-Medicaid-Coordination/Medicare-Medicaid- Coordination- Office/FinancialModelstoSupportStatesEffortsinCareCoordin ation.html New MMCO mailbox for questions about the Capitated Financial Alignment Demonstration: MMCOcapsmodel@cms.hhs.gov MMCOcapsmodel@cms.hhs.gov