1. Balancing Opportunities in the Affordable Care Act Centers for Medicare & Medicaid Services Julie Sharp, Christa Speicher, Alice Hogan & Effie George October 19, 2011

2. Who are Medicare-Medicaid Enrollees? 9.2 million individuals (2008) that are enrolled in both Medicare and Medicaid (or “dual eligibles”). More likely to have mental illness, have limitations in activities of daily living and multiple chronic conditions. Few are served by coordinated care models and even fewer are in integrated models that align Medicare and Medicaid. 2

3. Medicare-Medicaid Enrollees Account for Disproportionate Shares of Spending Total Medicare Population, 2006: 43 Million Total Medicare FFS Spending, 2006: $299 Billion Total Medicaid Population, 2007: 58 Million Total Medicaid Spending, 2007:$311 Billion Dual Eligibles as a Share of the Medicare Population and Medicare FFS Spending, 2006: Dual Eligibles as a Share of the Medicaid Population and Medicaid Spending, 2007:

4. Medicare-Medicaid Coordination Office Section 2602 of the Affordable Care Act (ACA) 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

5. State Demonstrations to Integrate Care for Dual Eligibles Develop, test, and validate fully integrated delivery system and care coordination models that can be replicated in other States. 15 states selected receive up to $1 million to design new models for serving Medicare-Medicaid Enrollees. Participating States: CA, CO, CT, MA, MI, MN, NY, NC, OK, OR, SC, TN, VT, WA, WI One year contracts through April 2012. 5

6. Financial Alignment Demonstrations to Support State Efforts to Integrate Care CMS seeks to test two financial alignment models with States to support integration of primary, acute behavioral health and long term services and supports for Medicare-Medicaid enrollees –Capitated Model: three-way contract among State, CMS and health plan to provide comprehensive, coordinated care. –Managed FFS Model: Agreement between State and CMS under which State would be eligible to benefit from savings resulting from initiatives to reduce costs in both Medicaid and Medicare. Open to all States able to meet established standards and conditions, including a target implementation by 2012. For more information: http://www.cms.gov/medicare-medicaid- coordination/08_FinancialModelstoSupportStatesEffortsinCareCoordi nationhttp://www.cms.gov/medicare-medicaid- coordination/08_FinancialModelstoSupportStatesEffortsinCareCoordi nation 6

7. New Models Expand and Promote State Partnerships Financial Alignment Initiative 7 DC States Financial Alignment Model Letters of Intent KEY: Submitted Letter of Intent

8. Medicare-Medicaid Coordination Office Questions & Suggestions: MedicareMedicaidCoordination@cms.hhs.gov MedicareMedicaidCoordination@cms.hhs.gov 8 http://www.cms.gov/medicare-medicaid-coordination/ For more information, visit:

9. Health Homes for Enrollees with Chronic Conditions Goal – expand upon the traditional and existing medical home models to build linkages to community and social supports, and to enhance the coordination of medical, behavioral, and long-term care. Financial Incentives – 90% increased FMAP for the first 8 fiscal quarters 9

10. Health Homes Services and Eligibility The health home services include: Comprehensive Care Management; Care coordination; Health promotion; Comprehensive transitional care from inpatient to other settings; Individual and family support; Referral to community and social support services; 10

11. Health Homes Services and Eligibility  Use of health information technology, as feasible and appropriate Eligibility – Medicaid eligible individual having: –two or more chronic conditions, –one condition and the risk of developing another, –or at least one serious and persistent mental health condition. 11

12. Health Homes for Enrollees with Chronic Conditions For more information visit: http://www.cms.gov/smdl/downloads /SMD10024.pdf 12

13. Balancing Incentive Program Section 10202 of Affordable Care Act Provides incentives for states to increase % of Medicaid long-term services and supports (LTSS) spending on community- based services 13

14. Balancing Incentive Program Focus on states with less balanced systems –<50% of Medicaid LTSS $ on community LTSS: +2% FMAP –<25% of Medicaid LTSS $ on community LTSS: +5% FMAP Community-based LTSS eligible for increased FMAP 14

15. By September 30, 2015, States must: Increase community-based spending to 50 or 25% of total Medicaid LTSS spending Implement three structural changes: – No Wrong Door/Single Entry Point (NWD/SEP) System – Core Standardized Assessment(s) – Conflict-Free Case Management 15

16. Monitoring Completion of Requirements Quarterly financial reporting through the 64 form Submission of a Work Plan, detailing processes for implementing structural changes Quarterly Progress Reports with Work Plan deliverables, demonstrating progress made to the structural changes 16

17. No Wrong Door/Single Entry Point System “Development of a statewide system to enable consumers to access all long-term services and supports through an agency, organization, coordinated network, or portal…and that shall provide information regarding the availability of such services, how to apply for such services, referral services for services and supports otherwise available in the community, and determinations of financial and functional eligibility…or assistance with assessment processes for financial and functional eligibility” 17

18. Characteristics of a NWD/SEP System Statewide Uniform, predictable processes for all individuals Streamlined: timely and efficient Case coordination –Single eligibility coordinator –Integrated case management system 18

19. Organization Medicaid Agency as the Oversight Agency Operating Agency delegated by Medicaid Agency Network of NWD/SEPs, for example: –Centers for Independent Living –Aging and Disability Resource Centers –Area Agencies on Aging 19

20. 20 Two-Stage Process for Enrollment into Community LTSS

21. Two-Stage Process for Eligibility Determination Level I Screen –Completed by individual, family member, advocate –Completed online, by phone, in person –Outcome = Identify those likely to meet functional eligibility for community LTSS Level II Assessment –Completed by “qualified” staff with assistance from individual, family member, advocate and/or others (e.g., physician records) –Completed in person, and with document review if necessary –Outcome = Identify those who meet functional eligibility community LTSS options 21

22. Stage 1: Entry and Level I Screen NWD/SEPs – Full-service locations – Conducts Level I screen Informational Website – Provides information about range of community LTSS available – May provide an online Level I screen 1-800 Number – Staffed by NWD/SEP staff or their contractors – Provides Level I screen 22

23. Stage 2: Streamlined Eligibility and Enrollment NWD/SEP conducts the following activities: Coordinates Level II functional assessment Supports individual in submitting Medicaid financial application Supports individual in choosing and enrolling in programs 23

24. Core Standardized Assessment Instruments “Development of core standardized assessment instruments for determining eligibility for non-institutionally-based long-term services and supports…which shall be used in a uniform manner throughout the State, to determine a beneficiary's needs for training, support services, medical care, transportation, and other services, and develop an individual service plan to address such needs.” 24

25. Purpose of Core Standard Assessment State is required to develop core standard assessment tools, which shall be used in a uniform manner throughout the State, to: Determine eligibility for community LTSS Determine an individual’s needs for support services Develop/inform an individual service plan to address needs 25

26. Core Standardized Assessment Requirements A given instrument is used uniformly for a given population CSA must capture a Core Dataset (i.e., domains and topics). States can choose:  Questions  Scoring system 26

27. Required Domains and Topics Activities of Daily Living Eating Toileting Bathing Mobility Dressing Positioning Hygiene Transferring Instrumental Activities of Daily Living Preparing Meals Transportation Housework Shopping Managing Money Telephone Use Managing Medication Medical Conditions/ Diagnoses Cognitive Functioning/ Memory Diagnoses tied to Cognitive Function Memory Judgment/Decision-Making Behavior Concerns Injurious Uncooperative Destructive Other Serious Socially Offensive 27

28. Conflict-Free Case Management “Conflict-free case management services to develop a service plan, arrange for services and supports, support the beneficiary (and, if appropriate, the beneficiary's caregivers) in directing the provision of services and supports for the beneficiary, and conduct ongoing monitoring to assure that services and supports are delivered to meet the beneficiary's needs and achieve intended outcomes.” 28

29. Conflict-Free Case Management Separation of case management from direct services provision Separation of eligibility determination from direct services provision Individuals performing evaluations, assessments, and plans of care cannot be:  Related by blood or marriage to the individual or any of the individual’s paid caregivers  Financially responsible for the individual  Empowered to make financial or health-related decisions on behalf of the individual 29

30. In Rural Areas where Providers are Limited.. Establish administrative separation between those doing assessments and case management and those delivering direct services Assure individuals can advocate for themselves Establish a consumer council and State Agency oversight to monitor issues of choice Establish means for consumers to make complaints and/or appeals Document the number and types of appeals and consumer experiences with measures that capture the quality of case management services CMS is reviewing the options for conflict-free case management in a managed care environment

31. Timeline CMS has released:  Application  State Medicaid Director Letter  Implementation Manual States submit applications on a rolling basis Six months after the application is submitted, States must submit a Work Plan of activities CMS and contractors will provide technical assistance to States

32. Guidance, Questions, Comments Balancing Incentive Program State Medicaid Director Letter and Application: https://www.cms.gov/SMDL/SMD/itemdetail.asp?filterTy pe=none&filterByDID=99&sortByDID=1&sortOrder=desce nding&itemID=CMS1252041&intNumPerPage=10 Contact Mission Analytics Group (info@balancingincentiveprogram.org) regarding Program requirements and technical assistance needs.info@balancingincentiveprogram.org Contact CMS (balancing-incentive-program@cms.hhs.gov) regarding policy-related questions or comments.balancing-incentive-program@cms.hhs.gov 32