Introduction to Dual Eligible Integration National Senior Citizens Law Center and Families USA Webinar July 13, 2011.

Introduction to Dual Eligible Integration

National Senior Citizens Law Center and Families USA Webinar

July 13, 2011

Dual Eligible Demographics Approximately 9 million dual eligibles

66% have 3 or more chronic conditions

61% have a cognitive or mental impairment

More than 50% have incomes below the federal poverty level, 93% have incomes below 200% FPL

Account for 25% of Medicare spending and almost 50% of Medicaid spending

Make up less than 25% of total enrollment in the programs

Why Better Integrate Medicare & Medicaid? Good reasons:

Improve health outcomes leading to reduced costs

Align incentives to avoid cost-shifting between programs that disrupts care

Bad reasons: Generate short-term savings by limiting care Expand private managed care for its own sake

Existing Models

Medicare Advantage Special Needs Plans Program for All-Inclusive Care for the

Elderly (PACE)

Medicare and Medicaid Coordination Office Created by the ACA, often referred to as

the Office of the Duals Two main responsibilities:

Making the programs work better for beneficiaries

Improving coordination between the federal government and the states

Center for Medicare and Medicaid Innovation Created by the ACA Allow Medicare, Medicaid, and CHIP to test

new, innovative models in a quick and timely manner

$10 billion in funding through 2019 Has the authority to waive certain

requirements within Medicare and Medicaid

State Demonstrations to Integrate Care for Dual Eligibles Test different delivery system and payment

models that integrate care for dual eligibles 15 states received $1 million contracts to design

new systems CMMI wants proposals that cover the full range of

health care services, the entire dual eligible population, and are administered statewide

The state can propose a new model, expand existing pilots, or a combination of both

New (July 2011) Options for Financing Integration Models CMS State Medicaid Director Letter

outlines two approaches to financing: Option for managed careOption for fee-for-service

Many details need to be clarified

Models of Integrating Medicare and Medicaid Shared savings and care coordination models Managed care models State as the integrated entity and blended

funding

Shared Savings and Care Coordination Models Shared savings models are intended to

align financial incentives for health care providers and encourage them to coordinate care

Care coordination models include primary care medical homes and accountable care organizations

Shared Savings and Care Coordination Models: Issues to Consider Adequate infrastructure

Enrollment

Ensuring quality

Managed Care Models The model states have the most

experience with Intended to lower costs and coordinate

care Financing and delivery have remained

separate

Managed Care Models: Issues to Consider Network adequacy Enrollment Can private plans truly manage

Medicare and Medicaid? Oversight

State as the Integrated Entity State receives Medicare money in exchange

for assuming full responsibility for administering Medicare benefits

State can become the integrated entity and administer both programs or contract with an outside entity to do so

Never allowed previously, but authorized by ACA

State as the Integrated Entity: Issues to Consider Accountability

Can states administer Medicare benefits?

The Role of Advocates Be at the table when decisions are being

made Develop principles the state should follow Ensure that the focus is on improving the

beneficiary’s experience and not just lowering costs

Ask questions!

Questions to Ask What integration options is the state considering? What state and federal laws, regulations, and rules apply?

What, if any, conflicts in the state and federal laws exist? How will these conflicts be resolved?

Will the state need a waiver of federal Medicare or Medicaid requirements? If so, is such a waiver available? What are the implications of the waiver for beneficiaries?

What is the scope of the integration proposal? Will all health care services be included? Will it be statewide or regional? Will all populations be included or only sub-populations?

Questions to Ask If the proposal is initially limited in scope, what is the state’s

timeline for scaling up? How will the state scale up? What are the implications of a proposal that is initially limited in scope?

How will the state enroll beneficiaries? Will enrollment be voluntary or mandatory? Will it be an opt-in or an opt-out model? Will the state use an attribution process? If so, will it be prospective or retrospective?

What are the patient’s rights and responsibilities? How will the state ensure the protection of these rights? Will there be an ombudsman? What will the appeals process look like?

Questions to Ask What role will care coordination play in the proposal? Will

all beneficiaries be eligible for care coordination or only certain sub-populations? How will beneficiaries access care coordination?

How will the state ensure that beneficiaries have adequate access to the full range of health care providers and support services that they may need?

Resources Medicare and Medicaid Coordination Office

http://www.cms.gov/medicare-medicaid-coordination/ Center for Medicare and Medicaid Innovation

http://innovations.cms.gov/ MedPAC, Coordinating Care for Dual-Eligible Beneficiaries

http://www.medpac.gov/chapters/Jun10_Ch05.pdf Center for American Progress, The Dual Eligible Opportunity,

http://www.americanprogress.org/issues/2010/12/pdf/dual_eligibles_execsumm.pdf

Center for Health Care Strategies, Technical Assistance for Dual Eligible Integrated Care Demonstrations, http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261263

Alissa Halperin, Key Questions and Issues in State Medicare-Medicaid Integration Efforts, http://www.healthaction2011.org/?db85f8f8

More Resources

Families USA, A Guide for Advocates: State Demonstrations to Integrate Medicare and Medicaid (http://familiesusa2.org/assets/pdfs/health-reform/State-Integration-of-Medicare-and-Medicaid.pdf)

National Senior Citizens Law Center, Ensuring Consumer Protections for Dual Eligibles in Integrated Models