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Integrating Care for Dual Eligibles

woman receiving helpThe Idaho Medicaid program was directed by the Idaho Legislature through HB 260 to develop managed care programs that result in an accountable care system with improved health outcomes. Legislation directed Medicaid to focus on high-cost populations, including dual-eligibiles. The Medicaid program is now seeking input of Idaho stakeholders for transitioning care of adults who are dually eligible for Medicare and Medicaid to an integrated, coordinated care system.

The Issue
 
People who are dually eligible are among the nation’s most chronically ill and costliest patients. They account for close to 50 percent of all Medicaid spending and 25 percent of all Medicare spending. As of June 2011, there were 17,172 people in Idaho who were dually eligible for Medicaid and Medicare. Many in this group have opted to enroll in the Idaho Medicare-Medicaid Coordinated plan for dual eligibles and have average monthly expenditures of $1,500. For dual eligibles not enrolled in the plan, their monthly Medicaid expenditures average $1,800.
 
The majority of the dual eligible beneficiaries receive fragmented and poorly coordinated care.  In an effort to make sure dual eligible beneficiaries have full access to seamless, high quality health care and to make the system as cost-effective as possible, the federal Medicare-Medicaid Coordination Office was established pursuant to Section 2602 of the Affordable Care Act.

Updates

Click here to expand contentClick here to collapse content  March 17031714DualStakeholderPresentation.pdf, 2014 - WebEx Presentation - Duals - Stakeholder Update

Presentation


Recording


Medicaid was participating in the Duals Demonstration to Integrate Care for Dual Eligibles in Idaho for 2014. However, Medicaid received communication from the Duals office in September 2013, that the prospect of a Demonstration with only one participating health plan was no longer a viable option. Although six Health Plans expressed initial interest in the Demonstration for 2015, Idaho Medicaid has decided to pursue expansion of the covered benefits in the MMCP in 2014 and beyond and will not be participating in the Demonstration. 

Idaho Medicaid has a Medicare-Medicaid Coordinated Plan (MMCP) for dual-eligible individuals with more than 650 participants enrolled in one participating Medicare Advantage plan. This model is a voluntary program that permits a dual-eligible beneficiary to enroll in a single managed care organization (MCO) that receives capitation payments to deliver both Medicaid and Medicare services to the individual.

With Idaho legislative direction in House Bill 260, Medicaid continues to work on the development of a managed care plan for dual eligibles that will result in an accountable system of care with improved health outcomes.  Medicaid remains interested in working with Health Plans and stakeholders to gather ideas on how to integrate primary, acute, behavioral health and long term services and supports.  Please send comments to LTCManagedCare@dhw.idaho.gov.

Idaho Medicaid has a Medicare-Medicaid Coordinated Plan (MMCP) for dual-eligible individuals with more than 600 participants enrolled in one participating Medicare Advantage plan. This model is a voluntary program that permits a dual-eligible beneficiary to enroll in a single managed care organization (MCO) that receives capitation payments to deliver both Medicaid and Medicare services to the individual. With Idaho legislative direction in House Bill 260, Medicaid continues to work on the development of a managed care plan for dual eligibles that will result in an accountable system of care with improved health outcomes.

Medicaid was participating in the Duals Demonstration to Integrate Care for Dual Eligibles in Idaho for 2014. However, Medicaid received communication from the Duals office in September 2013, that the prospect of a Demonstration with only one participating health plan was no longer a viable option. Medicaid remains interested in working with Health Plans to gather ideas on how to pursue integration of primary, acute, behavioral health and long term services and supports for full benefit Medicare-Medicaid enrollees. Because the landscape with the Demonstration has changed, Medicaid is evaluating options to meet the legislative direction. Current options being considered are:

  • Expand the covered benefits in the current MMCP in 2014.

  • Pursue the Demonstration starting in 2015.

  • Have multiple Health Plans participate in MMCP in 2015.

As of November 14, 2013, six Health Plans submitted a Notice of Intent to Apply (NOIA) for the Duals Demonstration for 2015.  These Health Plans must submit a completed application to CMS by February 21, 2014 to continue with the Demonstration.  Medicaid will continue to hold stakeholder webinars regarding the managed care program every 1-2 months, and stakeholders are encouraged to send comments to LTCManagedCare@dhw.idaho.gov.

Medicaid received communication from the Duals office that the prospect of a Demonstration with only one participating health plan gives them great discomfort for several reasons. First, it limits beneficiary choice. Second, having only one plan participate creates a potential risk for continuation of the Demonstration if the plan opted out during the Demonstration period. Third, with only one plan, we would potentially have passive enrollment in rural areas but not in urban areas, where the majority of duals live and where more robust provider networks exist in Idaho.

IDHW was directed by the Idaho Legislature in House Bill 260 to develop a managed care plan for dual eligibles that will result in an accountable care system with improved health outcomes. As the landscape with the Demonstration has changed, IDHW is in the process of evaluating options for meeting that directive.  Current options being considered are:

  • Move forward with a managed care plan for the Medicaid benefits for the dual population.
  • Pursue the Demonstration starting in 2015.
  • Evaluate transitioning the current Duals Special Needs Plan (D-SNP) into a fully integrated dual eligible (FIDE) SNP.

IDHW expects to have a clearer picture of how we will proceed in the next few weeks.  There is some work that needs to be completed to assist in the decision making process.  IDHW remains focused on moving forward and welcomes feedback from our stakeholders. 

Thank you for your patience, support and feedback throughout this effort!

Please submit comments and questions to  LTCManagedCare@dhw.idaho.gov

 

Greetings,

Idaho Department of Health and Welfare, Division of Medicaid, is pleased to announce that Blue Cross of Idaho has successfully completed and has an approved application to participate in the  Idaho Medicare-Medicaid Coordinated Plan Demonstration (Idaho MMCP Demonstration).   We look forward to partnering with Blue Cross of Idaho in this Demonstration.  

Regence Blue Shield has chosen to discontinue participation in the Idaho Medicare-Medicaid Coordinated Plan Demonstration. 

If you have any questions, please feel free to contact Natalie Peterson, Bureau Chief Long Term Care @ 364-1968 or PetersN2@dhw.idaho.gov.

Thank you.  

Contacts for Blue Cross of Idaho’s Provider Network Management

Lauri Rowell
Hospital, Long Term Care, Medical Services, Mental Health Health System Performance Specialist
(208) 387- 6654
(800) 637- 6655 ext. 6654
lrowell@bcidaho.com   

Heidi Stark
Assisted Living, Group Home, Certified Family Home, Home Care, Housekeeping, Transportation, Delivered Meals, Chore Services and other Waiver Services Provider Network Management Specialist
(208) 331- 7205
(800) 637- 6655 ext. 7205
hstark@bcidaho.com     

Idaho Duals Demonstration Stakeholder PowerPoint

You can listen to a video recording of the WebEx presentation.

Additional guidance to Health Plans regarding Medicaid benefits that must be included is available here and in the first document link at the top of the Information for Health Plans widget on this page. In that document, the right-most column represents IDHW’s clarifications and latest guidance on issues related to the PBP.  Please review ALL entries in the right-most column.

Health Plans participating in the Demonstration must submit a CY 2014 Additional Demonstration Drug (ADD) file, which will include Medicaid-covered drugs not covered by Medicare Part D, by June 7, 2013, in CMS’ Health Plan Management System (HPMS).  Questions and answers regarding the ADD are available here.

We would like to thank everyone who participated in the May 1st Stakeholder Meeting. Below are links to the PowerPoint presentaton, tranisition requirements and a recording of the meeting.

This is an update to the Guidance to Help Plans document that became available April 26th. In this update, pages 36 and 37 were added to the April 26th document. Please click here for the updated document.

Health Plans participating in the Demonstration must submit a Plan Benefit Package (PBP) by June 3, 2013, in CMS’ Health Plan Management System (HPMS).  Guidance to Health Plans regarding Medicaid benefits that must be included is available here.  Required Medicaid benefits include Medicaid services which are not covered at all by Medicare, and services covered by Medicaid to a greater extent than they are covered by Medicare.  Health Plans may choose to use more beneficiary-friendly standards if they wish, such as higher maximum benefit levels, less stringent criteria to be eligible to receive a benefit, etc.  However, Health Plans may not impose less beneficiary-friendly standards around any service. 

WHAT: WebEx Presentation-Idaho Medicaid’s Proposal to Integrate Care for Dual eligible – Stakeholder Update

WHEN: Tuesday, March 19, 2013 10:00 am, Mountain Daylight Time (Denver, GMT-06:00)

Idaho Duals Demonstration Stakeholder Update (PDF)

Idaho's Response to CMS Duals Proposal (PDF)

Stakeholder Update for Idaho Medicaid’s Proposal to Integrate Care for Dual Eligibles – WebEx Recording

CMS has issued guidance to states indicating that interested health plans must submit applications through the Health Plans Management System (HPMS) by February 21, 2013. Part of the application includes the Model of Care (MOC) submission, which must be consistent with requirements under 42 CFR §422.152(g). 

 • Model of care scoring criteria (see appendix 2)
 • Additional information 

Please note that organizations that have an approved MOC for a non-demonstration Medicare Advantage SNP will be required to submit a demonstration-specific MOC. 

Idaho Medicaid intends to supplement the Dual Eligible Special Needs Plan (D-SNP) Model of Care with additional requirements in its Request for Proposal (RFP). These Medicaid-specific requirements will be reviewed when Idaho Medicaid reviews health plans’ responses to its RFP.

Idaho Medicaid hosted a WebEx for more than 50 stakeholders on Monday, December 10th  to provide updates on Idaho's initiative to integrate care for dual eligibles, and Idaho's Medical Home Collaborative and Medicaid's Health Home programs. Natalie Peterson, Bureau Chief for Long Term Care Services, presented the update on the progress to integrate care for dual eligibles, while Idaho Medicaid Program Manager Brian Peace presented the health home information. 

Their PowerPoint presentation is available here. You can also access audio of the entire presentations

Idaho Medicaid hosted a WebEx for more than 50 stakeholders on Wednesday, October 10 to provide an update on Idaho's initiative to integrate care for dual eligibles. Natalie Peterson, Bureau Chief for Long Term Care Services, provided an overview. Other documents discussed during the presentation include:

An audio recording of the presentation is available here.

Idaho hosted a WebEx for stakeholders on Friday, May 25th, to review the stakeholder feedback for Idaho's Proposal to integrate care for dual eligibles. Approximately 25 people participated in the WebEx presentation, which was presented by Idaho Medicaid Long Term Care Bureau Chief Natalie Peterson. You can view a recording of the presentation, showing both the PowerPoint slides and audio.

Idaho hosted a WebEx for stakeholders on Friday, May 25th, to review the stakeholder feedback for Idaho's Proposal to integrate care for dual eligibles.  Approximately 25 people participated in the WebEx presentation, which was presented by Idaho Medicaid Long Term Care Bureau Chief Natalie Peterson. You can view a recording of the presentation, showing both the PowerPoint slides and audio.

Idaho Medicaid hosted a statewide videoconference to review Idaho’s draft proposal to integrate care for dual eligibles and collect feedback from stakeholders on Tuesday, April 17. Idaho Medicaid used stakeholder feedback and input to develop the proposal that was submitted to CMS at the end of May, 2012. 

Developing a managed care program for dual eligible participants is a statewide effort of Medicaid staff, providers, community partners and agencies, participants and families. Idaho Medicaid held a statewide meeting of these stakeholders to gather specific recommendations and priorities on October 26th, 2011. Over 50 people participated in the meeting, which was held at the Boise Medicaid state office and video-conferenced to six other sites throughout the state.

Idaho Medicaid Long Term Care Bureau Chief Natalie Peterson provided background and information for the dual eligible managed care initiative. Following her presentation, a panel of six stakeholders presented their ideas and priorities for the design of a managed care system for dual eligible participants. Members of the panel presented Powerpoint presentations, which are available by clicking the name of each stakeholder.

  • Natalie Peterson Bureau Chief, Idaho Medicaid Long Term Care
  • Cathy McDougallAssociate State Director - American Assoc. of Retired Persons (AARP)
  • Robert VandeMerweExecutive Director - Idaho Health Care Association (IHCA)
  • Dana GoverConsultant - Access Concepts and Training, and dual eligible participant
  • Scott BurpeeCEO and President -  Safe Haven Health Care
  • Raul EnriquezProgram Specialist -  Idaho Commission on Aging
  • Jason McKinleyPresident - Idaho Association of Home Care Agencies (IAHCA)

Recommendations from stakeholders will be used to develop the proposal to CMS. Read a synopsis from the stakeholder meeting panel discussion.

Archived Feedback Comments

The following are comments and recommendations from various parties that were sent in via this website. While the open comment period is over, you are still welcome to share your thoughts via email at: ltcmanagedcare@dhw.idaho.gov.

Category: Provider Qualifications & Syst. Delivery Standards

I am concerned that there has been so many cuts in home & community based Personal Care service this last couple years, that agencies that provide quality service & follow the rules, will not be able to endure the added costs of implementing new processes that will be required when managed care starts. If agencies cannot survive, then the consumers will not have much choice of agencies that can provide the level of care they need. They must pay at a rate that allows agencies to operate while following rules. They should not make new rules or reintrepret old rules that cost money to implement.


Category: Quality Assurance

RE Dual Eligible people with severe and persistent mental illness as per May 25, 2012 presentation. Please add to quality improvement items to track: Disengagement from treatment.

Category: Provider Qualifications & Syst. Delivery Standards

The managed care model needs to comply with the any willing provider statute 41-3927

Category: Participant Assessment & Eligibility

Please consider having a mechanism availbale for the beneficiaries to have weekend/after-hours access to a case manager. Having someone on call may help to ensure proper placement and quicker hospital discharges.

Category: Benefits

Questions, Comments and Concerns with the Managed Care Draft Plan 1. If a patient who meets nursing home level of care chooses a particular care setting, but the plan chooses a lower cost care setting… can the plan withhold payment to the setting the patient chose? Or require discharge? a. We recommend that patients have the right to choose their care setting within reason. This should be a negotiation between the plan and the participant.

Category: Benefits

CFHs are beneficial & cost effective to the state. However, the rate we get paid is miniscule and we are not allowed to have other employment outside the home. If you keep lowering the rate of pay, the clients will be forced to go to nursing homes and the cost will quintuple at best. This is not a money making exercise. Believe me there is no money to be made. It is a way for patients to have more freedom to be with family and friends while receiving one on one care. It allows them to be a part of a family and the community which keeps them healthier. My client is authorized for 25.89 hrs per week of home services and my pay is based on that. Yet I am required to be with her 24 hrs a day 7 days a week. I am not allowed to have another job to supplement and there are absolutely no benefits. Anyone who thinks this is a way to make money off the system is sadly mistaken. Don't let this new system make it any worse than it already is. The disabled people of Idaho are the ones who suffer.