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Updates
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. Additional guidance to Health Plans regarding Medicaid benefits that must be included is available 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. 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.
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. 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 McDougall, Associate State Director - American Assoc. of Retired Persons (AARP)
- Robert VandeMerwe, Executive Director - Idaho Health Care Association (IHCA)
- Dana Gover, Consultant - Access Concepts and Training, and dual eligible participant
- Scott Burpee, CEO and President - Safe Haven Health Care
- Raul Enriquez, Program Specialist - Idaho Commission on Aging
- Jason McKinley, President - 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.
Integrating Care for Dual Eligibles
 The 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.
To more effectively integrate the Medicare and Medicaid programs, CMS is partnering with states, health care providers, caregivers and beneficiaries to improve quality, reduce costs and improve the dual eligible beneficiary experience. This coordinated effort seeks to transcend boundaries and facilitate a national conversation with stakeholders from around the country to identify opportunities for alignments and improve the two programs. With this initiative from CMS and the directive from House Bill 260, Idaho Medicaid is designing a program to better coordinate care for dual eligible individuals.
To meet CMS requirements, Idaho must develop a detailed model describing how we will structure and implement an integrated program consistent with the following:
- Provide dual eligible individuals full access to the benefits to which such individuals are entitled under the Medicare and Medicaid programs
- Simplify the processes for dual eligible individuals to access the items and services they are entitled to under the Medicare and Medicaid programs
- Improve the quality of health care and long-term services for dual eligible individuals
- Increase dual eligible individuals' understanding of and satisfaction with coverage under the Medicare and Medicaid programs
- Eliminate regulatory conflicts between rules under the Medicare and Medicaid programs
- Improve care continuity and ensure safe and effective care transitions for dual eligible individuals
- Eliminate cost-shifting between the Medicare and Medicaid program and among related health care providers
- Improve the quality of performance of providers of services and supplies under the Medicare and Medicaid programs
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.
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