Acronyms, access, and appeals: Taking the long view on Medicare and Medicaid

care coordination

Introduction and Learning Objectives

What is ICS?- Independence Care System

- New York City based non-profit managed long term care plan

- Serving older adults and people with disabilities in four of the five boroughs of NYC

- Mission to help members live at home and remain independent

What is covered in today’s presentation?

– CMS and the states are undertaking financial alignment demonstrations to change health care delivery for dually eligible beneficiaries.

– Clear communication is needed around what these programs are and how they affect people with Medicare and Medicaid.

– Equally critical is communication regarding the way in which the program works once a beneficiary is enrolled.

Learning objectives• In today’s presentation, you will learn and be

able to identify:– Two key goals for the financial alignment

demonstration and how they affect dually eligible beneficiaries.

– Three potential barriers to accessing the appeals system.

– Two key stakeholders in the integrated appeals process.

The Financial Alignment Demonstrations

What are the Financial Alignment Demonstrations?

• The opportunity was created under the Affordable Care Act (ACA).– The ACA created two new offices, the Medicare-

Medicaid Coordination Office (MMCO) and the Center for Medicare Medicaid Innovation (CMMI).• Broad charge for both offices to improve the ways in

which Medicare and Medicaid work together• MMCO announced a financial alignment demonstration

opportunity in 2011.

What are the Financial Alignment Demonstrations (cont’d)?

• The Financial Alignment Demonstrations– States can apply for three-year demonstration

periods.– There are two options for states:• Fully capitated managed health care plans, or• Managed fee-for-service.

What is a fully capitated managed health care plan?

• Fully Capitated Managed Health Care Plans– Health insurance companies that are responsible for

all Medicare, Medicaid, and long term care and prescription medication needs

– These are different from Medicaid Advantage Plus plans or other existing capitated plans.

– CMS expects greater coordination and to create entirely new systems and processes that integrate both Medicare and Medicaid in the fully capitated health plans.

What is a managed fee-for-service model?

• Managed fee-for-service model – Uses the traditional fee-for-service model but

overlays some type of care management infrastructure• Accountable care organizations • Health homes• Patient-centered medical homes

Who is pursuing the Financial Alignment Demonstrations?

• 23 states applied to move forward with demonstrations.– The majority applied to use fully capitated

managed health care plans.– Washington State is moving forward with

managed fee-for-service, and New York may in the outer years of the demonstration.

Why are states looking to move forward with these models?

• Dually eligible beneficiaries are a relatively small number of Medicare and Medicaid beneficiaries but account a large portion of Medicare and Medicaid spending.– In New York, they account for 15% of the Medicaid

population and 45% of Medicaid spending.

• Dually eligible beneficiaries have health care conditions that require greater intervention and have higher needs for well-coordinated care.

Case example—Luz• Hospitalized for cerebral vascular accident and has

aphasias and right hemiparesis• History of diabetes, hypertension, and osteoarthritis• Now, following her hospitalization, she is ready to be

discharged.• Neither Luz nor her husband have a high school

education, and both state they have struggled with speaking English.

Policy, Procedures, and Stakeholders

With new systems come new acronyms

• New York is pursuing a fully capitated managed health care plan model called fully integrated dual advantage or FIDA plans.

• Promisingly, New York has integrated its appeals system for both Medicare and Medicaid—one pathway.

How do you integrate these systems?

• Internal appeal to the FIDA plan• A state administrative law judge (ALJ) hearing

—new office created to handle these appeals• The Medicare Appeals Council (Washington

DC)• Federal Court

How do you integrate these systems?

• Stakeholders in the appeals system– At the table

• Community-based and advocacy organizations• Health care providers• Health plans

– Will be affected but not at the table• Federal judges• State law judges• Primary care doctors• Beneficiaries

Looking down the road: Getting it right while in the planning process• Consequences to unclear communication and

stakeholder disenfranchisement – Beneficiaries cannot access needed services.– Stakeholders do not participate in the implementation.– Delays and backlogs happen in the process.– Important elements of the process are not considered.– The process and the key policy goals fail.

How to avoid the breakdown?

• Identify who is at the table and who needs to be at the table early in the process.– Bring in those groups who are not represented.

• Turn from policy to process.– When policy is completed on paper, begin to drill

down on how it will be implemented.

How to avoid the breakdown (cont’d)?

• The devil you know, versus the devil you don’t– New and improved systems are still—new. – Development of trainings for community-based

and advocacy organizations who can get the word out

– Clear communications and model notices– Simplicity of process• Circle and sign appeals

Questions?

Additional resources• National Senior Citizens Law Center

– www.dualsdemoadvocacy.org

• Community Catalyst– www.communitycatalyst.org

• Medicare Rights Center– www.medicarerights.org

• Medicare-Medicaid Coordination Office– http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-

and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html

Contact Information

Doug Goggin-CallahanDirector of Compliance

(T): 646.653.6142(E): dcallahan@icsny.org