Dual Eligible Demonstrations

2. Dual Eligible Demonstrations Families USA Health Action Conference Fay Gordon, National Senior Citizens Law Center January 25, 2014

4. Today

5. Demonstration map continues to change

6. The Dual Eligible Demonstration is Live in Several States

7. Passive enrollment began in January

8. Recent Guidance

9. MMCO: Website updated with new guidance • MOUs • Three-way contracts • Marketing Guidance • Enrollment Guidance • Plan reporting requirements • RTI Evaluation Plan • Readiness reviews • Joint rate setting guidance

10. Three-way contract details the specifics of state demonstration Basic structure: • Starting point to understand other state contracts See: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.htmlf for more information CMS: Medicare Advantage Contract & Guidance Medicare Advantage Three way contract State: Medicaid statute and managed care contracts MCOs

11. All states include an initial voluntary enrollment period • All states* include at least 60 day initial voluntary enrollment. • States will send individuals a notice informing them of their right to “opt-in” to demonstration. • Passive enrollment will be phased. *California will only have voluntary enrollment in Los Angeles County.

12. CMS is requiring all states include an independent ombudsman • MOUs include include similar language: • “The ombudsman will support individual advocacy and independent systematic oversight….with a focus on compliance with principles of community integration, independent living, and person-centered care in the home and community-based care context.” • So far, California and Virginia received ombudsman funding.

13. All state demonstrations include upfront savings reductions

14. Care continuity differences *Earlier only with enrollee consent. **If certain conditions are met

15. Appeals- Most states Fed Ct. Court Medicaid Services MAC External Medical Review ALJ Medicare Services If overlap State Hearing APP IRE Plan appeal APP Available in OH, CA Denial

16. Advocacy Takeaways

17. Ombudsman Takeaways • Consider clarifying in MOU and 3-way: • Best entity(s) in your state to maintain ombuds independence • Providing oversight of the demonstration as well as plan • Securing funding from CMS grant • Explicit assistance with all levels of appeal • Client is always the dual eligible; not state or plan

18. Appeals Takeaways • Consider the following issues for MOU: • Aid paid pending • Prohibit recoupment for aid paid pending • Shorten Fair Hearing decision timelines • Test for reasonableness of appeals route: can it be described in an intelligible consumer notice?

19. Questions for early implementation stages • Information—Getting accurate information out to consumers, providers, advocates. Enough lead time? Adequate outreach? • Care continuity—will it be robust? • State organization and capacity for oversight and problem-solving—Staffing levels? Coordination? Systems readiness?

20. Broad takeaways • Some, but limited, standardization is appearing in the MOUs around enrollment, savings, and ombuds. • No straight line progression in consumer protections. State protections vary widely among recent MOUs. Most are the result of vigorous advocacy and state initiatives. • CMS is open to state innovation if carefully thought out.

21. Duals Demo: www.dualsdemoadvocacy.org • Enrollment timelines • Informational webinars • Analysis and comparison of state demonstrations

22. Contact: Fay Gordon, fgordon@nsclc.org