dual eligible demonstrations
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Protecting the Rights of Low-Income Older Adults
2www.NSCLC.org
Dual Eligible DemonstrationsFamilies USA Health Action Conference
Fay Gordon, National Senior Citizens Law Center
January 25, 2014
The National Senior Citizens Law Center is a non-profit organization whose principal mission is to protect the rights of low-income older adults. Through advocacy, litigation, and the education and counseling of local advocates, we seek to ensure the health and economic security of those with limited income and resources, and access to the courts for all. For more information, visit our Web site at www.NSCLC.org.
Today
Overview
Recent Guidance and Common Features Across the States
Advocacy Takeaways
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Demonstration map continues to change
The Dual Eligible Demonstration is Live in Several States
State Proposals:26 states
MOUs: 9 states
Three-way contract: Mass., IL, VA
Readiness Review
Enrollment: Notices sent to Mass and
CA
Ongoing monitoring and evaluation
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Passive enrollment began in January
State Latest enrollment timeline
California April, 2014 (passive for all counties, except LA)April-July, 2014 (voluntary for LA county)
Illinois March, 2014 (voluntary)May, 2014 (passive)
Massachusetts Voluntary enrollment went live on October 1Passive enrollment went live on January 1
New York Community LTSS: July, 2014 (voluntary), September, 2014 (passive) Institutional LTSS: October, 2014 (voluntary), Jan. 2015 (passive)
Ohio* March, 2014 (voluntary)May, 2014 (passive)
Virginia February, 2014 (voluntary)May, 2014 (passive)
Washington MFFS went live on July 1July, 2014 (voluntary, capitated)September, 2014 (passive, capitated)
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Recent Guidance
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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
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Three-way contract details the specifics of state demonstration
Basic structure:
• Starting point to understand other state contractsSee: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.htmlf for more information
Medicare Advantage
State: Medicaid
statute and managed care
contractsMCOs
CMS: Medicare Advantage Contract & Guidance Three way
contract
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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.
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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.
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All state demonstrations include upfront savings reductions
VA NY SC WA cap
Year 1 1% 1% 1% 1%
Year 2 2% 1.5% 2% 2%
Year 3 4% 3% 4% 3%
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Care continuity differences
VA NY SC MA OH CA WA capNF residents
May stay thru demo
May stay thru demo
N/A Later of 90D or initial assess*
May stay through demo.
12 months**
180D or care plan
Medicare providers and services
180D or prior auth*
90D or care assess
180D Later of 90D or initial assess*
90D for high risk, 365D for all others
6 months**
Later of 90 D or care plan*
Rx drugs Part D Part D Part D Part D Part D Part D Part D
*Earlier only with enrollee consent. **If certain conditions are met
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Appeals- Most states
Plan appealAPP
IREState
HearingAPP
MAC
ALJ
Fed Ct.
If overlap
External Medical Review
Denial
Available in OH, CA
MedicareServices
MedicaidServices
Court
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Advocacy Takeaways
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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
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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?
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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?
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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.
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Duals Demo: www.dualsdemoadvocacy.org• Enrollment timelines• Informational webinars• Analysis and comparison of state
demonstrations
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