Fact Sheets

CMS AND OHIO PARTNER TO COORDINATE CARE FOR MEDICARE-MEDICAID ENROLLEES

CMS AND OHIO PARTNER TO COORDINATE CARE FOR MEDICARE-MEDICAID ENROLLEES

Overview

On December 12, 2012, the Department of Health and Human Services announced that the State of Ohio will partner with the Centers for Medicare & Medicaid Services (CMS) in the Financial Alignment Demonstration to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience. 

Under the Demonstration, Ohio and CMS will contract with Integrated Care Delivery System (ICDS) plans that will coordinate the delivery of and be accountable for all covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees.

Medicare-Medicaid Enrollees

Improving the care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees – sometimes referred to as “dual eligible individuals” – is a priority for CMS.  Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, cards, and providers (Medicare A/B, Part D, and Medicaid). 

Many Medicare-Medicaid enrollees suffer from multiple or severe chronic conditions and could benefit from better care coordination and management of health and long-term supports and services. 

The Financial Alignment Initiative – Partnerships to Provide Better Care

The new Demonstration seeks to provide Medicare-Medicaid enrollees with a better care experience by testing a person-centered, integrated care program that provides a more easily navigable and seamless path to all covered Medicare and Medicaid services. 

Last July, CMS announced this opportunity for states and CMS to better coordinate care for Medicare-Medicaid enrollees.  Under the Demonstration, CMS will test the effectiveness of two models:

1. Managed Fee-for-Service Model in which a state and CMS enter into an agreement by which the state would be eligible to benefit from savings resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid; and  
2. Capitated Model in which a state and CMS contract with a health plan or other qualified entity that receives a prospective, blended payment to provide enrolled Medicare-Medicaid enrollees with coordinated care.

Ohio is the third state to enter a Memorandum of Understanding (MOU) with CMS to participate in the Demonstration and the second to employ the capitated model.  CMS continues to work with other states to develop their Demonstration models.  All Demonstrations will be evaluated to assess their impact on the beneficiary’s care experience, quality, coordination, and costs.

The Ohio Demonstration

Ohio and CMS will contract with ICDS plans that will oversee and be accountable for the delivery of covered Medicare and Medicaid services for Medicare-Medicaid enrollees in seven regions of the state.  As a result, 115,000 Medicare-Medicaid enrollees in Ohio will have an opportunity for better, more coordinated care.

Under the Demonstration, ICDS plans will be responsible for conducting a comprehensive assessment of Medicare-Medicaid enrollees’ medical, behavioral health, long-term services and supports, and social needs.  Medicare-Medicaid enrollees and their caregivers will work with a care management team to develop person-centered, individualized care plans. The Demonstration also builds on the longststanding role of the Area Agency on Aging (AAA) in Ohio’s existing Medicaid waivers; the AAA’s will continue to play a key role with ICDS plans. 

The new Demonstration includes critical beneficiary protections that will ensure high-quality care is delivered.   CMS and Ohio have established a number of quality measures relating to the beneficiary and caregiver overall experience of care, care coordination, and fostering and supporting community living, among many others.  In addition, the Demonstration expands current Home and Community Based Services (HCBS) waiver services and includes robust continuity of care requirements.  Ohio is also leveraging its current Long-term Care Ombudsman to advocate on behalf of beneficiaries and provide systematic oversight of plans’ support for home- and community-based care.

Putting the Beneficiary First

Under the Demonstration, each Medicare-Medicaid enrollee will have a care manager working with a collaborative, multi-disciplinary care team responsible for their comprehensive care management.  Beneficiaries in the Demonstration and their families will have access to enhanced services to help support the family and caregivers as well as improve the beneficiary care experience. 

Enrollment will occur in phases.  Beneficiaries will be able to opt-in to the new program beginning in September of 2013.  In October, November and December of 2013, based on the region, eligible beneficiaries who have not made a choice will be assigned to an ICDS Plan, with the option to opt-out of the Demonstration or select an alternative ICDS plan.

Comprehensive Evaluation

CMS is funding and managing the evaluation of each state Demonstration.   CMS has contracted with an external independent evaluator, RTI International, to measure, monitor, and evaluate the impact of the Demonstrations, including impacts on Medicare and Medicaid service utilization and expenditures.  The evaluation for Ohio’s Demonstration will measure quality, including beneficiary overall experience of care, care coordination, care transitions, and support of community living in Ohio. There will be a unique, Ohio-specific evaluation plan using a comparison group to analyze the impact of the Demonstration. 

A Transparent Process Supporting Public Input

The Ohio Demonstration is the culmination of an extensive planning and development process through which the public helped shape the Demonstration’s design.  Ohio:

• Partnered with CMS to engage with both local and national partners to ensure a broad range of perspectives were captured in the overall Demonstration.
• Hosted several forums to solicit public involvement including regional meetings, statewide calls, and public hearings.
• Established an advisory group with both internal and external stakeholders to inform Demonstration development and policy.
• Posted its draft proposal for public comment and incorporated the feedback into its Demonstration proposal before officially submitting it to CMS.   The proposal was then posted by CMS for public comment.

Additional Information

The Demonstrations will be administered under the Center for Medicare & Medicaid Innovation authority.  Additional information about the Ohio Demonstration, including the MOU, is publicly available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/OHMOU.pdf

To learn more about the Ohio-CMS partnership, view the Ohio proposal, and to see proposals submitted by other states, visit: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html