Fact Sheets

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

Overview

On February 22, 2013, the Department of Health and Human Services announced that the State of Illinois will partner with the Centers for Medicare & Medicaid Services (CMS) to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience. 

Under the Medicare-Medicaid Alignment Initiative (Demonstration), Illinois and CMS will contract with health plans to 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. 

In July 2011, 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 financial alignment 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 health plans or other qualified entities that receive a prospective, blended payment to provide enrolled Medicare-Medicaid enrollees with coordinated care.

Illinois is the fourth state to enter a Memorandum of Understanding (MOU) with CMS to participate in the Demonstration and the third 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 Illinois Demonstration

Illinois and CMS will contract with health plans that will oversee and be accountable for the delivery of covered Medicare and Medicaid services for certain Medicare-Medicaid enrollees in two regions of the state.  As a result, over 135,000 Medicare-Medicaid enrollees in Illinois will have an opportunity for better, more coordinated care.

Under the Demonstration, health plans will be responsible for assessing Medicare-Medicaid enrollees’ medical, behavioral health, long-term services and supports, and social needs. Based on the results of the assessment and an analysis of available data, plans will stratify enrollees into three risk groups based on need.  Medicare-Medicaid enrollees and their caregivers will work with an interdisciplinary care management team to develop person-centered, individualized care plans. Each health plan will also be responsible for developing and operating specialized programs to assist with transition of care and to reduce avoidable hospital and nursing facility admissions.  Beneficiaries will also have 24-hour telephonic access to medical professionals.

The new Demonstration includes beneficiary protections that will ensure high-quality care is delivered.   CMS and Illinois 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 includes robust continuity of care requirements in which beneficiaries can continue to see their current providers and can continue their current course of treatment for 180 days.  Illinois is also supporting an independent Ombudsman outside of the state Medicaid agency to advocate and to safeguard due process for Illinois’ Demonstration enrollees.

Putting the Beneficiary First

Under the Demonstration, each Medicare-Medicaid enrollee will have access to a care coordinator qualified to meet his or her needs and who works with a collaborative, interdisciplinary 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 opportunities to direct their own care plan and long-term service and supports. 

Beginning October of 2013, eligible beneficiaries will have an opportunity to select a health plan and opt into the Demonstration.  Beginning January 1, 2014, those enrollees who did not make a selection or who did not opt out of the Demonstration will be assigned to health plan. Beneficiary assignment will be phased in over a six month period, during which no plan will receive more than 5,000 beneficiaries and CMS and the State will closely monitor the enrollment process.  Beneficiaries will always have the option to opt out of the Demonstration or select an alternative health 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 Illinois’s Demonstration will measure quality, including beneficiary overall experience of care, care coordination, care transitions, and support of community living in Illinois. RTI will develop a unique, Illinois-specific evaluation plan using a comparison group to analyze the impact of the Demonstration. 

A Transparent Process Supporting Public Input

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

• 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.
• 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 Illinois Demonstration, including the MOU, will be publicly available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/ILMOU.pdf 

To learn more about the Illinois-CMS partnership, view the Illinois 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