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Information and Guidance for Plans

This page includes resources on health plan application, readiness review, and implementation activities. For more information, email MMCOcapsmodel@cms.hhs.gov

Recent Posts: 

12/04/2017 The Capitated Financial Alignment Demonstration Chronic Care Improvement Project (CCIP) and Quality Improvement Project (QIP) requirements for Medicare-Medicaid Plans (MMPs), including Contract Year (CY) 2017 requirements for California (CA), Illinois (IL), Massachusetts (MA), Michigan (MI), New York Fully Integrated Duals Advantage for Individuals with Intellectual Disabilities (NYFIDA-IDD), Ohio (OH), Rhode Island (RI), South Carolina (SC), Texas (TX), and Virginia (VA), posted.

11/30/2017 - The Capitated Financial Alignment Demonstration Year 1 Quality Withhold Methodology for NYFIDA-IDD posted. 

11/17/2017 - The CY 2017 & 2018 MMP Spanish Member Handbook (MH) Chapters 4 (revised 11/16/2017) for CA posted.

11/08/2017 -  The CY 2018 MMP Marketing Practices and Beneficiary Disclosure Requirements Memorandum and Comparison Table posted.

11/02/2017 -  The CY 2018 MMP Marketing Guidance (rev. 11/01/2017) for TX posted.

10/31/2017 - The CY 2018 MMP Delegated Notices (DN) Exhibits 4, 22 & 30a (revised 10/25/2017) and CY 2017 DN Exhibit 4 for CA posted.

10/31/2017 - The CY 2018 MMP Core Reporting Requirements and associated Memo, and Core Value Sets Workbook, posted.

10/25/2017 - The CY 2017 & 2018 MMP English & Spanish MH Chapter 4 (revised 10/24/2017) for IL posted.

10/12/2017 - The Capitated Financial Alignment Demonstration Years 2-5 Quality Withhold Methodology for IL posted.

10/11/2017 - The MMP Reporting Requirements, Value Sets Workbook, and associated memo for RI posted.

 

  

General Plan Guidance

 

Plan Selection Criteria and Ongoing Requirements

All guidance materials are provided as a resource. Information in previously released guidance may be superseded by updated versions posted on the website or sent via the Health Plan Management System (HPMS).

Request for Comment (RFC) on the Contract Year (CY) 2019 MMP Application

Annual Renewal Requirements 

Guidance for Part D sponsors regarding CY 2017 Medication Therapy Management (MTM) programs including information to assist sponsors with the submission of their CY 2017 MTM programs, the requirements for establishing MTM programs for 2017, and instructions for submitting change requests.

Guidance for States participating in the capitated financial alignment model that are interested in allowing existing Medicare-Medicaid Plans (MMPs) to serve additional current demonstration counties, or are interested in allowing new organizations to apply to become MMPs in the existing demonstration service area. 

 

Reporting Requirements for Medicare-Medicaid Plans

Medicare-Medicaid Plans (MMPs) participating in the capitated model are required to regularly submit monitoring and performance data to CMS and participating states. The following documents provide guidance, technical specifications, and applicable codes for the core and state-specific measures that MMPs are required to report. Note that the core and state-specific measures supplement existing Medicare Part C and Part D reporting requirements, as well as measures that MMPs report via other vehicles or venues, such as HEDIS®, HOS, CAHPS® and state Medicaid agencies.

California

Illinois

Massachusetts

Michigan

New York - Fully Integrated Duals Advantage (FIDA) Demonstration

New York - FIDA Intellectual and Developmental Disabilities (IDD) Demonstration

Ohio

Rhode Island

South Carolina

Texas

Virginia

 

Network Adequacy Standards for Medicare-Medicaid Plans

Medicare-Medicaid Plans participating in the capitated model are required to demonstrate on an annual basis an adequate contracted provider network sufficient to provide access to covered services in each demonstration.

More information on MMP Medicare standards for annual network adequacy reviews is available:

 

Audit Programs for Medicare-Medicaid Plans

Medicare-Medicaid Plans participating in the capitated model will be required to audit their programs to ensure compliance with three-way contract requirements in Medicare-Medicaid Plan Care Coordination & Quality Improvement Program Effectiveness (MMP-CCQIPE), and Medicare-Medicaid Plan Service Authorization Requests, Appeals and Grievances (SARAG), program areas. 

More information on audit programs:

 

Medicare-Medicaid Plan Quality Withhold Methodology and Technical Notes

Medicare-Medicaid Plans participating in the capitated model will have a portion of their rates withheld; payment of these withheld amounts is subject to performance consistent with established quality requirements. The quality withhold analysis results for each demonstration will be posted to the state-specific pages as they become available.

More information on quality withhold methodology and benchmarks:

 

California

Illinois

Massachusetts

Michigan

New York - Fully Integrated Duals Advantage (FIDA)

New York - FIDA Intellectual and Development Disabilities (FIDA-IDD)

Ohio

South Carolina

Texas

Virginia

 

Medicare-Medicaid Plan Chronic Care Improvement Program and Quality Improvement Project

Medicare-Medicaid Plans (MMPs) that participate in the capitated model demonstrations will conduct all required quality and performance improvement projects outlined in the three-way contract, including Chronic Care Improvement Projects (CCIPs), Performance Improvement Projects (PIPs) and Quality Improvement Projects (QIPs), and submit all required reporting directly to the state. The state will review the submissions for approval. MMPs will conduct at least two (2) improvement projects: one that will meet general Medicare Advantage QIP requirements, and one focused on chronic care to meet Medicare Advantage CCIP requirements. Each MMP will work with the state to identify the improvement project topics to focus on, as well as how many projects must be conducted. More information on the current CCIP and QIP requirements for MMPs in each state is available below.

Information on the CCIP reporting requirements is available below:

Information on the current CCIP and QIP requirements for MMPs in each state is available below:

California

Illinois

Massachusetts

Michigan

New York - Fully Integrated Duals Advantage (FIDA)

New York - FIDA Intellectual and Development Disabilities (FIDA-IDD)

Ohio

Rhode Island

South Carolina

Texas

Virginia

 

Plan Benefit Package

 

Integrated Drug Benefit

 

Medicare-Medicaid Plan (MMP) Enrollment and Disenrollment Guidance

Technical Resources and Guidance 

Memos

Resources

 

Medicare-Medicaid Plan Encounter Data Reporting

Medicare-Medicaid Plans are required to regularly submit Medicare and Medicaid encounters to CMS on a rolling basis every month, within 180 days of the date of service. For more information: 

 

General Marketing Guidance

 

Medicare-Medicaid Plan Integrated Explanation of Benefits (EOB) Models 

Illinois

Michigan

New York Fully Integrated Duals Advantage (FIDA) model 

New York FIDA Intellectual and Developmental Disabilities (IDD) model

Ohio

South Carolina

Texas

 

State-Specific Information      

California

Model Marketing Materials for California Cal MediConnect Plans:

More information on the California Demonstration (Cal MediConnect)

Illinois

Model Marketing Materials for Illinois Medicare-Medicaid Alignment Initiative Plans:

More information on the Illinois Demonstration (Illinois Medicare-Medicaid Alignment Initiative)      

Massachusetts

Model Marketing Materials for Massachusetts One Care Plans:

More information on the Massachusetts Demonstration (One Care)

Michigan

Model Marketing Materials for Michigan Plans:

More information on the Michigan Demonstration

Minnesota

Model Marketing Materials for Minnesota Plans: 

More information on the Minnesota Demonstration

New York FIDA model

Model Marketing Materials for New York FIDA Plans:

More information on the New York FIDA Demonstration 

New York FIDA IDD model

Model Marketing Materials for New York FIDA IDD Plans:

More information on the New York FIDA IDD Demonstration

Ohio

Model Marketing Materials for Ohio Medicare-Medicaid Alignment Initiative Plans:

More information on the Ohio Demonstration

Rhode Island

Model Marketing materials for Rhode Island Medicare-Medicaid Plans:

South Carolina

Model Marketing materials for South Carolina Medicare-Medicaid Plans:

More information on the South Carolina Demonstration (Healthy Connections Prime)

Texas

Model Marketing materials for Texas Medicare-Medicaid Plans:

More information on the Texas Demonstration (Texas Dual Eligible Integrated Care Project)

Virginia

Model Marketing materials for Virginia Medicare-Medicaid Plans:

  • Member ID Card (2017)
  • Member Handbook (2017)
  • Provider and Pharmacy Directory (2017)
  • Summary of Benefits (2017)
  • List of Covered Drugs (2017)
  • Delegated Notices - Exhibit 5a & 29
  • Integrated Denial Notice (2017)
  • Annual Notice of Change (2017)

More information on the Virginia Demonstration (Commonwealth Coordinated Care)