CMS and Washington Partner to Coordinate Care for Medicare-Medicaid Enrollees
Overview
On November 25, 2013, the Centers for Medicare & Medicaid Services (CMS) announced that the State of Washington will partner with CMS to test a model for providing Medicare-Medicaid enrollees with more coordinated, person-centered care. Under the demonstration, CMS and the State of Washington will contract with health plans to offer an integrated set of benefits to 27,000 beneficiaries in King and Snohomish counties. This demonstration follows the capitated model of the Financial Alignment Initiative and complements a managed fee-for-service demonstration in the state that is already operational.
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 eligibles” – is a priority for CMS. Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers (Medicare Parts A and 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
Through the demonstrations approved under the Financial Alignment Initiative, CMS seeks to provide Medicare-Medicaid enrollees with a better care experience by offering a person-centered, integrated care experience that provides a more easily navigable and seamless path to all covered Medicare and Medicaid services.
In July 2011, CMS announced the opportunity for states to partner with CMS through one of two models:
- 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;
- 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.
Washington’s demonstration is the tenth to be approved by CMS. In July 2013, Washington began the nation’s first Medicare-Medicaid demonstration using the managed fee-for-service 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.
Washington’s Capitated Demonstrations
Under this capitated demonstration, an estimated 27,000 Medicare-Medicaid enrollees in Washington’s King and Snohomish Counties will be eligible to enroll. Washington and CMS will contract with health plans known as Medicare-Medicaid Integration Plans (MMIPs) that will oversee the delivery of covered Medicare and Medicaid services for Medicare-Medicaid enrollees.
All participating plans must first meet core Medicare and Medicaid requirements, state procurements standards and state insurance rules (as applicable). Every selected Medicare-Medicaid Plan must also pass a comprehensive joint CMS-state readiness review.
Enrollment will be phased in over several months. Eligible beneficiaries will begin opting into the demonstration no earlier than July 1, 2014. Beginning no earlier than two months later (i.e. no earlier than September 1, 2014), eligible beneficiaries who have not mad a choice to opt in or out will be assigned to a participating plan. Eligible individuals may opt out or disenroll from the Demonstration at any time.
Care Model
Under Washington’s capitated demonstration, MMIPs will use care managers and intensive care coordinators, with the latter focused on providing in-person care coordination services to those individuals with the most significant needs and for whom improved care coordination is likely to have the most benefit.
Use of Data
Washington will be using integrated Medicaid and Medicare data in its web-based predictive modeling and clinical decision support tool (PRISM) system to target interventions to individuals in most need of comprehensive care coordination.
Putting the Beneficiary First
Care Coordination
Under the demonstration, care coordination services will be available to all enrollees. MMIPs will offer an interdisciplinary care team to ensure the integration of the member’s medical, behavioral health, long-term services and supports, and social needs. The team will be person-centered and built on the enrollee’s specific preferences and needs.
Quality Measures
The new demonstration includes beneficiary protections to ensure that enrollees receive high-quality care. CMS and Washington have established quality measures relating to the beneficiary overall experience, care coordination, and fostering and supporting community living, among many others.
Other Protections
The demonstration also includes continuity of care requirements to ensure that beneficiaries can continue to see their current providers during transitions into the MMIPs. Ombudsman services will support individual advocacy and independent systematic oversight for the demonstration, with a focus on compliance with principles of community integration, independent living, and person-centered care.
Comprehensive Evaluation
CMS is funding and managing an external evaluation of each state. The evaluation for Washington’s demonstration will measure quality, including overall beneficiary experience of care, care coordination, care transitions, and support of community living. CMS will develop a unique, Washington-specific evaluation using a comparison group to analyze the impact of the demonstration.
A Transparent Process Supporting Public Input
The Washington demonstration is the product of an ongoing planning and development process through which the public helped shape the demonstration’s design. Washington:
- Worked with a diverse group of stakeholders including providers, health plans, nursing facilities, hospitals, state agencies, advocacy groups, associations, and individuals.
- Established an advisory team with external stakeholders to inform demonstration development and policy.
- Conducted beneficiary and provider focus groups, stakeholder engagement forums, and multiple information sessions across the state.
- Created and maintained a website to facilitate public participation in the demonstration design and planning process: http://www.altsa.dshs.wa.gov/duals/.
- 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.
Interaction with MFFS Demonstration
The capitated demonstration is intended to complement the approved MFFS initiative as part of a multi-faceted approach to improve the coordination of care for Medicare-Medicaid enrollees in Washington. The service areas of the demonstrations do not overlap, meaning beneficiaries can be a part of one, but not both, demonstrations.
Additional Information
The demonstration will be administered under the Center for Medicare and Medicaid Innovation authority.
Additional information about the Washington capitated demonstration, including the MOU, is publicly available at:
Additional information about the Washington managed fee-for-service demonstration is available at:
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2012-Fact-Sheets-Items/2012-10-25.html
###