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Coordinating Care for MedicareMedicaid Enrollees
Centers for Medicare & Medicaid Services
Claudia Simonson
December 2013
Who are Medicare-Medicaid
Enrollees?
• Over 9 million Americans are enrolled in both
Medicare and Medicaid (known as “dual
eligibles” or Medicare-Medicaid enrollees).
• More likely to have mental illness, have
limitations in activities of daily living and
multiple chronic conditions.
• Few are served by coordinated care models
and even fewer are in integrated models that
align Medicare and Medicaid.
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Medicare-Medicaid Enrollees Account for
Disproportionate Shares of Spending
Medicare Medicaid Enrollees as a Share of Program
Participants vs. Share of Expenditures, 2007
40
35
30
25
20
Participants
15
Expenditures
10
5
0
Medicare
Medicaid
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Medicare-Medicaid
Coordination Office
Section 2602 of the Affordable Care Act
• Purpose: Improve quality, reduce costs, and improve the
beneficiary experience.
– Ensure dually eligible individuals have full access to the
services to which they are entitled.
– Improve the coordination between the Federal government
and States.
– Develop innovative care coordination and integration
models.
– Eliminate financial misalignments that lead to poor quality
and cost shifting.
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Medicare-Medicaid Coordination Office
Major Areas of Work
The Medicare-Medicaid Coordination Office
(MMCO) is working on a variety of initiatives to
improve quality, coordination and cost of care
for Medicare-Medicaid enrollees in the
following areas:
• Program Alignment
• Data and Analytics
• Models and Demonstrations
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Tools to Support Care Coordination
Data and Analytics
• State Profiles: Examine the demographic characteristics, utilization,
and spending patterns of Medicare-Medicaid enrollees and the
programs that serve them in each State.
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-andMedicaid-Coordination/Medicare-Medicaid-CoordinationOffice/StateProfiles.html
• Analyze the impact of eligibility pathways to better understand the
beneficiary experience.
• Improve State access to Medicare data for care coordination.
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IL State Profile
TABLE 1. MEDICARE, MEDICAID, AND MEDICARE-MEDICAID ENROLLMENT AS PERCENT
OF POPULATION: ILLINOIS COMPARED TO THE UNITED STATES, 2007
Population Type
Population
Percent of State U.S. Percent
Count
Population
State
12,695,866
100%
n/a
Medicare
1,837,878
14%
15%
Medicaid
2,447,527
19%
20%
Medicare-Medicaid enrollees (Full 332,415
3%
3%
and Partial Benefit)
Source: State population, U.S. Census, Intercensal Estimates of the Resident Population for the United States, Regions,
States, and Puerto Rico (September 2011 release); Medicaid, Mathematica Policy Research, Medicaid Analytic Extract
State Anomaly Tables, Table 1; Medicare and Medicare-Medicaid enrollees, CMS 2007 linked analytic file.
Note: The Medicare, Medicaid, and Medicare-Medicaid population counts reflect beneficiaries "ever enrolled" during CY
2007.
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IL State Profile
• There were about 332,000 Medicare-Medicaid
enrollees in Illinois and about 9 million nationally.
• Medicare-Medicaid enrollees represented 3% of the
State’s population, compared to 3% for the United
States.
• They represented 18% of the State's Medicare
population and 14% of its Medicaid population,
compared to 20% and 15% for the United States,
respectively.
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Opportunity for Care Coordination:
Financial Alignment
Background: In July 2011, CMS announced new models to integrate the service
delivery and financing of the Medicare and Medicaid programs through a FederalState demonstration to better serve the population.
Goal: Test models for increasing access to quality, seamless integrated programs
for Medicare-Medicaid enrollees.
Demonstration Models:
– Capitated Model: Three-way contract among State, CMS and health plan
to provide comprehensive, coordinated care in a more cost-effective way.
– Managed FFS Model: Agreement between State and CMS under which
States would be eligible to benefit from savings resulting from initiatives to
reduce costs in both Medicaid and Medicare.
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Financial Alignment Initiative Vision
The Financial Alignment Initiative will promote a more seamless
experience for beneficiaries by:
– Focusing on person-centered models that promote coordination missing
from today’s fragmented system.
– Developing a more easily navigable and simplified system of services for
beneficiaries.
– Ensuring beneficiary access to needed services and incorporating
beneficiary protections into each aspect of the new demonstrations.
– Establishing accountability for outcomes across Medicaid and Medicare.
– Requiring robust network adequacy standards for both Medicaid and
Medicare.
– Evaluating data on access, outcomes and beneficiary experience to
ensure beneficiaries receive higher quality, more cost-effective care.
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Financial Alignment Update
•
Overall: Around 20 are actively pursuing one or both of the models (14
States capitated, 6 States managed FFS).
•
Public Comment Process: Demonstrations are the culmination of an
extensive planning and development process through which the public
continues to help shape the design.
– All public comments can be accessed here:
http://www.financialalignmentproposalcomments.org/default.aspx
•
All proposals are available here:
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-andMedicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialModelstoSupportStatesEffortsinCareCoordination.html
Timeline of Activities
1.
2.
3.
4.
5.
6.
7.
8.
9.
MOU
Plan Selection
Rates
Marketing
Plan Benefit Package
Formulary
Readiness Review
Contract
Implementation
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Integrated Care Resource Center
(ICRC)
Support for All States
Assist States in delivering coordinated care to high-need, high-cost beneficiaries.
•
Provides technical assistance to all States to better serve beneficiaries, improve
quality and reduce costs.
•
Examples of assistance available by the ICRC include:
– Develop resources to support States' efforts to integrate care for MedicareMedicaid enrollees.
– Conduct needs assessment and gap analysis.
– Work with States to develop and expand on health home models that build
and enhance coordination and integration of medical and behavioral health
care to better meet the needs of people with multiple chronic illness.
http://www.integratedcareresourcecenter.com
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State Activity
• MOUs
-- MA
-- OH
-- CA
-- NY
-- SC
-----
WA (MFFS)
IL
VA
MN
• All MOUs are available here:
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoor
dination.html
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State Activity
• Contracts (Cap Model)
-- MA
-- IL
• Final Demo Agreement (MFFS Model)
-- WA
• All Contracts are available here:
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCare
Coordination.html
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Illinois
State Enrollment—
MOU
start dates
Vol
Passive
IL
2/1/14
K
RR
5/1/14 Yes—MOU K posted Final RR
signed
to CMS
reports in
2/22/13. website
draft.
11/22/13.
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Plan
selection
Plans
selected
11/9/12: 6
in Chicago, 2
in Central IL.
More Information
Alignment Initiative: http://www.cms.gov/Medicare-MedicaidCoordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/AlignmentInitiative.html
Report to Congress: http://www.cms.gov/Medicare-MedicaidCoordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/Downloads/MMCO_2011_RTC.pdf
Financial Alignment Initiative:
General Information: http://www.cms.gov/Medicare-MedicaidCoordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordinationOffice/FinancialModelstoSupportStatesEffortsinCareCoordination.html
Integrated Care Resource Center:
http://www.integratedcareresourcecenter.com/
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Thank You!
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