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From Health Law Daily, March 28, 2013

California partners with CMS to provide better care for Medicare-Medicaid enrollees

By Susan L. Smith JD, MA

California has entered into a Memorandum of Understanding with CMS to test a new model for providing Medicare-Medicaid enrollees with a better, more coordinated, person-centered care experience, along with access to new services under a CMS Demonstration, according to a CMS Fact Sheet. “Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers.” CMS said. The Demonstration, which will provide a more easily navigable path to all covered Medicare and Medicaid services, is designed to offer opportunities for beneficiaries to self-direct services, be involved in care planning, and live independently in the community.

CMS Demonstration. CMS will evaluate the effectiveness of two models: (1) a managed fee-for-service in which CMS and a state 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) a 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. The Demonstrations will be administered under the Center for Medicare & Medicaid Innovation authority. In addition, CMS has contracted with an external independent evaluator, RTI International, to measure, monitor, and evaluate the impact of the each state Demonstration, including impacts on Medicare and Medicaid service utilization and expenditures. RTI will develop a unique, California-specific evaluation using a comparison group to analyze the impact of the Demonstration.

MMP requirements. California and CMS will contract with Medicare-Medicaid Plans (MMPs) to coordinate the delivery of and be accountable for covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees in the counties of Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. According to CMS, all participating plans must first meet core Medicare and Medicaid requirements, state procurements standards and state insurance rules (as applicable). Every selected MMP also must pass a comprehensive joint CMS-state readiness review. MMPs and Demonstration counties are developing agreements to facilitate integration of In-Home Supportive Services (IHSS) and behavioral health in the Demonstration including requirements for coordination of services and data sharing mechanisms to ensure care delivery is informed by accurate and timely information.

Enrollment and services. An estimated 456,000 Medicare-Medicaid enrollees will have coordinated care available along with access to dental, vision, and nonemergency transportation services. Medicare-Medicaid enrollees will be able to opt-in the program beginning October 2013 and will be able to opt-out of the Demonstration or select another MMP at any time. Enrollment will be phased-in over the next three to 15 months, varying by county. Eligible beneficiaries who have not selected an MMP will be assigned to a plan. MMPs will be responsible for providing a comprehensive assessment of Medicare-Medicaid enrollees’ medical, behavioral health, long-term services and supports, functional, and social needs. Medicare-Medicaid enrollees and their caregivers will work with an interdisciplinary care team to develop person-centered, individualized care plans to ensure the integration of the member’s medical, behavioral health, long term services and supports, and social needs.

Quality measures. CMS and California have established a number of quality measures related to the beneficiary overall experience, including care coordination and fostering and supporting community living. According to CMS, the Demonstration includes continuity of care requirements to ensure that beneficiaries can continue to see current providers during transitions into the Demonstration health plan. In addition, 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.

California developed a website to facilitate public participation in the Demonstration design and planning process and will maintain the website to provide information on the continued development and implementation of the California Demonstration.

MainStory: TopStory QualityNews MedicaidNews PartANews PartBNews PartCNews

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