2015 National Training Program

Dual Eligible Options: SNPs, PACE, & MMP

Session Objectives

This session should help you to Define Dual Eligible Review Cost of dual eligible population Recognize types of health plans available to dual

eligible beneficiaries Explain eligibility requirements and enrollment Identify which states in our regions offer MMP’s Review Financial Alignment Initiatives

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Lesson 1-Dual Eligible

Define Dual Eligible Review costs of dual eligible beneficiaries

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Dual Eligible

Dual eligible beneficiaries include individuals who receive full Medicaid benefits as well as those who only receive assistance with Medicare premiums or cost sharing.

They must meet certain income and resource requirements and be entitled to Medicare Part A and/or Part B

Dual Eligible 407/01/2015

Must be Entitled to One of the Following:

Full Medicaid Medicare Savings Programs• Four Programs

Qualified Medicare Beneficiary (QMB) Program; Specified Low-Income Medicare Beneficiary

(SLMB) Program; Qualifying Individual (QI) Program; and Qualified Disabled Working Individual (QDWI)

Program.

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Medicare Savings Programs

Enrollment into a MSP results in automatic eligibility for the Part D Low-income subsidy (Extra Help)

SLMB, QI and QDWI • They pay Medicare premiums• The do NOT pay Medicare Cost Sharing

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Medicare Savings Program Income Limits

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Cost of Dual Eligible

Dual-eligible beneficiaries account for a disproportionate share of Medicare FFS expenditures.

As 19 percent of the Medicare FFS population, they represented 34 percent of aggregate Medicare FFS spending in 2010.

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Cost continued…

On average, Medicare FFS per capita spending is more than twice as high for dual-eligible beneficiaries compared to non-dual-eligible beneficiaries

In 2010, $19,418 was spent per dual-eligible beneficiary, and $8,789 was spent per non-dual-eligible beneficiary.

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Cost continued…

In 2010, average total spending which includes Medicare, Medicaid, supplemental insurance, and out-of-pocket spending across all payers for dual-eligible beneficiaries was about $31,600 per beneficiary, more than twice the amount for other Medicare beneficiaries.

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Lesson 2—Medicare Health Plans for Duals

Special Needs Plans Programs of All-inclusive Care for the Elderly

(PACE) MMPs

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Coverage Options

Dual eligible beneficiaries may choose coverage under FFS Medicare or a Medicare Advantage (MA or MAPD) Plan.

Medicare-covered services are paid first by Medicare because Medicaid is always the payer of last resort.

Medicaid may cover the cost of prescription drugs and other care that Medicare does not cover.

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Medicare Special Needs Plans (SNPs)

Can you get your health care from any doctor or hospital?

You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out of area dialysis). ‑ ‑

Are prescription drugs covered?

Yes. All SNPs must provide Medicare prescription drug coverage (Part D).

Do you need to choose a primary care doctor?

Generally, yes.

Do you need a referral to see a specialist?

In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.

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Medicare Special Needs Plans (SNPs) Continued

What else do you need to know about this type of plan?

A plan must limit plan membership to people in one of the following groups: 1. Those living in certain institutions (like a nursing

home), or who require nursing care at home2. Those eligible for both Medicare and Medicaid3. Those with specific chronic or disabling conditions

Plan may further limit membership Plan should coordinate your needed services and

providers Plan should make sure providers that you use accept

Medicaid if you have Medicare and Medicaid Plan should make sure that plan’s providers serve people

where you live, if you live in an institution

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Plan Finder

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Plan Finder: Refine Your Search

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Medicare Program of All-inclusive Care for the Elderly (PACE) Plans

Combines services for frail, elderly people• Medical, social, and long-term care services• Include prescription drug coverage

Alternative to nursing home care Only in states that offer it under Medicaid Qualifications vary from state to state• Contact state Medical Assistance (Medicaid) office

for information Can be private pay or Medicare Only07/01/2015 Dual Eligible 17

PACE Plans By Region V and VII

Region V (12 total)• 1 – Indiana• 9 – Michigan (1 New plan effective August 1st)• 1 – Ohio• 1 - Wisconsin

Region VII (6 total)• 1 – Nebraska• 2 – Iowa• 1 – Missouri• 2 - Kansas

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Medicare-Medicaid

Medicare-Medicaid enrollees must navigate two separate programs: 1. Medicare for the coverage of basic acute

health care services and drugs2. Medicaid for the coverage of long-term care

supports and services, certain behavioral health services, and to help with Medicare premiums and cost-sharing.

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Medicare-Medicaid Enrollee Delivery System Transformation

FUTURE STATE

Person-Centered

Coordinated Care

Outcomes-Driven

Simplified Processes

CURRENT STATE

Provider and Payor-Centered

Fragmented Care Volume-Driven

Complicated Benefit Overlap

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Medicare-Medicaid Plans

A longstanding barrier to coordinating care for Medicare-Medicaid enrollees has been the financial misalignment between Medicare and Medicaid.

To begin to address this issue, the Centers for Medicare & Medicaid Services (CMS) will test models with States to better align the financing of these two programs and integrate primary, acute, behavioral health and long-term services and supports for their Medicare-Medicaid enrollees.

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Model Types

Capitated Model: A State, CMS, and a health plan enter into a three-way contract, and the plan receives a prospective blended payment to provide comprehensive, coordinated care.

Managed Fee-for-Service (FFS) Model: A State and CMS enter into an agreement by which the state would be eligible to benefit from a portion of savings from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid.

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Medicare-Medicaid Plans

RO V• Has 3 Medicare-Medicaid Plans

Illinois: MMAI o Coordinated care to >135,000 enrollment began

2014 Ohio: ICDS

o Coordinated Care >180,000 enrollment began 2014 Michigan (NEW)

o Enrollment began 2015 RO VII• No MMPs

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Lesson 3: Medicare-Medicaid

Explain Medicare-Medicaid Coordination Office

Review Updates on the Financial Alignment Initiative

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MEDICARE-MEDICAID COORDINATION OFFICE.

Created by the Affordable Care Act, the Medicare-Medicaid Coordination Office works to improve coordination between the federal government and states for Medicare- Medicaid enrollees in order to ensure full access to covered services and high quality care in both programs.

The Office is moving forward on improving access, coordination, and cost of care with a focus in three major areas: program alignment, data and analytics, and models and demonstrations.

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Medicare-Medicaid Coordination Office

Launched the Alignment Initiative, with the goal of eliminating unnecessary and inefficient conflicts in the regulatory, statutory, and policy requirements of the two programs, where feasible.

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Medicare-Medicaid Alignment Initiative

Alignment efforts in process. Since its development, the Alignment Initiative has served as CMS’ guide for streamlining Medicare and Medicaid program rules, requirements, and policies.

This Initiative includes support and involvement from a variety of components across CMS, primarily the Center for Medicare and the Center for Medicaid and CHIP Services.

Over the past few years, CMS has begun addressing the twenty-nine alignment opportunities listed in the Federal Register. For some, solutions have been identified that can be effectuated through rulemaking or policy changes.

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Prohibited Billing

Under Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997: Medicare and Medicaid payments you receive for

furnishing services to a QMB are considered payments in full.

You may not balance bill QMBs for any Medicare cost sharing (including deductibles, coinsurance, and copayments) for these services.

You are subject to sanctions if you bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing).

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Medicare Advantage and Other Medicare PlansResource Guide

Resources Resources Medicare ProductsCenters for Medicare & Medicaid Services (CMS)1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048Medicare.gov

CMS.gov

Social Security1 800 772 1213. TTY users should ‑ ‑ ‑call 1 800 325 0778‑ ‑ ‑socialsecurity.gov

Railroad Retirement Board1-877-772-5772. TTY users should call 1-312-751-4701RRB.gov

State Health Insurance Assistance Programs For telephone numbers call CMS1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048

2015 Medicare Marketing GuidelinesCMS.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c03.pdf

Medicare Managed Care ManualCMS.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html

Affordable Care Act HealthCare.gov/law/full/index.htm

MLN Dual Eligiblehttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf

2015 Medicare Savings Program Income Limits Job Aidhttps://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/Downloads/2015-Medicare-Savings-Program-Job-Aid.pdf

“Medicare & You Handbook”CMS Product No. 10050“Have You Done Your Yearly Medicare Plan Review?” CMS Product No. 11220“Medicare Supplement Insurance, Getting Started”CMS Product No. 11575“Your Guide to Medicare Private Fee-for-Service Plans” CMS Product No. 10144“Understanding Medicare Enrollment Periods” CMS Product No. 11219“Your Guide to Medicare Savings Account Plans”CMS Product No. 11206“Your Guide to Special Needs Plans”CMS Product No. 11302To access these productsView and order single copies at Medicare.gov/publicationsOrder multiple copies (partners only)at productordering.cms.hhs.gov. You must register your organization

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CMS National Training Program

To view all available NTP training materials, or to subscribe to our email list, visit

CMS.gov/Outreach-and-Education/Training/ CMSNationalTrainingProgram/index.html

For questions about training products email training@cms.hhs.gov