Jul 27, 2020
BPC has worked for a number of years
to improve integration of services for those who are eligible for Medicare and
Medicaid. In continuing that work over the past year, BPC conducted research,
hosted roundtable discussions, and interviewed key stakeholders to better
understand the barriers to integration of these programs and the challenges
faced by those who must navigate them. BPC also commissioned a study (see
Appendix I) to better understand the challenges and successes of federal and
state demonstrations to align these programs.
The primary goals in recommending alignment are to improve
beneficiary experience, outcomes, and well-being. Given the lack of
coordination in the current system, BPC believes there is also potential for
savings over the long term, primarily in the form of reduced hospitalizations,
hospital readmissions, emergency department visits, and post-acute care.
However, before those savings can be achieved, there will need to be up-front
investments to provide resources to states and to the office within CMS that
administers the program, to develop infrastructure where it is currently
lacking. Finally, this proposal would guarantee a simplified and seamless
integrated care option by a certain date.
Efforts to better integrate care should recognize the
heterogeneity of the dual eligible population, and the importance of a
transition to integrated care for distinct populations. Dual eligible
individuals should have comprehensive information about the benefits and
drawbacks of enrolling in a fully integrated care model. There should be ample
time for community-based education to help beneficiaries understand their
enrollment options and the benefits available to them before they are enrolled
in integrated care programs. Also, while these models should deliver a less
complex and costly care experience, beneficiaries should be given the
opportunity to opt-out of them at any time.
BPC’s recommendations are designed to create strong
incentives to states to integrate care. The report identifies three care models
from which states can choose to achieve full integration:
1.
improved Fully Integrated Dual
Eligible Special Needs Plans (FIDE SNPs) that reflect lessons learned from the
Financial Alignment Initiative (FAI) demonstration’s Medicare-Medicaid Plans
(MMPs)
2.
the Programs of All-Inclusive Care
for the Elderly (PACE)
3.
a flexible model negotiated between
the secretary of the U.S. Department of Health and Human Services (HHS) and a
state, building off the managed fee-for-service model used by the State of
Washington
Each model must cover all Medicare and Medicaid benefits and
meet all integration requirements identified in this report. These recommendations
are intended to build on best practices of the past 40 years in integrating
care for full-benefit dual eligible individuals.
These recommendations provide significant incentives to
states in the form of planning grants, technical assistance, and guaranteed
shared savings, if integration of services reduces costs over time. They also
include provisions to help dual eligible individuals better understand the
benefits and trade-offs of receiving care through a fully integrated plan, by
providing federal resources for consumer education, and by recommending closer
coordination between the Centers for Medicare & Medicaid Services (CMS) and
the Administration for Community Living (ACL).
To guarantee an integration option for all populations of
dual eligible individuals in every state by a date certain, these
recommendations include the framework for a federal fallback program to operate
in states that choose not to integrate care. Under this approach, the secretary
of HHS would contract with improved FIDE SNPs, which would be based on best
practices from the FAI demonstration’s Medicare-Medicaid plans. PACE would also
continue to be available as an option.
Over the last decade, stakeholders—including state and
federal policymakers, consumer advocates, health plans, and providers—have
worked to improve the complex challenges associated with improving care for
those who rely on Medicare and Medicaid to address their health and long-term
care needs. BPC is one of a small but growing group of organizations and agencies
seeking to accelerate integration of care for dual eligible individuals. BPC
does not hold a monopoly on good ideas and recognizes there are many paths
forward. BPC welcomes the opportunity to work with policymakers and other
organizations to identify viable solutions to improve care and lower costs for
a vulnerable and high-cost population.
I.
Framework for the Integration of Medicare and Medicaid Services for Dual
Eligible Individuals
To ensure that all full-benefit dual eligible individuals
have access to fully integrated care models by a date certain, Congress should:
A. Define “full integration” for programs serving dual
eligible individuals.
1.
Fully aligned financing, with a
single entity responsible for Medicare and Medicaid funding in all
counties/regions of a state
2.
A single set of benefits, including
medical benefits, behavioral health, and long-term services and supports
3.
A single point of access, which
requires a single plan or sponsor offering the full range of benefits with one
enrollment period, one set of member materials, one enrollment and
identification process, one point of access for all benefits, one point of
contact for benefit decisions, and a single grievance and appeals process
4.
A process that makes sure
beneficiaries are informed of and understand their options and rights within an
integrated program, and provides sufficient time to make decisions regarding
enrollment, with strong safeguards to protect beneficiaries
5.
Health plan access to claims and
encounter data for new enrollees to identify high-risk enrollees and provide
prompt assessments, including a standard functional assessment tool, a single
primary care provider, and an interdisciplinary care team to develop an
individualized person-centered care plan that is designed to meet the unique
needs of high-risk enrollees; the care plan should include primary, specialty,
acute and post-acute care, and pharmacy services. The care plan should be
updated as needed to address beneficiaries needs as they change over time and
across care settings
6.
Provider access to integrated
information systems and care transitions, to be able to identify high-risk
enrollees, to assure timely individual assessments, and to provide smooth care
transitions without disruptions in services
7.
A single and streamlined set of
measures across the two programs, including a set of quality measures and
performance evaluations developed for complex populations, to be used for
quality improvement and to serve as a basis for quality reporting to help
beneficiary decision-making
B. Require states to provide access to fully integrated
Medicare and Medicaid services for all dual eligible individuals. Provide
resources and technical assistance to states to implement full integration of
services. A federal fallback would go into effect in states that do not
integrate services.
C. Provide the Medicare-Medicaid Coordination Office with
direct funding and full regulatory authority for all programs serving dual
eligible individuals—including integrated care models implemented by states and
the federal fallback program. This would require increased staffing and
resources.
D. Provide general waiver authority to the secretary of HHS
to align administrative differences between the Medicare and Medicaid programs,
excluding issues related to eligibility, benefits, access to care, Medicare
freedom-of-choice protections, or beneficiary due process rights.
E. Direct the secretary of HHS to adopt best practices from the Financial Alignment Initiative demonstration and apply them to Fully Integrated Dual Eligible Special Needs Plans. The secretary should convene a working group to identify best practices where they have yet to be identified. The group should be composed of state agency officials, representatives of consumer organizations, private health insurance plans, consumer advocacy and other experts to develop uniform standards in the following areas:
E. Direct the secretary of HHS to adopt best practices from the Financial Alignment Initiative demonstration and apply them to Fully Integrated Dual Eligible Special Needs Plans. The secretary should convene a working group to identify best practices where they have yet to be identified. The group should be composed of state agency officials, representatives of consumer organizations, private health insurance plans, consumer advocacy and other experts to develop uniform standards in the following areas:
·
Care management standards for
integrated clinical health services, behavioral health, and LTSS
·
Network adequacy standards
appropriate for dual eligible individuals
·
Standard materials for marketing,
plan notices, and other member materials
·
A single open enrollment period
process
·
A process for joint oversight of
plans by CMS and states
II.
Enrollment and Eligibility
To ensure all full-benefit dual eligible individuals are
able to enroll in fully integrated plans, Congress should:
A. Limit enrollment in fully integrated models to
full-benefit dual eligible individuals.
B. Allow auto-enrollment into state-implemented, fully
integrated care models with a beneficiary opt-out available at any time.
Auto-enrollment with beneficiary opt-out should be the default in the federal
fallback program.
C. Permit and encourage states to implement 12-month,
continuous Medicaid eligibility for dual eligible individuals.
III.
State-Administered Integration of Care
To encourage states to integrate Medicare and Medicaid for
dual eligible individuals, Congress should:
A. Define and develop fully integrated models for states
that choose to integrate care. States would choose from three models
meeting the definition of “full integration”” defined above: (1) improved FIDE
SNP, (2) PACE, and (3) a flexible model negotiated between the secretary and a
state, building off the model used by the State of Washington.
B. Provide financial and technical assistance to states that
fully integrate care. For those states that notify the secretary of the
intent to integrate care as outlined above, the secretary should make available
to states adequate resources to develop, implement, and sustain a process for
integration of services. States should also receive technical assistance at a
level similar to assistance made available as part of demonstrations, building
on and expanding the existing Integrated Care Resource Center to help advise
individual states.
C. Provide the secretary of HHS with authority to develop a
guaranteed shared savings program for integrated care.
IV.
Federal Fallback Program for States that Do Not Integrate Care
A federal fallback program is critical to a well-functioning
program of Medicare and Medicaid integration. The following section provides a
general framework for the fallback, if states are not able or willing to
implement an integrated solution. BPC plans to fully explore the critical
details of the federal fallback— including eligibility, benefits, consumer
protections, reimbursement, contracts and procurement, and numerous other
details—as a next step to improve care for dual eligible individuals.
To ensure all dual eligible individuals have access to fully
integrated care models, Congress should:
A. Create a federal fallback to be implemented in states
that decide not to implement an integrated program. The federal fallback
program could include one or more of the integration models developed for state
implementation. PACE organizations would be considered an integrated option;
however, the existing state and federal oversight structure would continue.
1.
Eligibility – Options could
include SSI eligibility, state-specific eligibility levels as of the date of
enactment or some hybrid.
2.
Services – All Medicare and
Medicaid-covered benefits offered by an improved FIDE SNP should be offered as
a single benefit package that includes medical services, behavioral health
services, and long-term services and supports (LTSS). LTSS benefits would be
available to eligible individuals meeting the Health Insurance Portability and
Accountability Act of 1996 standard of a deficit of two or more activities of
daily living (ADLs) or a need for supervision as a result of cognitive
impairment.
3.
Delivery System – The primary
delivery system for the federal fallback should be through a risk-based model,
similar to the FIDE SNP. PACE would also qualify as an integrated care model.
4.
Financing – Financing for the
federal fallback would be existing state and federal spending for dual eligible
individuals. This would be similar to the recoupment, or “clawback,” of funding
authorized under Medicare Part D.
B. Provide authority for the secretary to require Medicare
Advantage carriers to offer one fully integrated plan in each service area in
which they offer coverage. States could also request that the secretary
exercise this authority as part of state-based integration efforts. This
requirement is necessary to ensure an integrated coverage option is available
in service areas that otherwise might not have a plan offering.
V.
Improving Beneficiary Experience
To ensure beneficiaries have a seamless experience in
integrated care models,
Congress should:
Congress should:
A. Direct the secretary of HHS to require collaboration
between CMS, the Administration for Community Living, and states to implement
model standards for outreach and education, and increase funding to the State
Health Insurance Assistance Program to expand and improve information and
counseling available for dual eligible individuals.
B. Provide resources and technical assistance to states for
consumer, provider, and plan engagement and education, and encourage states to
prioritize partnerships with community-based organizations and local
governments.
C. Direct the secretary to improve and expand training for
insurance brokers to include a training module on fully integrated plans.
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