Acute Long-Term Integrated Care Program Design Issues

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					Acute & Long-Term Integrated
 Care Program Design Issues




Department of Medical Assistance Services   September 7, 2006
      Presentation Outline


Covered Population(s)

Covered Services

Enrollment Options

Health Plan Coverage Options

Implementation Time Frame

Federal Approval Options
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Population(s) That May Be Covered in an
        Integrated Care Program

   Dual eligibles (persons eligible for Medicare/Medicaid services)

   Non-duals (Medicaid only)

   A specific aid category (Aged, Blind, and Disabled)

   Subpopulations
     – Persons with developmental disabilities
     – HIV/AIDS
     – Traumatic brain injury
     – Persons dependent on ventilators

   Levels of care (persons who are institutionalized or who are receiving
    home and community-based waivers)
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        Why It is Important to Discuss
           Covered Populations


   The comprehensiveness of Virginia’s integrated care program
    (ICP) will be determined by how many beneficiaries the program
    intends to cover

   Some populations and their care providers may be more distinct
    and separable than others, so it may be easier for states to start
    with one or more populations and “phase in” others
     – i.e., start with the elderly and phase in persons with
        developmental disabilities



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    Services That May Be Covered in an
         Integrated Care Program

   Acute care services not covered by Medicare

   Services covered by both Medicare and Medicaid
     – Durable medical equipment, home health, skilled nursing
       facility, pharmacy

   Medicaid long-term care (LTC) services
     – Nursing facility
     – Home health
     – Home and community-based services

   Comprehensive care management

   Behavioral health services                                   5
Issues to Consider When Determining
     Range of Covered Services


   Decisions about service coverage will shape the extent to which
    a managed care program can assist with a better and more
    equitable distribution of services, especially LTC services

   Including only Medicaid acute care services not covered by
    Medicare in a Medicare managed care organization (MCO)
    benefit package does not significantly advance integration,
    unless it is a step toward integrating LTC services

   If the goal for Virginia is to move toward a full integration of
    Medicare and Medicaid services as possible, experts
    recommend including all services in a single managed care
    benefit package
                                                                       6
            Enrollment Options for an
            Integrated Care Program

   States enroll participants in integrated care programs in one of
    two ways:

      Voluntary – Medicaid beneficiaries are given the option to
       participate in an integrated care program
        Given the choice to initially enroll
        Automatically enrolled with the choice to leave the
          program if not interested

      Mandatory – Medicaid beneficiaries are required to
       participate in an integrated program


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Issues to Consider When Deciding How to
    Enroll Integrated Care Participants

    Rate setting is more difficult for health plans when enrollment is
     voluntary because health care costs of those who choose to enroll in an
     ICP are very hard to predict
      – Mandatory plans still require estimating variation in enrollment mix
         by plan, if there is more than one participating plan

    Generating MCO interest is much more difficult in a voluntary program
      – Voluntary managed care programs tend to have low and
        unpredictable enrollment, which makes it hard to predict the
        number of participants and set rates

    Provider contracting is easier with mandatory programs because
     providers that do not contract with MCOs run the risk of losing patients
      – Providers can refuse to contract if it is a voluntary program because
         they will still be paid through the fee-for-service option

    Provider and beneficiary opposition may be greater if enrollment is
     mandatory                                                                  8
               Health Plan Coverage

   States can choose to contract with a variety of health plans, including:
     – Medicare Advantage (MA) only plans or MAs that offer Special
        Needs Plans (Snips)
     – Health Plans that cover Medicaid and Medicare services through
        plans that are separate for contracting, rate-setting, and
        administrative purposes
     – Medicaid MCOs for Medicaid LTC services, with no direct link to
        Medicare

   The option Virginia will choose will depend on:
     – the availability and willingness of SNPs and other MCOs to contract
       with the State
     – Provider and advocacy group concerns
     – State administrative and contracting resources
     – Virginia’s specific ICP goals
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             Integrated Care Program
                    Time Frame


   The time frame to develop and implement an ICP is important
     – If implemented too quickly, states can have significant
       technical and political disadvantages
     – If implemented too slowly, states run the risk of losing
       momentum and MCO interest

   A variety of phased-in approaches can be considered
     – Starting in limited geographic areas
     – Starting with a limited population
     – Allowing enrollees to opt-out if dissatisfied
     – Sharing risk with MCOs for a limited period of time
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            Federal Approval Options
             for States to Consider

   States have three options to pursue and receive approval from
    the Centers for Medicare and Medicaid Services to operate an
    integrated care program

    – State plan amendment (SPA), if seeking a voluntary program
       • Virginia could start with a SPA and then switch to a mandatory
          program by pursuing a waiver

    – The Deficit Reduction Act – allows for benefit plan flexibility, but
      program must be voluntary

    – Waiver, if seeking a mandatory program
       • 1115 – Demonstration
       • 1915(b) and 1915(c) combination (easier to obtain according to
         discussions with CMS)
       • More administratively burdensome than SPAs                          11