Doug Goggin-Callahan - Acronyms, access, and appeals: Taking the long view on Medicare and Medicaid care coordination


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Presented by Doug Goggin-Callahan, JD, on September 26, 2013 at the fourth annual Center for Health Literacy Conference: Plain Talk in Complex Times.

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Doug Goggin-Callahan - Acronyms, access, and appeals: Taking the long view on Medicare and Medicaid care coordination

  1. 1. Acronyms, access, and appeals: Taking the long view on Medicare and Medicaid care coordination
  2. 2. Introduction and Learning Objectives
  3. 3. What is ICS? - Independence Care System - New York City based non-profit managed long term care plan - Serving older adults and people with disabilities in four of the five boroughs of NYC - Mission to help members live at home and remain independent
  4. 4. What is covered in today’s presentation? – CMS and the states are undertaking financial alignment demonstrations to change health care delivery for dually eligible beneficiaries. – Clear communication is needed around what these programs are and how they affect people with Medicare and Medicaid. – Equally critical is communication regarding the way in which the program works once a beneficiary is enrolled.
  5. 5. Learning objectives • In today’s presentation, you will learn and be able to identify: – Two key goals for the financial alignment demonstration and how they affect dually eligible beneficiaries. – Three potential barriers to accessing the appeals system. – Two key stakeholders in the integrated appeals process.
  6. 6. The Financial Alignment Demonstrations
  7. 7. What are the Financial Alignment Demonstrations? • The opportunity was created under the Affordable Care Act (ACA). – The ACA created two new offices, the Medicare- Medicaid Coordination Office (MMCO) and the Center for Medicare Medicaid Innovation (CMMI). • Broad charge for both offices to improve the ways in which Medicare and Medicaid work together • MMCO announced a financial alignment demonstration opportunity in 2011.
  8. 8. What are the Financial Alignment Demonstrations (cont’d)? • The Financial Alignment Demonstrations – States can apply for three-year demonstration periods. – There are two options for states: • Fully capitated managed health care plans, or • Managed fee-for-service.
  9. 9. What is a fully capitated managed health care plan? • Fully Capitated Managed Health Care Plans – Health insurance companies that are responsible for all Medicare, Medicaid, and long term care and prescription medication needs – These are different from Medicaid Advantage Plus plans or other existing capitated plans. – CMS expects greater coordination and to create entirely new systems and processes that integrate both Medicare and Medicaid in the fully capitated health plans.
  10. 10. What is a managed fee-for-service model? • Managed fee-for-service model – Uses the traditional fee-for-service model but overlays some type of care management infrastructure • Accountable care organizations • Health homes • Patient-centered medical homes
  11. 11. Who is pursuing the Financial Alignment Demonstrations? • 23 states applied to move forward with demonstrations. – The majority applied to use fully capitated managed health care plans. – Washington State is moving forward with managed fee-for-service, and New York may in the outer years of the demonstration.
  12. 12. Why are states looking to move forward with these models? • Dually eligible beneficiaries are a relatively small number of Medicare and Medicaid beneficiaries but account a large portion of Medicare and Medicaid spending. – In New York, they account for 15% of the Medicaid population and 45% of Medicaid spending. • Dually eligible beneficiaries have health care conditions that require greater intervention and have higher needs for well-coordinated care.
  13. 13. Case example—Luz • Hospitalized for cerebral vascular accident and has aphasias and right hemiparesis • History of diabetes, hypertension, and osteoarthritis • Now, following her hospitalization, she is ready to be discharged. • Neither Luz nor her husband have a high school education, and both state they have struggled with speaking English.
  14. 14. Policy, Procedures, and Stakeholders
  15. 15. With new systems come new acronyms • New York is pursuing a fully capitated managed health care plan model called fully integrated dual advantage or FIDA plans. • Promisingly, New York has integrated its appeals system for both Medicare and Medicaid—one pathway.
  16. 16. How do you integrate these systems? • Internal appeal to the FIDA plan • A state administrative law judge (ALJ) hearing —new office created to handle these appeals • The Medicare Appeals Council (Washington DC) • Federal Court
  17. 17. How do you integrate these systems? • Stakeholders in the appeals system – At the table • Community-based and advocacy organizations • Health care providers • Health plans – Will be affected but not at the table • Federal judges • State law judges • Primary care doctors • Beneficiaries
  18. 18. Looking down the road: Getting it right while in the planning process • Consequences to unclear communication and stakeholder disenfranchisement – Beneficiaries cannot access needed services. – Stakeholders do not participate in the implementation. – Delays and backlogs happen in the process. – Important elements of the process are not considered. – The process and the key policy goals fail.
  19. 19. How to avoid the breakdown? • Identify who is at the table and who needs to be at the table early in the process. – Bring in those groups who are not represented. • Turn from policy to process. – When policy is completed on paper, begin to drill down on how it will be implemented.
  20. 20. How to avoid the breakdown (cont’d)? • The devil you know, versus the devil you don’t – New and improved systems are still—new. – Development of trainings for community-based and advocacy organizations who can get the word out – Clear communications and model notices – Simplicity of process • Circle and sign appeals
  21. 21. Questions?
  22. 22. Additional resources • National Senior Citizens Law Center – • Community Catalyst – • Medicare Rights Center – • Medicare-Medicaid Coordination Office – and-Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/FinancialModelstoSupportStatesEffortsinCareCoordination.htm l
  23. 23. Contact Information Doug Goggin-Callahan Director of Compliance (T): 646.653.6142 (E):