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Introduction to the new Illinois Medicare-Medicaid Alignment Initiative

Introduction to the new Illinois Medicare-Medicaid Alignment Initiative






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  • Medicare-Medicaid Alignment Initiative PlansThank you for joining this brief overview of the Illinois Medicare-Medicaid Alignment Initiative. My name is Bruce Lederman and in this presentation I will review how the health care delivery system for dual eligible beneficiaries in Illinois is being redesigned to become one that is more person-centered with a focus on improved health outcomes while reducing costs growth. With the voluntary enrollment period beginning on January 1, 2014, I believe that you will be hearing more about this demonstration in the coming months. So let’s get started.
  • Medicare is the federal program that provides health insurance to older adults and certain people with disabilities. It is paid for by two Federal trust funds and covers physician visits, medication costs and hospital and post-acute services. It does not provide for long term services and supports (or LTSS as it is called).Medicaid is a joint federal and state program and it provides health care coverage to people with low incomes who also fall into certain categories such as children, pregnant women, older adults or the disabled. It also pays for long term services and supports. Because Medicaid is funded by a combination of federal and state dollars, eligibility requirements and Medicaid benefits vary among the 50 states.
  • There are a number of individuals who are beneficiaries of both programs. They are technically referred to a Dual Eligible Beneficiaries and often the shorthand “Duals” is used. There are a variety of reasons why someone would qualify for both programs, but in general either an individual was qualified for Medicaid and became additionally eligible for Medicare once they reached age 65 or at some point after reaching age 65, the individual became eligible for the Medicaid enrollment due to change in their financial resources.Information from Kaiser Health News 2012 Information
  • The majority of the 9 million Duals are over the age of 65 and are among the sickest individuals covered by either the Medicare or Medicaid programs. These are people with complex health and long term care needs who have their acute medical care expenses paid for by Medicare, while Medicaid covers their premiums and other expenses and for those fully eligible duals who meet asset and income thresholds their long term services and supports needs are also paid for by Medicaid.In it’s annual report to Congress the Medicare Advisory Payment Commission noted that because the Medicare and Medicaid programs have different regulatory and reimbursement schemes, current coverage and payment policies for duals incentivizes cost shifting and hinders efforts to improve quality and coordination of care. In 2010 there were approximately 338,000 Duals in Illinois and Illinois Medicaid expenditures for this population mirrors the national Medicaid data shown on the slide. Source, Urban Institute 2010
  • On the national level Duals comprise 15% of those enrolled Medicaid enrollment, but are responsible for 39% of spending for that program. Similarly this disparity also in the Medicare program where Duals only constitute 16% of Medicare enrollment, but are responsible for 25% of Medicare spending. Half of the Medicare Duals are in fair or poor health, and that is more than twice the rate of other Medicare beneficiaries.As a group, Duals are more likely to have mental health needs, more likely to have less than a high school education and are more than twice as likely to be a member of a minority population. Here is something to consider, Duals are seven times more likely to be a long term care resident than non Dual Medicare beneficiaries.
  • So in response, the legislation creating the ACA included the creation of two new federal offices to explore how to improve access and delivery to care and control growth in spending: the Federal Coordinated Health Care Office (Coordination or Duals Office) and the Center for Medicare and Medicaid Innovation (also known as the Innovation Center). with Medicare and Medicaid expenditures as % of GDP expected to double in the next 25 years,
  • The coordination office seeks to improve the alignment of care between the two programs to improve quality and lower the cost of care to dually eligible beneficiaries by funding state Demonstrations.It is projected that in the next 25 years, Medicare and Medicaid expenditures will double as a percentage of GDP. The hope is that the demonstrations funded by the Coordination office, will produce interventions to impact this trend.
  • While the folks at the Coordination Office are keeping busy aligning the Medicare and Medicaid programs, the Innovation Center is busy developing new payment and service delivery models and is currently funding 28 states to implement strategies for payment reform.
  • One of the Innovation Center’s new payment and service delivery models that fully integrate care for Dual Eligible Beneficiaries is the, cleverly named, financial alignment and integrated demonstration. Six states are approved and this demonstration will last for 3 years and enrollment will eventually grow to two million nationally. CA, IL, OH, VA and MA will test a capitated payment model of reimbursement and WA will test a FFS model.In Illinois there are 1.9 million Medicare beneficiaries (2010) and 338,582 Duals (or 19% of all Medicare beneficiaries).In Illinois there were 2.8 million enrolled in Medicaid (2010) Duals are 25% of the Medicaid Spending
  • Voluntary enrollment in the Illinois initiative is scheduled to begin on January 1 and some consider this an ambitious goal and have suggested that Illinois should follow the recent example of California, which decided to delay enrollment in its own Alignment initiative for four months.The goals of this demonstration mirror those of others around the country: One To unify the administration process so dual will seamlessly be able to enroll and disenroll in both programs with a single appeal process.Two. To improve care coordination between the two programs to avoid unmet needs and underutilization of community based services and Three – integrate financing to facilitate care coordination.
  • There are many questions as to the source of these savings…Illinois currently has one of the highest rates of potentially avoidable hospital admissions nationally and;Illinois has one of the highest proportions of spending on institutional services compared to HCBS.
  • How much money can really be saved?Will managed care organizations be able to fully coordinate the complex needs of this challenging population?Will community-based organizations be able to participate fully in their traditional role as care providers?There are among the many questions that community-based providers of LTSS and elder advocates have for the Illinois Department of Healthcare and Family Services.

Introduction to the new Illinois Medicare-Medicaid Alignment Initiative Introduction to the new Illinois Medicare-Medicaid Alignment Initiative Presentation Transcript

  • Illinois Medicare-Medicaid Alignment Initiative Aligning Financing and Integrating Care for Dual Eligible Beneficiaries
  • Medicare Provides health insurance to older adults and certain people with disabilities Federal program funded by two trust funds Covers acute care services Does not cover long term services and supports (LTSS) Medicaid Provides coverage to people with low-incomes Joint federal and state program funded by both Covers both acute and long term services and supports (LTSS) Medicare and Medicaid Programs Differ in Funding and Scope of Services
  • Medicare $424 billion 46 million enrolled Medicaid $330 billion 60 million enrolled Who are Dual Eligible Beneficiaries? Dual Eligible Beneficiaries 9 million
  • Dual Eligible Beneficiaries Have Complex Health and LTSS Needs 70.10% 9.20% 14.90% 4.70% 1.10% US Medicaid Expenditures on Duals $120.5 Billion Age 65+ 5.9 million Age <65 3.4 million Total Dual Eligibles: 9 million US Medicaid Duals Population
  • Dual Eligible Beneficiaries Disproportionately Impact Medicaid and Medicare Spending US Medicaid Enrollment Children 28.8 million 49.5% Adults 14.6 million 25.2% Other Aged & Disabled 5.8 million 10% Dual Eligibles 9 million 15.3% US Medicaid Spending Non- Duals 61% Duals 39%
  • Affordable Care Act Created Two Offices to Address Care and Cost Issues for Duals US Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) Coordination Office Innovation Center
  • Medicare-MedicaidCoordination Office MEDICAI D MEDICARE MEDICAID Coordination Office Goals: • Align care and financing to support improvements in quality and cost of care for Dual Eligible Beneficiaries • Eliminate duplication of services • Expand access and improve quality of care • Simplify processes and lower costs • Eliminate regulatory conflict and cost shifting!
  • The Center for Medicare and Medicaid Innovation The Innovation Center has demonstration authority to… • Testing new payment and service delivery models that fully integrate care for Dual Eligible Beneficiaries • Evaluate results of demonstrations and advancing best practices • Engaging a broad range of stakeholders to develop additional demonstrations for testing
  • Financial Alignment and Integrated Care Demonstrations Are Beginning • Six states approved (June 2013) • 1 million beneficiaries nationwide • MA focusing on non- elderly disabled • WA targeting high- cost/high-risk beneficiaries • CA, IL, OH and VA focusing on elderly and disabled communities
  • Illinois Medicare-Medicaid Alignment Initiative - Design • 135,825 beneficiaries anticipated to participate • Capitated financial model • Initiative will last three years • Voluntaryenrollment beginning January 2014 (for 6 months)* • Benefits will include nearly all Medicare and Medicaid services • Unified administration process • Improve care coordination • Integrate financing
  • Illinois Medicare- Medicaid Alignment Initiative - Goals • Provide savings – 1% in first year, 3% in second year; and 5% in third year – Managed Care with capitated payment – Increased care coordination – Use of HCBS over institutional care • Improve care – Decreased emergency room visits – Reduced hospitalizations
  • Illinois Medicare-Medicaid Alignment Initiative – Questions CMS Illinois Dept. of Healthcare and Family Services Managed Care Organization • Specifics to be spelled out in three-way contracts between the entities: – How will beneficiaries be notified? – How will plans and providers meet the needs of beneficiaries? – What counseling assistance will be provided and by whom? – What will the sources of program savings be? – What grievance and appeals process will be available?
  • Prepared by: Bruce J. Lederman, JD b: chicagonow.com/aging-in- chicago/ t: @aginginchicago