Doug Goggin-Callahan - A bridge to integrated care for Medicare and Medicaid beneficiaries


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Presented by Doug Goggin-Callahan, JD, on September 7, 2012 at the third annual Center for Health Literacy Conference: Plain Talk in Complex Times.

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Doug Goggin-Callahan - A bridge to integrated care for Medicare and Medicaid beneficiaries

  1. 1. A Bridge to Integrated Carefor Medicare and Medicaid beneficiariesPlain Talk Conference September 2012 © 2012 Medicare Rights Center
  2. 2. Presentation Outline What does it mean to be ‘dually eligible’ State and Federal efforts to improve program and care coordination of Medicare and Medicaid  The creation of the Federal Medicare and Medicaid Coordination Office (MMCO)  New York Medicaid Redesign Team (MRT) efforts  The privatization of New York’s Medicaid program Areas of promise and concern © 2012 Medicare Rights Center
  3. 3. What does it mean to be duallyeligible? Eligible for both Medicare and Medicaid  ‘Full dual’—eligible for Medicare and for full Medicaid health benefits  In New York this means a person has:  Income: at or below 85% FPL  Assets: at or below $4,350  The beneficiary must see providers who accept both Medicare and Medicaid  ‘Partial dual’—eligible for Medicare and a Medicare Savings Program (MSP) such as QMB, SLMB, or QI  In New York this means a person has:  Income: at or below 135% FPL  Assets: no asset test © 2012 Medicare Rights Center
  4. 4. Why are states focused on dualeligible beneficiaries? Full dual eligible beneficiaries are:  15% of the Medicare population  27% of Medicare expenditures  15% of New York’s Medicaid population  45% of New York’s Medicaid expenditures Previous efforts to improve care coordination have failed or are not popular with beneficiaries  E.g. Special Needs Plans (SNPs), New York’s MedicaidMedicare Rights Center Plans © 2012 Advantage
  5. 5. Why are states focused on dualeligible beneficiaries? Beneficiaries must navigate the different Medicare and Medicaid:  Coverage rules;  Benefits;  Appeals processes; and  Standards of medically necessity Beneficiary communication and plan enforcement is bifurcated between the State and Federal government © 2012 Medicare Rights Center
  6. 6. State and Federal efforts Federal health care reform  The creation of the Medicare and Medicaid Coordination Office (MMCO)  The creation of the Center for Medicare and Medicaid Innovation (CMMI)  Dollars to fund demonstration projects specifically aimed at caring for dually eligible beneficiaries  25 States with plans into CMS to change the ways in which care is provided to Medicare and Medicaid beneficiaries New York’s health care reform  Creation of the Medicaid Redesign Team (MRT)  A movement to managed care for all Medicaid beneficiaries © 2012 Medicare Rights Center
  7. 7. New York’s demonstrationproject proposalTwo tracks  Fully Integrated Dual Advantage (FIDA) Insurance Plans  Managed fee for service (MFFS) health homePhased implementation  FIDA: January 2014  MFFS: January 2013The demonstration effects nearly 260,000 New YorkersGeographic area  FIDA: 8 downstate counties  MFFS: Statewide © 2012 Medicare Rights Center
  8. 8. Promising elementsAims to improve care coordination and lower state and Federal expensesOmbudsmans office and consumer advisory panels (CAPs) for beneficiaries in the FIDA plansDual eligible beneficiaries can disenroll from a FIDA plan at least once per six month periodAllows for other programs and demonstrations to coexistMFFS builds on the existing health home program © 2012 Medicare Rights Center
  9. 9. Areas of concernSome of these concerns will be directly addressed in yet to be formed workgroups:  Plan payment  Beneficiary notice  Enrollment  Due process protections  Oversight and monitoring  Memorandum of Understanding (MOU) process © 2012 Medicare Rights Center
  10. 10. Beneficiary notice andenrollment How will you explain what this new program is to dually eligible beneficiaries? How will you explain their right to opt-out and remain in Medicare fee-for-service or PACE? How will you help them compare the choices of FIDA plans and explain the meaningful difference between the plans? How will you explain the effect, if any, of switching their health plan will have on their existing benefits? © 2012 Medicare Rights Center
  11. 11. Beneficiary notice andenrollment Threshold questions beneficiaries will have:  How will this affect my Medicare?  Can I still see my doctor?  What’s the difference between Medicare and Medicaid?  What does it mean that I was exempt from a Medicaid waiver?  Which plan will cover my medications?  Why is the State sending me a letter about my Medicare?  Who can help me figure this out? © 2012 Medicare Rights Center
  12. 12. What will beneficiaries need?Tools to compare insurance options like Medicare’s Plan Finder  Providers  Formularies  NetworksClear notices that explain steps beneficiaries will need to take to enroll in a plan or opt out  No abbreviations  Available in multiple languages  Multiple communications  Accommodations for people with disabilities © 2012 Medicare Rights Center
  13. 13. What is needed from theenrollment broker? Look holistically at all the services and providers Use safeguards and counseling to prevent combinations of plans that might be detrimental to access to health services. Provide an explanation of the beneficiary’s rights to opt out of a FIDA plan and their options for accessing both primary medical care Provide information to beneficiaries about other independent sources of counseling © 2012 Medicare Rights Center
  14. 14. For additional information Medicare Rights   National Senior Citizens Law Center (NSCLC)  Avalere Health Info Graphic  e_Dual_Eligibles_full_size.html MMCO  Coordination/Medicare-MedicaidCoordination.html © 2012 Medicare Rights Center
  15. 15. Contact Doug Goggin-CallahanDirector of Education and New York State Policy 520 8th Avenue, North Wing, 3rd Floor New York, NY 10018 212.204.6275 © 2012 Medicare Rights Center