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

1. A Bridge to Integrated Care
for Medicare and Medicaid
beneficiaries
Plain Talk Conference September 2012
© 2012 Medicare Rights Center

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. What does it mean to be dually
eligible?
 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. Why are states focused on dual
eligible 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. Why are states focused on dual
eligible 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. 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. New York’s demonstration
project 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. Promising elements
Aims to improve care coordination and
lower state and Federal expenses
Ombudsman's 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. 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. Beneficiary notice and
enrollment
 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. Beneficiary notice and
enrollment
 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. 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. What is needed from the
enrollment 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. For additional information
 Medicare Rights
 www.medicarerights.org
 www.medicareinteractive.org
 National Senior Citizens Law Center (NSCLC)
 www.dualsdemoadvocacy.org
 Avalere Health Info Graphic
 http://www.avalerehealth.net/news/spotlight/Avaler
e_Dual_Eligibles_full_size.html
 MMCO
 http://www.cms.gov/Medicare-Medicaid-
Coordination/Medicare-MedicaidCoordination.html
© 2012 Medicare Rights Center

15. Contact
Doug Goggin-Callahan
Director of Education and New York State Policy
520 8th Avenue, North Wing, 3rd Floor
New York, NY 10018
dgoggin-callahan@medicarerights.org
212.204.6275
© 2012 Medicare Rights Center