Pursuant to authority created by the Affordable Care Act (ACA), the Medicare-Medicaid Coordination Office (MMCO) is supporting state demonstration programs to integrate Medicare and Medicaid services for individuals who are dually eligible for both programs. About half of the states are seeking to implement such dual integration demonstrations, with the first demonstrations scheduled to begin on January 1, 2014 (assuming the demonstrations are ultimately approved). In these demonstrations, individuals will be enrolled into some kind of managed care entity (MCE), such as a managed care organization, that will be responsible for providing and coordinating care.
The process MMCO laid out for state demonstrations began with design and proposal phases followed by state and federal public notice and comment periods. Although many consumer stakeholders provided comments to the integration proposals, many state proposals were vague with respect to core policies and standards and deferred these details to subsequent phases of the process. Currently, MMCO and states are signing Memorandums of Understanding (MOU), which are an opportunity to set out some of these details. Other details may subsequently be addressed through the three- way contracts which will be signed between MMCO, the states, and the MCEs delivering the integrated benefit.
As consumer stakeholders struggle to ensure that consumer protections are included with sufficient specificity in state demonstration programs for dual eligibles, NHeLP has developed five key contractual standards for all demonstrations. Advocates should work to have these terms included in their state?s Memorandum of Understanding, or failing that, included as a contractual term in the three-way contract.
1. Continuity of Care
Why it is important: MMCO is authorizing states to ?passively enroll? individuals into new integrated managed care demonstrations. In many cases, these enrollees will be individuals with serious health issues who already have carefully calibrated treatment plans and a team of doctors, specialists, hospitals, home care workers, etc. If they are suddenly transitioned into a new managed care entity, which may have a different network or treatment criteria, these individuals can suddenly lose access to the providers they depend upon or face denials of services they need.
What the MOU should say:
If there are multiple managed care entities, the state must use a ?smart assignment? process when assigning enrollees to an MCE. The smart assignment system must place the enrollee in the MCE which includes the greatest number of the individual?s providers in its network. MCEs not meeting or exceeding all annual performance measures will not be eligible for auto assignments. Individuals will not be auto-assigned to MCEs whose providers have reached the acceptable provider to patient ratios or have stated they are not accepting new enrollees (unless the person is already a patient of the provider at the time of assignment).
All enrollees who are auto-assigned to an MCE must be allowed to continue to see their existing providers, including those outside the MCE network, during a transition period. The transition period shall last at a minimum for twelve months after enrollment. During the continuity period, the enrollee shall have access to all providers and on-going treatments, without additional cost-sharing or utilization requirements. This continuity period cannot be broken at the end of an authorization period if continued treatment or related treatment is a reasonable, foreseeable or necessary part of an on-going treatment plan. The MCE?s continuity period must apply with equal force to all of the MCE?s subcontractors, including independent practice associations. During the transition period, non- participating providers will be reimbursed for covered items and services at the higher of the FFS rate or the plan network rate.
Enrollees must receive the required notice of their assignment or auto- assignment and the state must make available to them independent consumer assistance which can help the enrollee determine the plan that will best meet their ongoing health care needs, including participation of providers and service coverage policies. . The MCE must use available information, including application, diagnosis, and claims data, to identify new enrollees with special needs and make a ?rapid contact? to those members. This contact must help enrollees coordinate continuation of their on-going treatments and providers and coordinate referral to the MCE?s formal health needs assessment.1 Notices, consumer assistance, and rapid contacts must all specifically inform enrollees of their right to opt-out of the demonstration.
2. Network Adequacy
Why it is important: The population of older adults and persons with disabilities who will be enrolled into dual eligible demonstrations is incredibly diverse and relies on a wide range of medical providers. Many individuals in this population are also in poor health and need speedy and dependable access to providers. Network adequacy standards will help ensure the managed care network can meet the needs of the enrolled population.
What the MOU should say:
State Medicaid standards shall be utilized for long-term supports and services or for other services for which Medicaid coverage is exclusive, and Medicare standards shall be utilized for pharmacy benefits and for other services for which Medicare is exclusive. Any services for which Medicaid and Medicare may overlap, regardless of which is primary (e.g. home health and durable medical equipment), shall be subject to state Medicaid standards, if such standards are more protective than Medicare standards; otherwise, Medicare standards or an alternative standard that is more protective than the Medicare and Medicaid
standards shall apply.2
In establishing a network, the MCE shall include all classes of providers necessary to furnish covered services, including but not limited to hospitals, physicians (specialists and primary care), nurse midwives, nurse practitioners, pediatric nurse practitioners, federally qualified health centers, medical specialists, dentists, pharmacy, mental health and substance abuse providers, allied health professionals, ancillary providers, DME and prosthesis providers, home health providers and transportation providers.3 Members with special health care needs who need a specialized course of treatment or regular care monitoring must have direct access to specialists.4 Members may use a specialist as their PCP, at their choice.5 The MCE?s network shall include adequate numbers of providers with the training, experience, and skills necessary to furnish quality care to enrollees. MCEs are required to maintain the following within 20 minutes (urban) or 45 minutes (rural) travel time from an enrollee?s residence:
- At least two PCPs;
- At least two specialists in every medical and surgical specialty, including at least two obstetricians and two gynecologists;
- At least two outpatient mental health providers;
- At least two hospitals;
- At least two nursing facilities; and
- At least two community LTSS Providers per covered service; and
- At least two pharmacies.6
Providers who are not accepting new patients shall not be considered in determining compliance with the above network adequacy standards. Providers must be able to demonstrate that they can accept patients while maintaining their overall patient load within professional and industry norms and community standards.7
In addition, MCEs must also monitor and comply with access to care for the providers listed above.8 An enrollee must have the option of at least one provider who meets the following access to care standards:
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