Michigan Awaits Delayed OK for CMS Duals Demo; Ariz. Goes Slowly in Starting Its Own

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care. By James Gutman, Managing Editor March 27, 2014 Volume 20 Issue 6 An indicator of the future direction of programs for Medicare-Medicaid dual eligibles could come soon when CMS will decide whether to approve a Michigan proposal that would keep behavioral health care separate from physical health care despite the goal of integrated care (MAN 11/21/13, p. 6). When Michigan selected eight health plans for its duals initiative last November, the state said it was in the process of “finalizing” its Memorandum of Understanding (MOU) with CMS. But more than four months later, there has been no MOU, and industry insiders tell MAN the major obstacle has been the separation of behavioral health. The delay in working out issues related to this separation already has been a factor in pushing back the projected start date for passive enrollment of duals in two large Michigan counties (Wayne and Macomb) from July 1 to Oct. 1. And now even the Oct. 1 start date “is at very significant risk,” one plan executive says. The executive points out that to make the October date, CMS site visits would need to occur by summer. In the meantime, the situation is further complicated by a new Michigan Medicaid redesign program that aims to shift some costs to beneficiaries, with the aid of health savings accounts. This program begins April 1, but the cost-sharing aspects would not kick in until Oct. 1. Michigan Department of Community Health spokesperson Angela Minicuci says only that MDCH hopes to have the duals MOU finalized “soon.” It has held a few forums with stakeholders since the plan selections were unveiled last November, Minicuci tells MAN, but otherwise there is nothing new to report. CMS itself is adhering to a policy of not commenting about the time frame for MOUs until they actually are finalized, but there are indications a decision on Michigan could be imminent. The major complication in Michigan’s proposal is that it wants to preserve a longstanding system of separate, albeit responsive, Prepaid Inpatient Health Plans (PIHPs) to cover the behavioral health needs of the state’s more than 200,000 duals. The Integrated Care Organizations (ICOs) that the state selected last November would be responsible for “all physical health, long-term supports and services, and pharmacy services,” MDCH said in its Request for Proposals. They would have to coordinate with the PIHPs on behavioral health, which accounts for about 10% of Michigan’s duals spending. This split responsibility is counter to CMS’s oft-expressed desire for its huge duals demonstration program to have organizations fully accountable for all coordinated care of duals. But the agency’s duals office has found a way of dealing with a related issue in the Massachusetts demo it approved by excluding duals with intellectual development disabilities from the demo. CMS also agreed to a limited behavioral-health carve-out in California’s duals demo. Texas, one of the two states with capitated duals demo proposals that haven’t gotten a decision from CMS yet (Rhode Island is the other), also is looking to carve out some services, although there the carve-out relates to nursing facilities. So the decision on Michigan might give some insight into how Texas’ proposal might be resolved. The difference in Michigan’s proposal from CMS’s preferences “has been a major sticking point since the beginning,” says Rich Bringewatt, co-chair of the SNP Alliance trade group. Michigan’s assumption, he tells MAN, is that ICOs and PIHPs “would work together but not in a way that some might consider as being ‘integrated.’” While the state has not informed plans about the reasons for the delay in the MOU, “we can only infer that it is related to working through the details of the Care Bridge model,” Bringewatt says. This is the state’s name for a care model that MDCH says “requires the coordination of services and supports between the two entities and involved providers.” Bringewatt does note that CMS signed off on the concept of the Care Bridge model before the state started procuring plans for the duals demo, but adds that working through the details of how the model actually will function is more complex. “We’re still looking forward to starting Oct. 1,” Tom Standring, vice president, Medicare at Molina Healthcare, Inc., tells MAN. Molina is one of the plans Michigan selected for multiple regions, and it stands to serve the two most populous counties, Wayne and Macomb. Standring points out that for the Oct. 1 start to be feasible, the state and CMS will need to release their readiness-review tools right after the MOU is approved. Another unresolved matter, he acknowledges, is payment rates, adding that Molina hasn’t seen final or even draft rates yet. State Duals Programs Also Face Slow Going With the continued slow rollout of the CMS-backed demo, some states are pushing their own initiatives more, but they also face issues delaying the cost savings and full integration that they seek. Arizona, for instance, which withdrew its CMS duals demo application in April 2013 to focus on an approach aimed at a permanent program centered on Medicare Advantage Special Needs Plans for duals (D-SNPs), is still in the formulation stage for its new duals initiatives. The state does have 53,000 duals in D-SNPs (MAN 10/24/13, p. 1), and “we believe the D-SNP model is the right path for us,” Monica Higuera Coury, assistant director in the Office of Intergovernmental Relations in the Arizona Health Care Cost Containment System (AHCCCS), tells MAN. Specific areas it is focusing on, adds Kijuana Wright, who leads duals integration efforts for AHCCCS, include behavioral health integration for “acute care plans” serving duals starting in 2015. She also notes that Arizona told plans they needed to have contracts with AHCCCS to furnish Medicaid services in order to continue as a D-SNP in 2014 and beyond. Wright tells MAN that AHCCCS’s specific goals in “strategic duals alignment” include a “single accountable entity” to improve care coordination, a single entity capable of better aligning financial incentives and “enhanced appropriate community placement for members at risk of institutionalization.” One of the reasons Arizona feels urgency to take broad action on duals is that about 41% of the state’s full duals now are in fee-for-service. A key goal for Arizona, as reflected in a Medicaid procurement last October, is to have duals in the same plan for Medicare and Medicaid, says Katrina Cope, director, Medicare operations for Health Choice, an Arizona-based “safety-net” plan operator that has one of the state’s eight D-SNPs. Arizona still is working with CMS on ways to smooth the “transition” for duals at such times as when they age into Medicare or lose Medicaid eligibility, she adds. http://aishealth.com/archive/nman032714-02?utm_source=Real%20Magnet&utm_medium=Email&utm_campaign=37253579