Minnesota Signs Memorandum of Understanding with CMS: Becomes Partner in Medicare-Medicaid Dual Eligibles Integration Effort
October 4, 2013 03:34 PM
On September 12, 2013, the Centers for Medicare and Medicaid Services (CMS) and the Minnesota Department of Human Services (MDHS) signed a Memorandum of Understanding (MOU) establishing a Demonstration to Align Administrative Functions for Improvements in Beneficiary Experience (Demonstration). The Demonstration began on September 13, 2013 and will continue until December 31, 2016.
Minnesota is implementing this Demonstration independently of the Medicare-Medicaid Alignment Initiative (MMAI) in place in Massachusetts, Washington, Ohio, Illinois, California, Virginia, and New York. Sixteen other states have active MMAI proposals submitted to CMS. Like the MMAI, the Demonstration is a joint federal and state project which seeks to improve care and reduce costs associated with beneficiaries eligible for both Medicare and Medicaid, or “dual eligibles.” While Minnesota originally considered the MMAI, the Demonstration will be based on the Minnesota Senior Health Options program (MSHO), an existing program for dual eligibles which focuses on alignment with Medicare Advantage and state Medicaid.
Overview of the Demonstration
Basic prior framework maintained: The Demonstration largely follows the basic framework of MSHO; it does not “fundamentally change” benefits, choice of providers, choice of plans, the contracting process between MSHO and MDHS or MSHO and CMS, the enrollment process, or network standards. MSHO Plans that participate in the Demonstration will continue to contract with CMS as is required for participation in Medicare Parts C and D, and will also contract with MDHS to provide Medicaid services to beneficiaries. State contracts with MSHO Plans will be modified to be compliant with the Minnesota MOU.
Objectives:Key objectives for the Demonstration include: improvement of quality of care for dual eligibles, reduction of costs to CMS and MDHS, and further alignment and integration of Minnesota’s Medicaid and Medicare Advantage programs. The Demonstration also creates a great opportunity for home care as it seeks to further independence in the community as promoted by MSHO.
Benefits:The MSHO Plans will provide Medicare and Medicaid benefits, including acute, behavioral health, LTSS, and primary care services. Like the Virginia MMAI MOU, the Minnesota MOU defines LTSS. For the full definition of LTSS, see p. 14, here. All current Medicaid medical necessity criteria and covered benefits will be governed by existing Medicaid-MSHO Plans contracts.
Rebalancing:The Demonstration furthers the MSHO objective to shift LTSS from the institutional setting to a community-based setting, “by helping MSHO Enrollees access home and community-based alternatives to institutional placement.”
Delivery Systems
The Demonstration does not make changes as significant as the MMAI, as stated in the lack of “fundamental change” above. However, the State will develop relationships between the MSHO Plans and providers called Integrated Care System Partnerships (ICSPs). The ultimate goal of the ICSPs is to “to help Beneficiaries remain in their homes or choice of community settings and improve health outcomes in all settings.”
The Demonstration highlights three models of ICSP arrangements. One such model includes health care home (HCH) or an alternative model to provide acute, primary, and/or long term care ICSPs. This model will “further integrate primary and long term care coordination and delivery.” Each MSHO Plan must submit ICSP proposals to MDHS no later than January 2014. These arrangements will include “pay for performance goals, performance pools, and total cost of care systems with risk/gain parameters.” The other two models deals with integration of physical and behavioral health ICSPs, and primary care.
Qualifying Populations
The Demonstration will encompass all beneficiaries enrolling in or presently enrolled in MSHO. Specifically, MSHO enrollees are aged 65 or older, enrolled in Medicare Parts A and B, and are eligible for Medicaid. For a complete definition of MSHO, see page 15, here.
Enrollment
The Demonstration’s enrollment process will not differ significantly from the current MSHO enrollment process. The Demonstration will incorporate an “integrated enrollment system” to promote accuracy and simplification of enrollment. MDHS reserves the right to act as a third-party administrator of the enrollment, as it currently does with some MSHO Plans. The enrollment process will have “an integrated form, notices, and process.” Specifically, the integrated enrollment form will allow for simultaneous Medicare and Medicaid enrollment and disenrollment. While D-SNPs must normally submit enrollment requests to CMS within 7 days of verification, this is waived in the Demonstration to give more time for verification and finalization of Medicaid enrollments.
No Passive Enrollment: The Demonstration will not include passive enrollment.
Payment Rates
Payment rates to providers are not elaborated upon in the MOU with the exception of Medicare and Medicaid primary care payments. The MSHO SNPs may integrate these payments to develop health care homes. For details, see page 22, here. Those who wish to be network providers must prepare to negotiate payment rates.
Network Adequacy
According to the MOU, “[t]he Demonstration will not fundamentally change either the State or Medicare Advantage methodology for determining provider network standards.” However, CMS and the State will initiate a new network review for all MSHO Plans beginning in 2014, for contract years starting no earlier than 2015.
Quality Management and Monitoring
The MSHO Plans are subject to the same Medicare Advantage and Medicaid quality management and monitoring standards, including the Medicaid External Quality Review Organization (EGRO) and Medicaid management and reporting systems. However, MDHS will be testing new quality measurement initiatives that may include LTSS. MDHS will also conduct research on feasibility testing on integration measures for duals, including focusing on LTSS, if funding permits. Lastly, CMS and MDHS agreed to “identify other measures related to community integration,” which they will then “refine and update.” For details, see pages 25-27, here.
No New Cost Sharing
The Demonstration will not include new cost sharing requirements. MSHO Plans will use the Part D and Medicare Advantage bidding process to calculate Medicare capitation rates and premiums, but CMS and MDHS will maintain zero premiums for MSHO.
Model of Care
A model of care will be required for all Special Needs Plans under Medicare Advantage.
Analysis
While the Demonstration will transform the way that dual eligibles receive care, many unknowns remain for providers, and home care providers specifically. The MOU does not cover how providers will be compensated. The MOU also does not mention if there are any quality standards to which home care providers will be held as part of the Demonstration.
Minnesota has consistently been an early adopter of dual eligible integration efforts. In 1995, Minnesota was the first state to get CMS approval for a demonstration that integrated Medicare and Medicaid managed care contracts, which financed acute, primary, and long-term care services for senior beneficiaries in the Minneapolis-St. Paul metropolitan area. The demonstration added people with disabilities in 2001, according to the National Governors Association, here.  Minnesota hopes to further integrate care for duals by strengthening MSHO, but the lack of specificity in the MOU makes success uncertain. The Demonstration deserves a vigilant oversight as it develops to ensure that access to a robust and high quality home care program continues.
Notwithstanding persistent stakeholder concerns (see here, here, and here) regarding MMAI, home care providers can look to this Demonstration and MMAI as an opportunity to increased clinical coordination among the dual eligible population. In addition, the Demonstration will give home care providers rebalancing opportunities, as a stronger emphasis is placed on community based systems over institutional settings. Home care providers are encouraged to keep abreast of Demonstration and MMAI developments on CMS’ website, and to contact the Council with any questions or concerns.
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