Demonstration Proposal to Integrate Care for Dual Eligible Individuals: FIDA Update

Managed Care Policy and Planning Meeting
Mark Kissinger, Director,
Division of Long Term Care
December 12, 2012

Update - FIDA

  • CMS Action:
    • Comments/Questions on original proposal pending
    • Budget discussions underway
    • Focus is on MFFS and 2013 States
    • Participating in New York stakeholder work groups

2014 Timeline

Milestone Date
Notice of Intent to Apply Web Tool released Early October 2012
Recommended date to submit Notice of Intent to Apply to ensure HPMS Access Early November 2012
CMS User ID form due to CMS December 6, 2012
Final Application posted by CMS and available in HPMS January 10, 2013
Application due to CMS February 21, 2013
Formulary due to CMS April 2013
Medication Therapy Management Program due to CMS May 2013
Plan Benefit Package due to CMS June 3, 2013

FIDA Work Groups

  • Stakeholders Engagement Fall 2012:
    • Plan Qualifications and Quality Metrics
    • Outreach and Enrollment
    • Navigation, Appeals and Grievances
    • Finance

Demonstration Parameter: Quality Metrics

  • CMS and States must jointly conduct a consolidated, comprehensive quality management reporting process
  • Core set of CMS measures for all plans in all States
    • Focus on national, consensus-based measurement sets
    • Relevant to broader Medicare-Medicaid enrollee populations
  • State-specific measures
    • Targeted to State-specific demonstration population
    • Focus on long-term supports and services measures that are underrepresented in national measures
  • Work Group Activity:
    • Review of national, consensus-based measurement sets including Massachusetts MOU - over 140 measures
    • Discussed measures already in use by NYSDOH and Plans as well as general considerations (data source, collection method, nationally accepted, validated, etc)
    • Discussed interest in reporting on grievance/appeals; member satisfaction, etc .
    • Recommended consideration of performance standards
    • Discussed collection methods (include focus groups and more frequency on satisfaction measures)

Demonstration Parameter: Plan Selection

  • Utilize joint plan selection process, either procurement certification process (where approved) to select limited number of qualified plans
  • The joint selection process will take into account previous performance in Medicaid and Medicare
  • Work Group Activity:
    • Discussed Plan Selection Options the Work Group did not come to consensus - competitive procurement vs approval of certified plans

Demonstration Parameter: Enrollment related Beneficiary Protections

  • Notification in advance of the enrollment
  • Ability to opt out at any time
  • Understandable beneficiary notification
  • Resources to support beneficiaries
  • Work Group Activity:
    • Discussed advantages and disadvantages of passive enrollment of members: importance of continuity of care, option of disenrollment and individual choice.
    • Discussed role of licensed agent for Medicare enrollees and enrollment/assessment roles for Medicaid enrollees.
    • Consensus:
      • Develop Medicaid and Medicare compliant marketing guidelines, simplify and condense existing materials and devote resources to conducting a review all materials in a timely manner.
      • Develop and ensure all communications between plan and member are comprehensive, clear, consistent and ADA compliant including member handbooks, enrollment notification and training of plans´ member services staff in options counseling to ensure informed choice by consumer

Demonstration Parameter: Navigation, Appeals, and Grievances

  • Uniform appeals process
  • One document for explanation of intergrated process
  • Part D appeal standards will remain unchanged
  • Use Medicare standard of 60 days to file appeal, unless State Medicaid standard is allows more time
  • External appeals after internal appeals complete
  • Continuation of benefits: during internal appeals continue at external appeal level use Medicare standard which is to end coverage
  • Medicare standard for timeframe for resolution of appeals
  • Work Group Activity:
    • Interest in exploring incorporation of Part D appeals into the FIDA process
    • Suggested focus on Member Services training regarding integration of Medicare/Medicare benefits and appeals
    • Consensus:
      • Develop integrated model grievance and appeal notices/forms for consistency and streamlined review, including uniform explanation of benefits
      • Maintain internal plan level review for appeals, strengthen the process to ensure impartial review and secure all available information
      • Attempt to devise mechanism for integration of 2nd Level External Review, devote resources training