10/4/2015. ACA-based integrated care demonstration for beneficiaries with dual (Medicare/Medicaid) eligibility. Phased in start up in 2015

Transcription

1 David LaLumia, President/CEO Health Care Association of Michigan October 11, MI Health Link (dual eligibles) FY2017 state budget Corporate practice of medicine legislation Healthy Michigan (Medicaid expansion) issues CMS Requirements of Participation rule Other federal issues 2 ACA-based integrated care demonstration for beneficiaries with dual (Medicare/Medicaid) eligibility Phased in start up in 2015 Operating in 4 regions 3 1

2 221,000 Total estimated number of dual eligibles in MI 110,811 Number of dual eligibles in the 4 demonstration regions 4 Region 1 Entire Upper Peninsula Upper Peninsula Health Plan Region 4 Southwest MI (8 counties) Battle Creek, Kalamazoo, St. Joseph/Benton Harbor Aetna Better Health of MI Meridian Health Plan 5 Region 7 Region 9 Wayne County (Detroit) Macomb Aetna Better Health of Michigan AmeriHealth Fidelis Securecare HAP Midwest Health Plan Molina Healthcare 6 2

3 February 1, Voluntary enrollment begins March 1, 2015 Services begin for voluntary enrollees May 1, 2015 Services begin for first passive enrollees June 1, 2015 Services begin for all passive enrollees 7 April 1, Voluntary enrollment May 1, 2015 Services begin for voluntary enrollees July, August and September 2015 Services begin for passive enrollees 8 110,811 eligible duals in demonstration regions July 1, 2015, total enrolled 28,171 August 1, 2015 total enrolled 35,102 September 1, 2015 total enrolled 42,728 July 1, 2015, total unenrolled 82,640 August 1, 2015 total unenrolled 73,579 September 1, total unenrolled 66,

4 July 1 opt out rate (29,368) 36% August 1 opt out rate (36,132) 33% September 1 opt out rate (41,255) 38% 6,869 other exclusions (9/1) such as PACE, hospice or current HCBS consumers 6% As of 9/1 18,690 in process 10 State contract with health plan specific about health plans paying Medicaid rate as determined by the state rate setting process Contract says health plan will pay the Medicare rate. Most health plans are paying RUG rates Complications with rates -- provider tax calculation and QAS, understanding RUG categories, Medicaid rates updated on 10/1/15 11 No protection for SNFs Health plans learning they will work with many SNFs in their region 12 4

5 Health plans little experience with LTC Beneficiary notification problems Members slow in building relationships with health plans in their areas and vice versa State concerns with enrollment practices Members anticipating cash flow delays Health plans unhappy with overly prescriptive program design and contract 13 Managed care committee Managed care newsletter Meet health plan leadership and staff Q and A calls Engage MI Association of Health Plans Memorandum of understanding between HCAM and MAHP Standardization of process, information sharing, joint advocacy

6 Upgrade web site to accommodate expanded member profile information Develop concept of statewide network of HCAM members Michigan opts to extend demonstration for 2 additional years through 12/31/19 16 State match shortfalls due to use and HICA taxes Pressure to fix roads may impact state GF budget State share of Healthy Michigan Plan kicks in beginning April 1, 2017 Unexpected enrollment numbers stress state budget 17 Permit proprietary SNFs to directly employ physicians Clarify 19 th century learned professions doctrine SB 65, 66, 67 amend public health code, business corp act and LLC corp act Headed to Gov s desk for signature A tool in the toolbox. Do not specify any model of care or medical practice Permissive and do not mandate anything 18 6

7 Medicaid expansion authorized by ACA April 1, 2014 effective date Enrollment strong over 600,000 9/1 -- State of MI submitted second waiver requesting higher cost sharing limits. Federal approval needed by 12/1 to continue program beyond 4/1/16 Act 107 of the Public Acts of 2013 Section 105d.(4) 19 Section 105d. (4) By September 30, 2015, the department of community health shall develop and implement a plan to enroll all existing fee-for-service enrollees into contracted health plans if allowable by law, if the medical assistance program is the primary payer and if that enrollment is cost-effective. This includes all newly eligible enrollees as described in subsection (1)(a). The department of community health shall include contracted health plans as the mandatory delivery system in its waiver request. The department of community health also shall pursue any and all necessary waivers to enroll persons eligible for both medicaid and medicare into the 4 integrated care demonstration regions beginning July 1, By September 30, 2015, the department of community health shall identify all remaining populations eligible for managed care, develop plans for their integration into managed care, and provide recommendations for a performance bonus incentive plan mechanism for longterm care managed care providers that are consistent with other managed care performance bonus incentive plans. By September 30, 2015, the department of community health shall make recommendations for a performance bonus incentive plan for long-term care managed care providers of up to 3% of their medicaid capitation payments, consistent with other managed care performance bonus incentive plans. These payments shall comply with federal requirements and shall be based on measures that identify the appropriate use of long-term care services and that focus on consumer satisfaction, consumer choice, and other appropriate quality measures applicable to community-based and nursing home services. Where appropriate, these quality measures shall be consistent with quality measures used for similar services implemented by the integrated care for duals demonstration project. This subsection applies whether or not either or both of the waivers requested under this section are approved, the patient protection and affordable care act is repealed, or the state terminates or opts out of the program established under this section page proposed rule issued 7/16/15 Revise requirements for participation Medicaid and Medicare New staffing requirements, compliance and ethics, transitions and general provisions Physician services (e) Cost estimate $47,000/facility understated Grassroots campaign 7,000 comments to CMS CMS deadline October 14, es/snf-requirements-of-participation.aspx 21 7

8 Bundled payment initiative Payment reform priority CARES Act eliminates Medicare 3 day stay Observation stay problem Protect Medicaid funding Impact of debt ceiling debate on health care Congressional action extends funding for government ops through December 11, David LaLumia President/CEO Health Care Association of Michigan 7413 Westshire Drive Lansing, MI davidlalumia@hcam.org