The Centers for Medicare & Medicaid Services (CMS) announced that CMS is partnering with the State of Rhode Island to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience.
The demonstration builds upon Rhode Island’s existing Integrated Care Initiative. Under Phase I of the Integrated Care Initiative, Rhode Island established the Rhody Health Options (RHO) Medicaid managed care program. In RHO, Medicaid members – including Medicare-Medicaid enrollees – enroll in a health plan that coordinates their Medicaid services, including long-term services and supports. The new demonstration will allow a contracted, qualifying RHO plan to also serve as a Medicare-Medicaid Plan (MMP) that will newly cover Medicare benefits in addition to the existing set of Medicaid benefits it currently offers, allowing for an integrated set of benefits for enrollees.
Improving the care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees – sometimes referred to as “dual eligibles” – is a priority for CMS.
Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers (e.g. Medicare Parts A and B, Part D, and Medicaid). Many Medicare-Medicaid enrollees suffer from multiple or severe chronic conditions and could benefit from better care coordination and management of health care and long-term services and supports.
he Financial Alignment Initiative – Partnerships to Provide Better Care
Through the demonstrations approved under the Financial Alignment Initiative, CMS seeks to provide Medicare-Medicaid enrollees with a better care experience by offering a person-centered, integrated care initiative that provides a more easily navigable and seamless path to all covered Medicare and Medicaid services.
In July 2011, CMS announced the opportunity for states to partner with CMS through one of two models:
- Managed Fee-for-Service Model in which a state and CMS enter into an agreement through which the state is eligible to benefit from savings resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid;
- Capitated Model in which a state and CMS contract with health plans or other qualified entities that receive a prospective, blended payment to provide enrolled Medicare-Medicaid enrollees with coordinated care.
The Rhode Island demonstration uses the Capitated Model.
The Integrated Care Initiative
Rhode Island currently operates Phase I of the Integrated Care Initiative, which is designed to provide enhanced care coordination services to Medicaid members, including those dually eligible for Medicaid and Medicare. Under Phase I of the Initiative, eligible Medicaid members may enroll in either an enhanced Primary Care Case Management model called Connect Care Choice Community Partners (CCCCP) or the Rhody Health Options Medicaid managed care program for their Medicaid benefits.
The Rhode Island Demonstration
Under the new Rhode Island demonstration, which is part of Phase II of the Integrated Care Initiative, the participating MMP will cover Medicare benefits in addition to the Medicaid benefits currently covered through RHO. This change will allow the MMP to offer Medicare-Medicaid enrollees an integrated set of benefits to more comprehensively address their individual service needs. Approximately 30,000 individuals will be eligible to enroll in the demonstration.
To ensure the MMP is prepared to serve Medicare-Medicaid enrollees, any participating plan must first meet core Medicare and Medicaid requirements, state procurement standards, and state insurance rules (as applicable). The plan must also pass a comprehensive readiness review operated by both CMS and the state.
Enrollment is scheduled to begin no sooner than December 1, 2015 with at least two months of opt-in only enrollment, followed by at least three waves of phased passive enrollment.
Putting the Beneficiary First
Under the demonstration, care coordination services will be available to all enrollees. The participating MMP will offer a service coordination team to ensure the integration of the enrollee’s medical, behavioral health, long-term services and supports, and social needs. The team will be built on the enrollee’s specific preferences and goals.
The new demonstration includes beneficiary protections to ensure that enrollees receive high-quality care. CMS and Rhode Island have established quality measures relating to the beneficiary’s overall experience, care coordination, and fostering and supporting community living, among many others.
The demonstration also includes continuity of care requirements to ensure that enrollees can continue to see their current providers during their transitions into the MMP. The Rhode Island Ombudsman program will support individual advocacy and provide Rhode Island and CMS with feedback on plan performance for the demonstration, with a focus on compliance with principles of community integration, independent living, and person-centered care.
CMS is funding and managing an external evaluation of each demonstration under the Financial Alignment Initiative. The evaluation for the Rhode Island demonstration will measure quality, including overall beneficiary experience of care, care coordination, and support of community living, as well as changes in Medicare and Medicaid costs. CMS will develop a unique, Rhode Island-specific evaluation using a comparison group to analyze the impact of the demonstration.
A Transparent Process Supporting Public Input
The Rhode Island demonstration is the product of an ongoing planning and development process through which the public helped shape the demonstration’s design. To develop this demonstration, Rhode Island:
- Worked with a diverse group of stakeholders, including beneficiaries, providers, health plans, advocacy groups, associations, and state agencies;
- Held public information sessions with external stakeholders to inform demonstration development and policy; and
- Posted its draft proposal for public comment and incorporated the feedback into its demonstration proposal before officially submitting it to CMS. The proposal was then posted by CMS for public comment.