BROWN ADMINISTRATION SUBMITS REVISED “DUAL ELIGIBLES” DEMONSTRATION PROJECT PROPOSAL TO FEDERAL GOVERNMENT FOR APPROVAL
Federal Government Will Have 30 Day Public Comment Period on the Revised Proposal
- Project Would Start Up in California By June 2013 Instead of January 1st
SACRAMENTO, CA (CDCAN) [Last updated 05/31/2012 03:05 PM] – The Brown Administration formally submitted to the federal government today, California’s demonstration project proposal to shift hundreds of thousands of people with disabilities and seniors who are eligible for both Medicare and Medi-Cal from “fee for services” to Medi-Cal managed care-type plans in 8 selected counties, with a delay in the starting date from January 1, 2013 to “…no earlier than March 1, 2013 and no later than June 2013.” A copy of the 65 page proposal, saved as a document pdf file, is attached to this CDCAN Report titled “20120531 – Department of Health Care Services – CA Dual Eligibles Demonstration Project Revised Proposal Submitted to CMS May 31 2012 (65 Pages).pdf”
For more information and other documents related to the dual eligible demonstration project go to the Department of Health Care website page at:
The Brown Administration says that the revised proposal “…reflects recommendations and concerns voiced through our public comment process,” and the document reflect changes made to the original proposal first posted for public comment on April 4, 2012 (before final version was sent to the federal government for review and an additional 30 day public comment period), after holding “…13 public meetings with hundreds of stakeholders to get their input on details of the proposal. Additionally, we received a range of comments from a variety of stakeholders. The proposal balances the concerns and suggestions raised by a diverse group of stakeholders.”
The dual eligible demonstration project proposal has drawn sometimes intense controversy about the scope, readiness of certain selected health plans, monitoring, and impact on the health and safety of hundreds of thousands of people with disabilities and seniors who are eligible for both Medicare and Medi-Cal. The demonstration project would impact several other long term services and supports including the Multipurpose Senior Services Program and In-Home Supportive Services (IHSS).
SOME KEY CHANGES MADE TO PROPOSAL
- The Department of Health Care Services included a 6 page attachment that outlines changes made to the original April 4th proposal to the revised proposal submitted to the federal government today.
- Those changes covered scope and timelines, enrollment process, who is included and excluded in the demonstration project, enrollment process and status of those under the Medicaid Home and Community Based Service 1915(c) Waiver, Multipurpose Senior Services Program, Behavioral Health Coordination, clarifications on “models of care”, consumer protections (including plan readiness), quality monitoring, and rate setting issues.
- A copy of the 6 page attachment, saved as a pdf document file is attached to this CDCAN Report titled “20120531 – Department of Health Care Services – Duals Eligible Demonstration Project Changes Attachment (6 Pages).pdf”
Number of Counties Reduced from 10 to 8
- Number of counties in the demonstration project reduced for the first year from the proposed 10 counties to 8 counties. [CDCAN Note: The Legislature still needs to approve the Governor’s proposal to expand the project from 4 counties to 8 counties]
Implementation Date Change
- Implementation date change from January 1, 2013 to no earlier than March 1, 2013 and no later than June 2013.
- Enrollment Process: Brown administration is still proposing a “passive enrollment process” but with clarification in the proposal that there will be a process to “…ensure that communications [to people with disabilities and seniors who are dual eligible in the project counties] will be specific and easily understandable.”
- The Brown Administration is still proposing a six month “stable enrollment” period, with Native Americans the only group exempt from that requirement.
Persons Included and Excluded From Demonstration Project
- Persons with Developmental Disabilities – persons with developmental disabilities eligible for regional center services or services in a developmental center under the Lanterman Developmental Disabilities Services Act would be excluded from the dual eligible demonstration project.
- End-Stage Renal Disease (ESRD) – Saying that stakeholders offered “mixed opinions” about the inclusion of people with End-Stage Renal Disease, the Department of Health Care Services indicated it will propose to follow the Medicare Advantage policy. ESRD recipients would not be eligible for the dual eligible demonstration project, but that persons who develop End-Stage Renal Disease after they have been enrolled in the dual eligible demonstration project may stay enrolled. Recipients with ESRD who are currently enrolled in a demonstration health plan and their subcontracting partners may choose to stay in that plan under the dual eligible demonstration project.
- Under Age 21 – the Department of Health Care Services cited that based on stakeholder feedback and analysis of data, children under the age of 21 who are eligible for both Medicare and Medi-Cal would be excluded from the dual eligible demonstration project. The department estimates that would impact about 1,700 children.
- Share of Cost Beneficiaries – the Department of Health Care Services indicated that based on stakeholder feedback, that all beneficiaries with a Medi-Cal share of cost will be passively enrolled in the dual eligible demonstration project for those months in which they meet their Medi-Cal share of cost.
- Beneficiaries Exempt From Passive Enrollment – the Department of Health Care Services noted that in addition to current enrollees of PACE programs and the AIDS Health Care Foundation, the dual eligible demonstration project proposal “…clarifies that dual eligible enrolled in a non-demonstration plan Medicare Advantage program are exempt from passive enrollment.” Persons who are dual eligible in a Special Needs Plan (D-SNPs) will be included in the dual eligible demonstration project and exempt from passive enrollment until January 2014.
Appeals and Grievance Process
- The Department of Health Care Services indicated that “based on stakeholder input and due to the complexities of both systems and need to amend state regulation, the existing Medi-Cal and Medicare grievance systems will remain in place for the first year of the demonstration.
- The Department of Health Care Services will work with the federal Centers on Medicare and Medicaid Services (CMS) to develop a single process (including unified forms) through which grievances and appeals would be filed.
- The Department of Health Care Services indicated that there will be “…ongoing collaboration between the State, CMS and stakeholders to develop a unified state and federal grievance and appeals process by the second year of the demonstration.”
- The revised dual eligible demonstration project also, according to the department, “…clarifies that the current rights and protections for IHSS [In Home Supportive Services] consumers will remain in place during the demonstration, including the fair hearing process for consumer appeals for hours authorized by counties and the right to self-direct care. “
Multipurpose Senior Services Program (MSSP)
- Revised proposal “clarifies the transition of the MSSP program in the demonstration, noting that the State will continue working with stakeholders to develop a transition plan that is seamless and incorporates the principles of MSSP into the managed care benefit.”
- Health plans would contract with MSSP providers to continue their case management functions under the dual eligible demonstration project.
- Stakeholders would, according to the proposal, submit a transition plan to the Legislature no later than January 2015, as requested by stakeholders, for additional “…detail and the need to maintain the integrity and principles” of the program.
FEDERAL GOVERNMENT WILL HAVE 30 DAY PUBLIC COMMENT FOR CALIFORNIA PROPOSAL
The Centers on Medicare and Medicaid Services (CMS), the federal agency under the US Department of Health and Human Services responsible for administering both federal programs nationwide, will have a 30 day public comment period on the California proposal (the California proposal is not yet posted on the federal government website – but should be by June 1st).
Interested persons can comment on the California proposal – or any of the other posted proposal from 9 other states by going to the federal government’s Integrated Care Resource Center website at:
The following other states have submitted proposals to integrate care that are currently open for public comment (California’s proposal is not yet posted on the website but should be by June 1st):
- South Carolina (posted May 29, 2012; comment period through June 28, 2012). State Demonstration to Integrate Care for Dually Eligible Individuals (South Carolina Department of Health and Human Services).
- Tennessee (posted May 22, 2012; comment period through June 21, 2012). TennCare Plus: A Proposal for an Integrated Medicaid/Medicare Model (Bureau of TennCare).
- Oregon (posted May 14, 2012; comment period through June 13, 2012). Medicare/Medicaid Alignment Demonstration to Integrate Care for Individuals who are Dually Eligible (Oregon Health Authority).
- Vermont (posted May 11, 2012; comment period through June 10, 2012). Vermont’s Demonstration Grant to Integrate Care for Dual Eligible Individuals (Vermont Agency of Human Services). \
- North Carolina (posted May 4, 2012; comment period through June 3, 2012). North Carolina’s Demonstration to Integrate Care for Dual Eligible Individuals (North Carolina Department of Health and Human Services, Division of Medical Assistance).
- Wisconsin (posted May 2, 2012; comment period through May 31, 2012). Wisconsin’s Demonstration to Integrate Care for Individuals Dually Eligible for Medicare and Medicaid (Wisconsin Department of Health Services).
- Minnesota (posted May 1, 2012; comment period through May 31, 2012). Redesigning Integrated Medicare and Medicaid Financing and Service Delivery for People with Dual Eligibility in Minnesota (Minnesota Department of Human Services).
- Michigan (posted April 30, 2012; comment period through May 30, 2012). Integrated Care for People who are Medicare-Medicaid Eligible (Michigan Department of Community Health).
- Washington (posted April 30, 2012; comment period through May 30, 2012). A Medicare and Medicaid Integration Project for Washington State (Washington State Department of Social and Health Services and the Washington State Health Care Authority).
COMPLETE TEXT OF ATTACHMENT FROM DEPARTMENT OF HEALTH CARE SERVICES ON CHANGES MADE TO REVISED PROPOSAL
For those persons who may not have the ability to open the attached attachments, the following is the complete text of the Department of Health Care Services attachment that outlines the major changes made to the dual eligible demonstration project proposal submitted to the federal government today:
Description of Changes to California’s Proposal to Integrate Care for Dual Eligible Individuals
The Department of Health Care Services (DHCS) posted a draft Demonstration Proposal to Integrate Care for Dual Eligible Individuals on its website April 4, 2012 for a 30-day public comment period. DHCS received a range of written comments from a variety of stakeholders. All comments can be found on the DHCS demonstration proposal web page:
The draft demonstration proposal being submitted today to the Centers for Medicare and Medicaid Services (CMS) reflects stakeholder comments on the April draft of the proposal. Through the process of developing the version being submitted today, DHCS has addressed many of the stakeholders’ key suggestions and has improved the proposal. A version of the proposal being submitted shows edits compared to the draft proposal to help stakeholders track specific changes.
Please note that the proposal as submitted to CMS provides a high-level description of the demonstration. Many stakeholder comments requested details that cannot be addressed in this high-level policy document with a set page limit. Further details and processes will be described in subsequent documents that will be available to the public, such as the Memorandum of Understanding between DHCS and CMS (to be developed) and further written guidance issued by CMS and other state departments.
Please note that this is not a summary of the proposal; it only flags significant changes.
Scope and Timeline
In response to stakeholder comments that more time was needed to prepare for enrollment and implementation, the proposal delays the implementation date from January 2013 to no earlier than March 2013 and no later than June 2013. Enrollment will be phased in over 12 months. Additionally, the proposal calls for scaling back the size of the demonstration in 2013 — from ten counties to eight counties. The State believes this additional time will help ensure readiness of the state demonstration health plans.
In addition, several aspects of the proposal call for maintaining the status quo for a period of time. For example, the state proposes no changes be made toward creating a unified grievance and appeals process for Medi-Cal, Medicare, or IHSS in the first year to allow further time to work on this complex issue.
Clarifications on the Enrollment Process
The integrated service delivery system created by the demonstration will result in better care for beneficiaries. California is pursuing passive enrollment process through which beneficiaries will receive multiple notices of their options to participate. In response to comments on the importance of beneficiary communications, the proposal being submitted clarifies that there will be a process to ensure that communications will be specific and easily understandable.
Stable enrollment period. The State believes that a six-month stable enrollment period is needed to promote continuity of care. Indeed, DHCS believes that a stable enrollment period is needed to ensure sufficient time for health plans to complete the assessment process and fully implement care plans, thereby demonstrating to beneficiaries that improved care can be achieved by the health plan. The stable enrollment period also will avoid churning and interruptions in beneficiary care. As part of this, DHCS is committed to maintaining continuity of care for beneficiaries coming into the demonstration.
Native Americans will be the only group exempt from the proposed stable enrollment period.
Share-of-Cost Beneficiaries. Based on stakeholder feedback that supported the inclusion of all beneficiaries with a Medi-Cal share of cost in the demonstration, all beneficiaries with a Medi-Cal share of cost will be passively enrolled in the demonstration for those months in which they meet their Medi-Cal share of cost. The State will work with health plans and CMS to make the administrative changes necessary to implement this policy.
Beneficiaries exempt from passive enrollment. In addition to current enrollees of PACE programs and the AIDS Health Care Foundation, the demonstration proposal as submitted clarifies that dual eligible enrolled in a non-demonstration plan Medicare Advantage program are exempt from passive enrollment. Dual eligible in Special Needs Plans (D-SNPs) will be included in the demonstration and exempt from passive enrollment until January 2014.
Populations excluded from the demonstration
- Under age 21. Based on stakeholder feedback and analysis of the data, the demonstration proposal as submitted excludes dual eligible beneficiaries under age 21, excluding approximately 1,700 children.
- ESRD. Stakeholders have offered mixed opinions regarding the inclusion of beneficiaries with End-Stage Renal Disease (ESRD). DHCS has chosen to follow the Medicare Advantage policy. ESRD beneficiaries will not be eligible for the demonstration, but beneficiaries who develop ESRD after enrollment in the demonstration may stay enrolled. Beneficiaries with ESRD who are currently enrolled in a demonstration health plan and their subcontracting partners may choose to stay in that plan under the demonstration.
- Developmentally Disabled Beneficiaries. Dual eligible beneficiaries receiving services through a California Regional Center or a State Developmental Center are not eligible for the demonstration. The State’s 1915(c) waiver for the developmentally disabled provides significant Medicaid services, and the demonstration is not proposing to include those services; as such, beneficiaries receiving those services will be excluded.
Home and Community Based Service 1915(c) Waiver: Enrollment Process and Status
California has always been committed to helping those who want to remain in their home and communities. With the demonstration, DHCS intends to increase that support. As such, DHCS will work with health plans to develop their programs toward fulfilling that goal and to provide services similar to those under the 1915(c) waivers. While the April draft proposal included beneficiaries enrolled in the 1915(c) waiver programs, the demonstration proposal as submitted to CMS excludes beneficiaries altogether. Stakeholder feedback indicated strong interest in continuing the programs outside the demonstration.
California offers several important waiver programs, although their enrollment is limited. For the following small waiver programs, enrollees will be excluded from the demonstration: Nursing Facility/Acute Hospital Waiver Service, HIV/AIDS Waiver Services, Assisted Living Waiver Services, and In-Home Operations Waiver Services. This affects about 3,700 dual eligible beneficiaries statewide. At the same time, those on waiting lists for those waivers will be subject to passive enrollment (if they are eligible) and no further enrollment into the waivers will take place.
Multipurpose Senior Services Program (MSSP)
The demonstration proposal clarifies the transition of the MSSP program in the demonstration, noting that the State will continue working with stakeholders to develop a transition plan that is seamless and incorporates the principles of MSSP into the managed care benefit. Health plans will contract with MSSP organizations to continue their case management functions. Stakeholders will submit a transition plan to the legislature no later than January 2015 — per the request by stakeholders for additional detail and the need to maintain the integrity and principles of the MSSP program.
Behavioral Health Coordination
The proposal as submitted includes a new Appendix that describes a “Framework for Shared Accountability” for coordinating and aligning delivery of behavioral health services between demonstration health plans, county mental health plans (MHPs) and county substance use disorder agencies. CMS and stakeholders requested greater detail on this aspect of the demonstration.
There is now a more detailed description of a shared accountability strategy to achieve the demonstration aims of seamless access to services and reduced cost shifting for individuals receiving county-administered specialty mental health and Drug Medi-Cal services, both of which would not be included in the capitated payments to health plans, at least initially. The framework, developed in consultation with stakeholders, recognizes the value of existing service delivery structures and aims to build on this existing infrastructure to improve coordination and meet the demonstration goals.
Clarifications on the Model of Care
Stakeholder comments reflected a desire for additional detail on the risk-assessment process (medical and social), care planning process, and composition and role of the interdisciplinary care teams. The demonstration proposal provides overarching guidance for these care components, but they will be described in detail in each health plan’s Model of Care, which will be submitted to CMS for review. Additionally, through activities of the State’s ongoing stakeholder work groups, criteria for demonstration health plan readiness will be further developed.
The proposal as submitted includes a definition of “person-centered” as meaning the beneficiary has the primary decision-making role in identifying his or her needs, as well as preferences and strengths. In addition, person-centered care means a shared decision-making role in determining the services and supports that are most effective and helpful for the beneficiary.
Beneficiary and Provider Outreach and Education. The demonstration proposal as submitted clarifies that the state will design an outreach and education strategy for beneficiaries and providers in participating counties. An important part of this process will be to leverage the knowledge of existing community-based organizations. Indeed, DHCS has already begun working on this plan with stakeholders, including consumer advocates and the California Medical Association. Additionally, the demonstration proposal includes requirements that health plans educate their provider networks regarding the availability and usefulness of available social services and also establish teams dedicated to ensuring smooth transitions for all beneficiaries.
PACE. The proposal clarifies that the enrollment process will present an opportunity to indicate an interest in the Program of All-‐Inclusive Care for the Elderly (PACE) with follow-up taking place with those who indicate an interest.
Network Readiness. The proposal as submitted makes it clear that health plans in the demonstration will be required to meet Medicare network adequacy standards for medical services and prescription drugs, as well as Medi-Cal network readiness standards for long-term services and supports. The latter standards are being developed with stakeholder input through a public work group and will be complete in advance of the readiness review process. The requirements will ensure that beneficiaries have access to providers sufficient to achieve access standards. As part of this process, health plans will need to demonstrate that they have achieved access standards related to cultural competency and accessibility.
Appeals and Grievances. Based on stakeholder input and due to the complexities of both systems and need to amend state regulation, the existing Medi-Cal and Medicare grievance systems will remain in place for the first year of the demonstration. DHCS will work with CMS to develop a single process (including unified forms) through which grievances and appeals would be filed. There will be ongoing collaboration between the State, CMS and stakeholders to develop a unified state and federal grievance and appeals process by the second year of the demonstration.
In addition, the demonstration proposal as submitted clarifies that the current rights and protections for IHSS consumers will remain in place during the demonstration, including the fair hearing process for consumer appeals for hours authorized by counties and the right to self-direct care.
Continuity of Care. DHCS has made continuity of care as a top priority. The draft proposal described a policy aimed at maintaining continuity so that beneficiaries will be able to maintain relationships with their out-of-network physicians for six months for their Medicare benefits and 12 months for their Medi-Cal benefits. In addition, the proposal clarifies that health plans will:
- Enter into agreements with counties and public authorities for care coordination activities; and,
- Establish care coordination teams based on the unique care needs of the individual, with attention to HIPPA issues.
Ongoing Stakeholder Input. The proposal as submitted adds additional details regarding the ongoing stakeholder engagement and feedback process that will continue throughout implementation of the demonstration, including the creation of local advisory boards.
The proposal strengthens the conversation around plan monitoring and oversight. As part of quality monitoring, it is important to keep in mind that all demonstration plans must meet Medicare rules to qualify as a Medicare health plan.
Health Plan Oversight. The proposal includes a new Appendix that offers a graphic on the oversight approach for the health plans. This plan is being further developed and refined prior to the launch of the demonstration.
Role of the Department of Managed Health Care (DMHC). The proposal as submitted expands its description of the role that DMHC will have in health plan monitoring and providing assistance to health plan members through its help center.
Each health plan seeking to participate in the demonstration holds a current license issued by the DMHC under the Knox-Keene Act. To maintain its license, each health plan is required to continuously meet defined regulatory standards, including timely access to care through adequate provider networks, care coordination, continuity of care, financial solvency, and treatment decisions unencumbered by fiscal or administrative considerations. In addition, the DMHC provides comprehensive assistance to health plan members through its Help Center.
Transparent Quality Monitoring Process. The State is holding a series of public work group meetings on quality monitoring and the evaluation of the demonstration. Leading this effort are Dr. Neal Kohatsu, DHCS Medical Director, and Dr. Kenneth Kizer, Distinguished Professor, University of California Davis School of Medicine and Betty Irene Moore School of Nursing. They will guide discussion of the overall approach to evaluating the program, as well as specific performance measures that will be required in contracts with health plans.
Process for discontinuing the demonstration based on quality performance. The April draft proposal described the potential state statutory requirement that the demonstration be discontinued if certain fiscal requirements were not met. The proposal as submitted today responds to stakeholders by clarifying the similar provision that exists in proposed statute that are based on quality requirements, rather than only fiscal requirements.
Several stakeholders commented on the lack of specific information around the rate development process and the need for greater transparency. While much of this is dependent on forthcoming negotiations between DHCS, CMS and the health plans, DHCS recognizes the importance of providing this information as soon as possible and is working diligently on the necessary data analysis. More information will be provided as soon as possible.
TEXT OF LETTER SENT TO FEDERAL GOVERNMENT BY BROWN ADMINSTRATION
The following is the complete text of the cover letter sent with the 65 page revised “dual eligible” demonstration project proposal to the federal government from the Brown Administration.
Medicare-Medicaid Coordination Office
Centers for Medicare & Medicaid Services
200 Independence Ave SW
Mail Stop: Room 315-H
Washington, D.C. 20201
Dear Ms. Bella:
It is our pleasure to submit the enclosed proposal for the Duals Demonstration to integrate care for dual eligible beneficiaries as part of California’s Coordinated Care Initiative. This proposal is the result of an extensive design process, including robust stakeholder engagement over the past 18 months. It reflects strong partnerships across the departments of California’s Health and Human Services Agency and our commitment to providing the highest quality, integrated care to beneficiaries eligible for both Medi-Cal and Medicare.
This demonstration proposal builds on months of stakeholder discussions and state interest in
developing a coordinated care delivery system, as well as groundbreaking work to develop the
innovative Program of All-Inclusive Care for the Elderly (PACE), the longstanding consumer-directed
In-Home Supportive Services (IHSS) program, and the state’s existing network of experienced Medicare and Medi-Cal managed care health plans. The proposal promotes coordinated care models that provide timely, seamless access to the full continuum of medical, social, long-term, and behavioral supports and services that enable dual eligible beneficiaries to attain or maintain personal health goals.
We strongly believe that this demonstration will support better health outcomes for our beneficiaries, improve quality, and reduce costs. Today’s care system is complex, confusing and costly. Better coordination and care management will lead to improvements in chronic disease management, enhanced use of community-based support services, and reduced hospital and skilled nursing admissions. The capitated payment model to health plans will align incentives and provide needed flexibility to deliver the right care at the right time and place.
The demonstration proposal reflects recommendations and concerns voiced through our public comment process. Between posting this document on April 4, 2012 for public comment and submitting it today, we have held 13 public meetings with hundreds of stakeholders to get their input on details of the proposal. Additionally, we received a range of comments from a variety of stakeholders. The proposal balances the concerns and suggestions raised by a diverse group of stakeholders.
At your request, enclosed is a memo outlining the revisions made to the draft proposal in response to that input. Submission of this proposal is an important step in the partnership between the State and CMS to improve care for dual eligible beneficiaries. We look forward to ongoing collaboration with your office on this demonstration.
Department of Health Care Services
Department of Social Services
California Department of Aging
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