This blog was originally published by the Health Affairs Forefront on October 14, 2022.
MACPAC, the Bipartisan Policy Committee, and others, including Keohane and Hwang (2022) in an earlier Forefront article, have noted the value of incorporating elements of the state demonstrations under the Financial Alignment Initiative (FAI) into future policies focused on integrating care for dually eligible enrollees. As the CY 2023 Medicare Advantage Final Rule stated, CMS intends to work with states to transition the FAI capitated demonstrations to integrated Dual-Eligible Special Needs Plans (D-SNPs) by 2025. The CY2023 Medicare Advantage rule includes several features of the FAI demonstrations that will be applicable to Dual Eligible Special Needs Plans (D-SNPs), including enrollee advisory committees and expanded use of integrated grievance and appeals processes. While these features are a step forward, as others have pointed out, additional elements could further support integrated care models.
Throughout our work conducting the CMS evaluation of the FAI demonstrations, we have found that a team approach helps to align Medicare and Medicaid at the state level. States need to better understand Medicare regulations and data, and need support in shifting to fully integrated dual eligible special needs plans (FIDE SNPs), highly integrated special needs plans (HIDE SNPs), and D-SNPs with aligned enrollment with a Medicaid plan, i.e, individuals enrolled in a D-SNP are also enrolled in a Medicaid plan administered by the same parent company. FIDE-SNPs are managed care organizations delivering Medicare and Medicaid services under separate federal and state managed care contracts. HIDE-SNPs also have contracts with both Medicare and their respective states, but the state Medicaid contract focuses on either long-term services and supports (LTSS) or behavioral health services or both. Some other D-SNPs only contract with Medicare but are aligned with a Medicaid managed long term services and supports (MLTSS) plan.
Further administrative alignment between states and the Centers for Medicare & Medicaid Services (CMS) will be key to the success of future integration efforts. The experience of the Contract Management Teams (CMTs) implemented under the FAI, as discussed more below, could be brought forward to facilitate future integration efforts.
As part of our evaluation work, we interviewed demonstration states, CMS, Medicare-Medicaid Plans, and other stakeholders at least annually since the first FAI demonstration began in 2013. Medicare-Medicaid Plans are the managed care plans that contract with the state and CMS to deliver integrated primary, acute, and LTSS services to demonstration enrollees. We identified the CMT in the capitated model demonstrations, and its analog, the Demonstration Management Team (DMT) in the Minnesota administrative model demonstration, as key features supporting Medicare and Medicaid integration. These teams foster communication between CMS and state Medicaid authorities, work to align federal and state policies and practices, and, in the capitated models, share responsibility for monitoring the activities of Medicare-Medicaid Plans. Developing shared contract management when D-SNPs operate with aligned managed LTSS (MLTSS) enrollment could be a valuable mechanism to promote administrative alignment and support states in effective Medicare-Medicaid coordination.
Capitated Models’ Contract Management Teams
To oversee and reconcile the often-different administrative policies and processes of the Medicare and Medicaid programs, new management or governance structures were established for the demonstrations under the FAI. In the capitated models, these structures take shape in the form of a joint CMT comprised of state agency and CMS Regional Office and Medicare-Medicaid Coordination Office (MMCO) staff. The CMT is required under each demonstration’s CMS-state-Medicare-Medicaid Plan three-way contract. Its aim is to align all of the complex Medicare and Medicaid administrative processes in a manner that is seamless to enrollees.
The CMT is responsible for day-to-day monitoring of the Medicare-Medicaid Plans, including monitoring plans’ compliance with the three-way contract and reviewing performance and enrollment data, marketing materials, and beneficiary protections data such as complaints, grievances and appeals data, and reports from demonstration ombudsmen.
As part of its contract monitoring responsibilities, each CMT also meets regularly with each Medicare-Medicaid Plan. At these meetings, core CMT members share their specific expertise to help the rest of the team understand and resolve alignment issues. For example, the state shares its expertise in Medicaid, LTSS, and behavioral health. MMCO provides insight on broad Medicare policies and oversight of specific issues (e.g., marketing and enrollment processes), and CMS Medicare regional office staff bring knowledge of Medicare operations. CMT members from the state and CMS also bring in additional staff with specific area expertise (e.g., state home and community-based services [HCBS] waiver experts, enrollment team members, or quality management staff) as needed.
In these meetings in one state, for example, the CMT and Medicare-Medicaid Plan staff discussed marketing materials, staffing, and provider training; they also reviewed a dashboard that displayed key performance indicators, including frequency and accuracy of health risk assessments, grievances and appeals, and claims. Participants brainstormed solutions to issues that surfaced in the dashboard data. In other meetings of the CMT and Medicare-Medicaid Plan, participants worked together on special initiatives like quality improvement projects, and the CMT helped Medicare-Medicaid Plan staff understand Medicare and Medicaid policies and guidance.
Stakeholders in capitated model demonstration states consistently highlight the importance of the CMT in addressing ongoing issues related to the integration of Medicare and Medicaid policies and processes. In particular, states report it is difficult to keep up with Medicare Advantage policies, procedures, and processes that may impact their integrated programs, ranging from member materials and marketing to network adequacy, enrollment, and benefits. Meeting regularly with CMS via the CMT provides an opportunity for states to learn about upcoming changes and ask questions about new and existing policies that may impact integration.
Minnesota’s Demonstration Management Team (DMT)
The Minnesota Administrative Alignment Demonstration is based on the state’s well-established Minnesota Senior Health Options (MSHO) program, which launched in 1997. The current demonstration began in 2013 and is not formally part of the FAI demonstration but rather a vehicle to develop and codify administrative processes that promote Medicare Advantage and MLTSS administrative consistency. A key feature is the Demonstration Management Team (DMT), which draws on aspects of the CMT model and offers an approach that CMS and states could utilize with FIDE-SNPs, HIDE-SNPs, and D-SNP-MLTSS aligned enrollment models.
While Minnesota has been a forerunner in integrated care for dually eligible beneficiaries, the DMT provides a previously missing element necessary for administrative alignment. In site visit calls, Minnesota and MSHO plans said that prior to the demonstration—and prior to creation of the MMCO, authorized by the Patient Protection and Affordable Care Act—the state relied on the plans for information about Medicare Advantage changes, and state officials were seldom able to talk directly with Medicare. One plan said that in those days the plans were like “children of divorced parents” who needed to explain each parent’s rules to the other parent.
The DMT does not have a three-way contract to manage. MSHO plans are FIDE-SNPs, with CMS overseeing the Medicare Advantage contract and the state Medicaid agency overseeing the Medicaid managed care contract. The DMT meets every other week to address alignment challenges, coordinate oversight by CMS and the state, and share information. Unlike the capitated model CMTs, the DMT does not meet with the plans; rather, CMS and the state each manage their own contracts with the plans.
Initially the DMT focused on specific administrative alignment activities outlined in the demonstration memorandum of understanding, such as developing collaborative processes for reviewing the adequacy of plans’ provider networks and annual updates of integrated member materials. As demonstration activities were completed, the DMT continued to address alignment challenges as they emerged by providing a channel for dialogue and coordination.
The DMT has played an important role in aligning MSHO enrollment across Medicare and Medicaid. Older adult dually eligible beneficiaries in Minnesota may voluntarily enroll in an integrated D-SNP, and the state functions as the third-party administrator for enrollment, essentially the enrollment broker. In 2019, for example, the DMT helped the state prepare for a change in the Special Enrollment Period for dually eligible beneficiaries, which posed a challenge for MSHO, and explore the option of default enrollment, which Minnesota hopes to implement.
The DMT continues to be the vehicle for coordinating annual updates to integrated member materials, developing and piloting a streamlined process for revisions and review. The DMT helps coordinate state participation in annual Medicare Advantage network adequacy reviews, which have greatly reduced the number of exceptions plans need to submit to Medicare for gaps in some of the sparsely populated rural counties.
From the federal perspective, the DMT has helped CMS identify best practices used by Minnesota, pilot a new process for annual updates of member materials, and test integrated denial notices. The state has said that the DMT may be the most important feature of the Minnesota demonstration, because “alignment is never completed," and ongoing collaboration and problem solving are essential. Alignment challenges continue to arise as Medicare works to maintain consistent policies, procedures, and processes nationwide, while states adapt Medicaid policies to meet their needs.
Lessons Learned For Future Integrated Care Models
As CMS, states and managed care organizations move toward integrated care models that use D-SNPs aligned with Medicaid managed care as their foundation, joint CMS-state teams will be important for coordinating Medicare-Medicaid integration through integrated D-SNPs and helping states better understand Medicare regulations. While states pursuing integration through integrated D-SNPs will not have the same level of joint management as the FAI capitated demonstrations, CMS is well-positioned to apply lessons learned from both the capitated demonstrations and Minnesota's administrative alignment demonstration. Even without a three-way contract to manage, it will be important to create mechanisms for promoting coordination and communication between CMS and state Medicaid agencies. The types of administrative alignment challenges addressed in the FAI demonstration will be present in every state, with both sides—CMS and state agencies—needing to understand each other’s policies and regulations and work together to resolve differences.
In Minnesota, MMCO members expect to continue meeting as a team with the state after the demonstration ends. Other states with D-SNPs can do the same thing, and some of them already have regular meetings, including Arizona, New York, Indiana, and Washington, DC. Given states’ need to better understand Medicare and evolving regulations, a Medicare-Medicaid alignment team addressing integration issues as done in the CMTs and the Minnesota DMT could provide a vehicle for much needed ongoing coordination.