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Update: Financial Alignment Demonstrations for Dual Eligible Individuals

Posted on July 18, 2012 | No Comments

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Implementation Briefs
Key Developments

By Katherine Jett Hayes


The Affordable Care Act (ACA) included a number of provisions designed to improve the delivery of health and long-term care support services for individuals who are eligible for and enrolled in both the Medicare and Medicaid programs, commonly referred to as “dual eligibles.” An earlier Health Reform GPS Implementation Brief outlined these changes. Among the provisions identified in the Brief was new demonstration authority provided to the Department of Health and Human Services (HHS) to permit states to waive certain provisions of Medicare law to better coordinate care for dual eligibles, new grant funding available to as many as 15 states to plan and implement integrated programs of care for dual eligibles, and the release of a July 11 State Medicaid Director (SMD) Letter providing preliminary guidance to states on demonstration models designed to improve care coordination for dual eligibles, including both capitated and fee-for-service models. This Brief provides an update on the financial alignment model outlined in the SMD letter, with a focus on subsequent guidance to states and health plans seeking to participate in capitated demonstrations. This demonstration is being followed closely at the federal level, and both the Senate Finance Committee and the House Energy and Commerce Committee have held hearings on the demonstrations.[1] In addition, Commissioners from both the Medicare Payment Advisory Commission (MedPAC) and the Medicaid and CHIP Payment and Access Commission (MACPAC) have discussed the demonstration in public meetings and have expressed concern about the ability of the federal government, states and plans to achieve savings and protect consumer access to care for this vulnerable population.[2]

New Guidance to States and Plans

The Centers for Medicare and Medicaid Services (CMS), under the auspices of the Medicare-Medicaid Coordination office and the Center for Medicare, has issued guidance[3] for states and health plans that choose to participate in a capitated demonstration for dual eligibles. Under this three-year demonstration, CMS will work with states to combine Medicare and Medicaid requirements to test new payment and service delivery models under Medicare and Medicaid, with a goal of reducing expenditures under the programs while improving quality of care. Under the demonstrations, plans would begin delivering services in January 2013. The guidance documents lay out timelines and requirements for states and plans that wish to participate in the program. The guidance includes details on requirements relating to deadlines and other conditions pertaining to the availability of information to the public and opportunity for comments on state plans at the state and federal levels. In addition, CMS has provided information for plans that wish to be considered for participation as a qualified plan, as well as additional detail as to how conflicting provisions of Medicare and Medicaid requirements will be addressed in the three-way contracts negotiated between states, CMS, and participating plans.[4]

State Interest in Dual Eligible Realignment Models

In response to the July 11 SMD letter, thirty-eight states and the District of Columbia expressed interest in testing models of care for dual eligibles, and 15 states were awarded funding to design programs. Selected states include California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington and Wisconsin. The financial alignment initiative is not limited to states that were awarded funding, however; as part of the review and approval process, CMS has posted plan summaries for 26 states and have sought public comment as part of the review and approval process.[5] As of this posting, CMS has officially posted plans the public comment period remains open for 18 of these proposals.[6]

CMS’s January 25, 2012 guidance included information relating to how payment rates for participating plans will be developed, stressing that plans must offer the full continuum of Medicare and Medicaid benefits. The guidance summarized the process for submission, review and federal approval of the demonstration proposals in order for health plans to have an effective date of January 1, 2013. CMS indicated the plans will be jointly selected by the states and the federal government. Plans will be required to meet standards outlined in the guidance, as well as any additional state-specific requirements. The guidance also provided instructions for plans that seek to participate, noting that plans that failed to meet the April 2, 2012 deadline would not be permitted to participate in the demonstration in 2013. Finally, CMS outlined a process for plans to demonstrate network adequacy, including how plans may seek exceptions from Medicare network adequacy standards for non-drug medical services. CMS indicated that plans will be required to meet all Medicare Part D requirements under the demonstration. As part of the March 25, 2012 guidance memorandum, CMS provided additional clarification on plan requirements, the process that CMS and states will employ to review marketing and beneficiary materials, as well as oversight.

The demonstration requires three-way joint procurement contracts, and reimbursement to plans will be based on a blended capitated rate for the full range of benefits. Rates will be developed by CMS with each state based on baseline spending in both programs, less anticipated savings resulting from integration and improved care management. The Part D portion will be based on the standardized national average bid and will be risk-adjusted as currently applicable under Part D. The rate must provide upfront savings to both CMS and the state or will not proceed. CMS Office of the Actuary will work with state actuaries to determine portion of capitated payment paid by state and federal governments.

Key Program Requirements

In developing the policy framework for this demonstration, CMS determined that Medicare and Medicaid policies are inconsistent in a number of key areas. CMS resolved these areas of inconsistency in one of two ways. First, in some instances CMS established requirements, referring to them as “pre-established parameters”, that will be used in the three-way contracts between plans, states and the federal government. Second, where CMS is willing to permit flexibility, the agency established “preferred requirement standards.”[7] Using these two approaches, CMS has established certain requirements. Unless otherwise indicated, the policies stated below are mandatory “pre-established parameters:”

  • Payments to plans – Plans will be paid on a capitated basis for the full range of Medicare and Medicaid services. Plans may not charge cost-sharing under Parts A and B, and may not charge premiums under Parts C or D. CMS will use Medicare Part D payment principles for prescription drugs, and will retain all other Part D requirements. Payments to part D plans will be based on the standardized national average Part D average bid amount. CMS also provided additional guidance to plans with respect to Part D formulary requirements and how they should be submitted, the submission of the plan benefit package.
  • Enrollment – States may request CMS approval of a “passive enrollment process,” in which beneficiaries are auto-enrolled, but the individual retains the right to “opt out.” In order to be approved, states’ passive enrollment policies must include advance notice to beneficiaries of enrollment in a plan, permit a beneficiary to opt out prior to or following enrollment, and must permit individuals to switch to another plan. According to guidance, CMS and the states will work together to select qualified plans in each state either through a procurement or certification process. CMS’s “preferred requirement standard” indicates that the joint selection process will consider plans’ past performance in Medicare and Medicaid.
  • Medical loss ratios (MLR) – Beginning in 2014, all Medicare Advantage (MA) plans will be required to maintain medical loss ratios of 85 percent. Although plans participating in the demonstration will not be required to meet the MLR requirements for their demonstration-participating plans, they will be required to report on costs, so CMS indicated that the agency will have MLR information.
  • Network Adequacy – Under current law, most state contracts require plans to provide assurances of network adequacy along with supporting documentation that demonstrates they have the capacity to serve expected enrollment in accordance with state access standards. Federal law also requires plans to have a sufficient number, mix and geographic distribution to meet the needs of the anticipated number of enrollees in the service area. Accordingly, CMS has indicated that the “preferred requirement standard” would be to utilize state standards for long-term care networks, and current law Medicare standards for medical services and prescription drugs. Where services are covered under both Medicare and Medicaid, the appropriate network standard will be determined in a memorandum of understanding negotiated between states, CMS and plans.
  • Appeals– CMS has indicated that the “pre-established parameter” will include a uniform appeals process; most of the provisions outlined in the January 25 guidance are “preferred requirement standards,” which indicates CMS will permit flexibility in many areas. Recognizing that some states may require regulatory changes or legislative approval, as in the area of timeframes for filing an appeal, CMS has established a “preferred requirement standard” of 60 days, which is consistent with Medicare requirements. If states are unable to change Medicaid standards by 2013, plans will use Medicare standards unless the state allowable timeframe is greater than 60 days. In addition to appeals timeframes, other issues addressed in the guidance include:
    • Access to State-level or external review: The “preferred requirement standard” developed by CMS suggests that beneficiaries be required to appeal at the plan level, then have access to external appeal. Since some states permit bypass of internal appeal, states will be encouraged to provide for initial appeal to be made at the plan level. The agency noted that CMMO does not have the authority to override this state-level bypass requirement.
    • Continuation of benefits during appeal: Under the demonstration, CMS has indicated that the “preferred requirement standard” would be a hybrid approach that covers services during the initial plan review, however, once appeals reach external review, benefits would not be covered. Medicaid-only benefits, such as long-term care services and supports not covered by Medicare, would continue as under the Medicaid standard. CMS also notes that only benefits that are initially provided and later reduced or terminated would continue pending the initial appeal.
    • Document notifying beneficiaries of appeal rights: CMS indicated that the “preferred requirement standard” at the state level would be a single document that explains an integrated appeals process.
    • Timeframes for resolution of an appeal related to benefits: CMS has indicated that the ”preferred requirement standard” for plan resolution of benefits appeals will be 30 days for standard appeals and 72 hours for expedited appeals, utilizing the Medicare standard, rather than the longer standard permitted under Medicaid.
  • Benefits/Medical Necessity – States must ensure that all services covered under the state plan are available and accessible. States define medical necessity under Medicaid, but the medical necessity standard for managed care may be no more restrictive than under fee-for-service. Medicare defines medical necessity as those services designed to diagnose or treat illness or injury, or to improve the function of malformed body members. In its guidance, CMS indicates that the agreement may allow greater flexibility in supplemental benefits than provided under current law, and that the preferred Medicare standard for acute care services and prescription drugs and that the Medicare standard would apply for long-term care services and supports. Overlap will be addressed in contracts.
  • Marketing/Beneficiary Information – CMS indicated that a flexible approach will be taken to both minimum marketing requirements and review processes. The agency will defer to which standard is more beneficiary-friendly for readability and translation standards. CMS indicated that it is implementing modifications to the Health Plan Management System (HPMS) Marketing Module, and that it plans a joint review (CMS and each state) consistent with the module for each demonstration. CMS indicated that the module would be released on June 6, 2012.
  • Quality Reporting – CMS and states will determine applicable standards and jointly conduct single comprehensive quality management and consolidated reporting process. CMS indicated that the preferred standard would require strong consistent quality oversight and monitoring requirements, and that the requirements would be integrated to include some measures used by both programs. The core set of measures would permit comparison with plans in the capitated demonstration, as well as in the fee-for-service demonstration. Prescription drug quality reporting measures will be consistent with Medicare Part D program requirements. CMS also include standards to performance improvements and quality incentives.
  • Model of Care – CMS’ “preferred requirement standard” will include uniform model of care requirements for participating health plans and that plans must submit model of care (MOC) information to CMS. CMS will review and approve MOC submissions based on the same elements and scoring standards established for Medicare Advantage Special Needs Plans, but must also be structured to meet any additional State requirements. CMS included details relating to the MOC criteria in the March guidance memorandum MOC criteria at appendix 2.
  • Oversight, Monitoring, Auditing and Program Integrity – CMS-State management teams will insure access to quality, program integrity, and financial solvency. CMS’ “preferred” approach is coordinated oversight negotiated and determined by a memorandum of understanding (MOU) or contract, providing states with the authority to conduct auditing functions and plan monitoring if they establish that the state standard meets or exceeds the Medicare standard. Part D requirements will continue as under current law, and states will be informed of results and actions taken by CMS. Finally, the goal of oversight will be to improve performance and remove consistently poor performers from the program.

Key Dates

Plans that desire to participate in the demonstration must have notified CMS prior to April 2, 2012. CMS has indicated that plans would be selected through a joint selection process by July 30, 2012. CMS and the states will conduct readiness reviews for selected plans through September of 2012. Beneficiaries will be able to select plans from October 15, through December 7, 2012, and will begin receiving services through plans on January 1, 2013. More detailed timelines for states and plans are available in guidance documents.

Key Questions

Passive Enrollment & Disruption of Services

Although states have been permitted to require enrollment in managed care for Medicaid services, this demonstration represents the first time CMS has approved mandatory enrollment in managed care for Medicare services. Although the policy is characterized as “passive enrollment” with an opt-out, a number of states are seeking minimum lock-in periods, some as high as six months.[8] The issues of auto-enrollment with an opt-out and proposed lock-in periods has become a point of contention at the state and federal levels. While plans insist that auto-enrollment is necessary to assure sufficient volume to justify plan investments in care coordination services, and CMS has gone along with that assertion, many consumer-based organizations have expressed concern that both the pace of implementation and the volume of enrollment proposed in many states could jeopardize quality of care and patient safety if plans are not ready or are not experienced in providing both acute and long-term care services and supports for this population. How will CMS and states address these concerns, and will CMS approve minimum “lock-in” periods in defining passive enrollment?

Under Medicare Part D, beneficiaries who do not auto-enroll in plans are auto-assigned. In addition, some duals have already enrolled in Medicare Advantage plans. Will individuals already enrolled (or auto-assigned under Part D) face disenrollment in their current plans and auto-assignment into new demonstration plans, and if so, how will states and CMS address disruptions in services to beneficiaries?

Financing of Long-term Care Services and Supports

Under Medicaid, states define medical necessity. The Medicare standard has been interpreted by courts to limit access to services for Medicare beneficiaries with chronic conditions where services do not have the effect of improving function.[9] The CMS guidance indicates that state Medicaid medical necessity standards apply to long-term care services and supports, while the Medicare standard continues to apply to preventive, primary, and acute services. At the same time, the use of state medical necessity standards for long-term services and supports for which at least some Medicare coverage is available, suggests that Medicare coverage might be available in ways not previously allowed under traditional Medicare financing and coverage standards. How will blended Medicare and Medicaid payments expand coverage?


Guidance indicated that CMS would provide states with the authority to conduct audits and monitor plans, provided the state meets or exceeds the Medicare standard. In addition, CMS will continue to implement the oversight applied to Medicare Advantage managed care and Part D plans to demonstration plans. How will CMS determine whether a state meets or exceeds the Medicare standard?

Effects of Policy on Part D

Proponents of Medicare Part D’s private plan structure have expressed concerns about the impact of this project on payments to Part D plans. Since Part D plans often compete in their bidding to bid below the low-income subsidy benchmark in order to be eligible for auto-assignment of dual eligibles into their Part D plans, the movement of duals from the Part D bidding model to the demonstration plans could have an impact on this downward pressure on the benchmark plan. What impact the demonstrations have on the bidding for Part D plans seeking this population?

[1] “Dual-Eligible Beneficiaries: Improving Coverage while Lowering Costs,” Senate Committee on Finance. September 21, 2011. “Dual-Eligibles: Understanding this Vulnerable Population and How to Improve their Care,” House Energy and Commerce Subcommittee on Health. June 21, 2011.
[2] MedPAC meetings, March 8-9, 2012 and April 5-6, 2012. Agenda and transcript available online at MACPAC meeting April 19, 2012. Agenda available online at
[3] Guidance documents, which include two memoranda as well as Frequently Asked Questions (FAQ) and other documents are available online at
[4] Id.
[5] Summaries are available online at
[6] Id.
[7] Memoranda from Melanie Bella, Director Medicare-Medicaid Coordination Office and Jonathan Blum, Director, Center for Medicare to Organizations Interested in Offering Capitated Financial Alignment Demonstration Plans in Interested States. January 25, 2012 and March 29, 2012.
[8] For a summary of state enrollment proposals see: “Proposed Enrollment Methods,” National Senior Citizens’ Law Center. Available online at
[9] For a detailed discussion, see Vicki Gottlich, “Medical Necessity Determinations in the Medicare Program: Are the Interests of Beneficiaries With Chronic Conditions Being Met?” Center for Medicare Advocacy, Inc. January 2003.
“Dual-Eligible Beneficiaries: Improving Coverage while Lowering Costs,” Senate Committee on Finance. September 21, 2011. “Dual-Eligibles: Understanding this Vulnerable Population and How to Improve their Care,” House Energy and Commerce Subcommittee on Health. June 21, 2011.
MedPAC meetings, March 8-9, 2012 and April 5-6, 2012. Agenda and transcript available online at MACPAC meeting April 19, 2012. Agenda available online at
Guidance documents, which include two memoranda as well as Frequently Asked Questions (FAQ) and other documents are available online at
Memoranda from Melanie Bella, Director Medicare-Medicaid Coordination Office and Jonathan Blum, Director, Center for Medicare to Organizations Interested in Offering Capitated Financial Alignment Demonstration Plans in Interested States. January 25, 2012 and March 29, 2012.
For a summary of state enrollment proposals see: “Proposed Enrollment Methods,” National Senior Citizens’ Law Center. Available online at
For a detailed discussion, see Vicki Gottlich, “Medical Necessity Determinations in the Medicare Program: Are the Interests of Beneficiaries With Chronic Conditions Being Met?” Center for Medicare Advocacy, Inc. January 2003.

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