Improving health is our policy
By March 1, 2010, directs HHS to establish a CMS Federally Coordinated Health Care Office (“Medicare–Medicaid Coordination Office” or “Duals Office”). Specifies that the office’s purpose is to, among other functions, integrate and coordinate Medicare and Medicaid benefits for dual-eligibles. Directs HHS to report to Congress (via the Department’s annual budget submission process) on the office’s efforts, including legislative recommendations.
2012
Prior to January 2013, the Federal Coordinated Health Care Office (“Medicare-Medicaid Coordination Office” or “Duals Office”) was up and running and actively involved in a number of initiatives focused on improving the coordination and quality of care for dual-eligibles. A CMS consolidated webpage for this office contains details on the current activities of the office (e.g., Financial Alignment initiative), as well as background information on the office’s establishment and reports to Congress. More information can also be found here. For more information on the leadership of the “Duals Office,” visit here.
2013
On January 9, 2013, CMS posted guidance regarding the requirements and timeframes for the Medicare portion of the Capitated Financial Alignment demonstration. CMS also posted the application for participation in this program in CY2014.
On January 30, 2013, CMS issued guidance providing an overview of CY 2014 Medicare requirements and timeframes for Medicare-Medicaid plans (MMPs) in states that anticipate implementing the Financial Alignment demonstration in 2013.
On February 8, 2013, CMS issued an updated set of FAQs describing CMS’ joint rate-setting process for Medicare and Medicaid capitated Financial Alignment initiative models.
In February 2013, CMS finalized a MOU with California under the Financial Alignment initiative, bringing the total number of participating states with approved MOUs up to five (MA, WA, OH, and IL). Details here.
In April 2013, CMS posted a FY 2012 report to Congress detailing recent developments of the Medicare-Medicaid Coordination Office pursuant to the ACA. See also new information during April from the State Data Resource Center to assist state Medicaid agencies obtain and use Medicare data for care coordination of the dual-eligibles. CMS also posted an update on the Financial Alignment initiative last month – see here.
See the CMS Financial Alignment webpage for Medicaid-Medicare plan marketing guidance and model materials, posted in May.
On June 27, CMS announced a 3-year, $12 million funding opportunity designed to support states in providing coordinated care to dual-eligibles through Demonstration Ombudsman Programs. Through this opportunity, states can apply for funding to develop independent Demonstration Ombudsman Programs to support their current demonstrations through the Financial Alignment initiative. CMS has provided three rounds of applications with the first round due July 30; then October 8; and finally, January 14, 2014. CMS intends to enter into three-year cooperative agreements with states as early as this fall (September). A CMS fact sheet regarding this opportunity is available here. On a related note, on June 6, the CBO released a report examining the characteristics and costs of dual-eligible beneficiaries, an executive summary of which is available here.
On June 27, 2013, CMS announced a 3-year, $12 million Funding Opportunity Announcement designed to support states in providing coordinated care to dual-eligibles through Demonstration Ombudsman Programs. Under these programs, states will provide beneficiaries with access to new resources and person-centered assistance in resolving issues related to the demonstration. These programs will also monitor beneficiary experience and offer recommendations to CMS, the states, and participating plans on how the beneficiary experience could be improved. CMS estimates that $4.8 million is projected to be given to states in fiscal 2013 and $4 million in fiscal 2014. The total amount expected for each state ranges from $275,000 to $3 million over three years. With respect to the application timeframe, CMS has provided three rounds of applications with the first round due July 30; then October 8; and finally, January 14, 2014. CMS intends to enter into three-year cooperative agreements with states as early as this fall (September). A CMS fact sheet is available here and a press release here.
On August 6, CMS posted updated information on grants.gov pertaining to the next cycle of funding to support state Demonstration Ombudsman Program services to individuals who participate in the Financial Alignment model. The second round of applications are due by 3pm EST on October 3, with the third round due by 3pm EST on January 14, 2014. Also, note that on August 26, CMS and the state of New York formally announced their partnership to move forward with the implementation of the state’s Fully Integrated Duals Advantage (FIDA) demonstration under CMS’ broader Financial Alignment initiative. A webinar on the initiative was held on August 29.
On October 25, CMS approved South Carolina’s duals demonstration project known as “Healthy Connections Prime” under the agency’s Financial Alignment initiative. Additional information on implementation of the South Carolina demonstration is available here.
On Nov. 14, 2013, CMS posted here information pertaining to the recent issuance of the Contract Year (CY) 2015 Notice of Intent to Apply (NOIA) and related information under its Financial Alignment Initiative (“Duals Demonstration”). On Nov. 19, CMS posted the responses from the State of South Carolina given to several clarifying questions posed by CMS in order to determine whether the state’s ‘Duals Demo’ proposal meets the standards and conditions for the program. On Nov. 25, CMS and Washington State formalized a MOU for the state to proceed with a capitated model (via a three-way contract with Medicare-Medicaid Integration Plans) under the Financial Alignment initiative to improve care for dual-eligibles. The latest model is intended to complement the state’s managed FFS demonstration, which is already underway. CMS also recently updated its Financial Alignment Demonstration webpage to include: (1) Final CY 2014 Marketing Guidance for Ohio Medicare-Medicaid Plans; (2) Final CY 2014 Marketing Guidance for Illinois Medicare-Medicaid Plans; (3) Chapters of the Member Handbook for Virginia (see here to download the Pharmacy Provider Directory; here to download the Member Handbook; here to download the Summary of Benefits; and here to download the List of Covered Drugs); and (4) Translations of the Pharmacy Provider Directory, Summary of Benefits and List of Covered Drugs for Illinois (see here to download the Pharmacy Provider Directory). On Nov. 26, CMS posted the final contract for plans participating in the capitated model under Illinois’ Medicare-Medicaid Financial Alignment initiative.
On December 5, 2013, GAO released a report describing variations in consumer protections in place for dual eligibles in traditional Medicare and Medicaid and managed care options in those programs. The Senate Finance Committee held a hearing on this and other topics relating to dual eligibles on December 13, 2013.
On December 17, 2013, CMS provided an overview of the “readiness review” it will conduct to ensure the soundness of state Financial Alignment Initiative programs.
2014
On January 6, 2014, CMS issued a proposed rule delineating Contract Year 2015 MA and Part D policy and technical changes. The rule proposes, among other things, to limit and redefine, based on new criteria, Part D’s protected drug classes to initially include anticonvulsants, antiretrovirals and antineoplastics — but not antidepressants and immunosuppressants – as “drug categories and classes of clinical concern” for the 2015 coverage year. The rule addresses each of these provisions of the ACA in some manner. A CMS fact sheet is available.
In late December 2013, CMS issued Draft Medicare-Medicaid Plan (MMP) Marketing Guidance for the New York Capitated Financial Alignment Demonstration (here) as well as posted Chapter 8 of the Virginia MMP Evidence of Coverage (EOC)/Member Handbook model for CY 2014 & model member ID card for CY 2014 (here). Also, on a related note, on December 18, 2013, MedPAC and MACPAC released a data book entitled, Beneficiaries Dually Eligible for Medicare and Medicaid. In January 2014, CMS issued the 2015 MMP Annual Requirements and 2015 Capitated Financial Alignment Application, along with 2015 new applicant guidance (see here). Also in January 2014, CMS posted Appendix 5: State-Specific Enrollment Guidance for California and Illinois (here and here, respectively); Massachusetts’ evaluation design report here; contracts for plans participating in the California demonstration here and in the Virginia demonstration here; as well as Readiness Review tools for South Carolina (here) and Washington State (here).
In February 2014, CMS posted the following information: (1) Illinois – a revised version of the Illinois Medicare-Medicaid Plan (MMP) Enrollment and Disenrollment Guidance Exhibit 5a: MMP Welcome Letter; and the Integrated Denial Notice; (2) California – the California MMP Enrollment and Disenrollment Guidance [Exhibit 5a: MMP Welcome Letter for County Organized Health System (COHS) and Non-COHS plans]; the California Spanish-language MMP Member Handbook (Chapters 6,7,8 and 11); the MMP Member Handbook (Chapters 1 and 9), Spanish-language MMP Member Handbook (Chapters 1,2,3 and 5) and Spanish-language Pharmacy Provider Directory; (3) Virginia – Appendix 5: Additional State-Specific Enrollment Guidance Requirements for Virginia MMPs; and the Virginia MMP Enrollment and Disenrollment Guidance (Exhibit 5a: MMP Welcome Letter for Passively Enrolled Individuals and Exhibit 29: Model Notice for Enrollment Status Update); (4) Ohio – three-way template contact. Details here; and (5) Massachusetts – updated version of the Capitated Model Reporting Requirements for Massachusetts. On February 26, CMS posted an updated version of the Capitated Model Reporting Requirements here.
In March, CMS posted updated MMP Member Handbook information for Ohio (see here); revisions to the CY14 Marketing Guidance for California MMPs as well as other updates (see here); and information pertaining to Illinois Appeal Decision Notices (see here). More broadly speaking, CMS issued MMP Monthly Enrollment Payment Data Guidance (available here) and Guidance and Training Resources for the 2015 Formulary Submission Process with respect to the integrated drug benefit (see here).
In April, CMS posted updated Financial Alignment demonstration information pertaining to: (1) The Enrollment Data Validation (EDV) process for States and Medicare-Medicaid Plans (MMPs) (see here); (2) a webinar series for providers working with individuals with developmental disabilities (see varying dates here); and (3) 2015 Plan Benefit Package (PBP) Training (available here). Regarding state-specific developments, CMS posted: (1) Illinois – Reporting Requirements and FAQs (available here); (2) Ohio – the Spanish-language MMP Member Handbook Chapters 1-3, 5-8, and 11 available here; Spanish-language MMP templates for the Provider and Pharmacy Directory and List of Covered Drugs here; and Ombudsman Technical Assistance Program award here; and (3) California – revised version of the California Integrated Denial Notice available here.
On May 19, CMS issued a final rule on MA and Part D contract year 2015 technical changes. While the final rule codifies a number of fraud and abuse-related proposals, as signaled in an earlier letter to Congress the final rule does not adopt controversial proposed modifications to Part D protected drug classes or limitations on offering more than two Part D plans in a given region. The rule addresses each of these provisions of the ACA in some manner. A fact sheet is available here.
In May, CMS posted the following updates: (1) California – Revised versions of the Spanish-language California Medicare-Medicaid Plan (MMP) Member Handbook Chapters 2, 9, and 12 were issued. Spanish-language Chapters 8 and 10 for Los Angeles plans posted on the Information and Guidance for Plans page; (2) Washington – The Evaluation Design Plan is available here; and the Ombudsman Technical Assistance Program award is available here; (3) New York – Guidance for New York FIDA Plans regarding new marketing codes and model marketing materials is available here and here, respectively; (4) Massachusetts – Updated reporting templates for plans is available here; (5) Illinois – Updated reporting templates for plans is available here; and the state’s evaluation design plan is available here; (6) Virginia – the state’s evaluation design plan is available here; and (7) Texas – for details regarding the partnership/MOU between CMS and Texas, see here.
Key updates in June included: (1) New York – posting of the Chapter 8 Explanation of Benefits and Handbook here; the Summary and List of Covered Drugs here; and the Spanish-language Member Handbook for select chapters (1, 6, and 11) here; (2) Virginia – posting of the Reporting Appendix here; (3) Washington – posting of the Capitated Evaluation Design Plan here; (4) Ohio – posting of the Reporting Appendix and Templates here; and certain guidance documents available in Spanish here; and (5) Texas – posting of the addendum to the state’s MOU here. Finally, generally speaking, CMS published the Financial Alignment Demonstration Year 1 Quality Withhold Methodology and Core Technical Notes here.
Key updates for July include: (1) New York – the Integrated Explanation of Benefits (EOB) Models for CY 2015 were posted here; the Spanish-language New York MMP Member Handbook Chapter 8 was posted here; and both MMP Member Handbook Chapters 2, 5, and 7, in addition to the Spanish-language New York MMP Summary of Benefits and List of Covered Drugs were posted here; (2) Ohio – the Integrated Explanation of Benefits (EOB) Models for CY 2015 were posted here; and the MMP 2015 Member Handbook, Marketing Guidance, Member ID Card, Provider and Pharmacy Directory, Summary of Benefits, List of Covered Drugs, Integrated Denial Notices, Delegated Notices and Annual Notice of Change was posted here; (3) Illinois – the MMP 2015 Member Handbook, Marketing Guidance, Member ID Card, Provider and Pharmacy Directory, Summary of Benefits, List of Covered Drugs, Integrated Denial Notices, Delegated Notices (5a, 16, 27, 29, 30) and Annual Notice of Change were posted here; (4) Massachusetts – the MMP 2015 Member Handbook, Marketing Guidance, Member ID Card, Provider and Pharmacy Directory, Summary of Benefits, List of Covered Drugs, Integrated Denial Notices, Delegated Notices (5a & 5b) and Annual Notice of Change was posted here; (5) Virginia – the MMP 2015 Member Handbook, Member ID Card, Provider and Pharmacy Directory, Summary of Benefits, List of Covered Drugs, Integrated Denial Notices and Annual Notice of Change was posted here; and (6) Colorado – the final demonstration agreement was posted here. Also, in mid-July, CMS issued modifications to its ongoing funding opportunity to support states in the deployment of demonstration ombudsman programs serving Financial Alignment demonstration beneficiaries. Applications under this fifth funding round are due by 3pm ET on October 1, 2014.
Key updates in August include a general update of reporting requirement templates here(zipped file). Of note on the state-specific front: (1) Massachusetts – updates to the Spanish-language MMP 2015 Member Handbook, Provider and Pharmacy Directory, Summary of Benefits, List of Covered Drugs, and Annual Notice of Change here; (2) Ohio – updates to the Spanish-language MMP 2015 Member Handbook, Provider and Pharmacy Directory, Summary of Benefits, List of Covered Drugs, and Annual Notice of Change, as well as the MMP 2015 Final EOB and Delegated Notice (5a), posted here; (3) New York – MMP Member Handbook (Chapters 10 & 12), Part D Model Excluded Provider Letter and Part D Model Prescription Transfer Letter posted here; (4) Virginia – MMP Delegated Notices (5a, 29), MMP Reporting Requirement Templates (ongoing data collection tool), and MMP 2015 Marketing Guidance posted here; (5) Illinois – MMP 2015 Delegated Notice (4) posted here; and (6) California – MMP 2015 Member Handbook, Member ID Card, Provider and Pharmacy Directory, Summary of Benefits, List of Covered Drugs, Integrated Denial Notices, Delegated Notices (5a, 5b) and Annual Notice of Change posted here.
In September, CMS posted Version 2.1 of the MMP technical manual for submitting enrollment-related transactions to CMS. Regarding state-specific developments: (1) California – MMP 2015 Reporting Requirement Appendix and CY 2015 Marketing Guidance, as well as various other document and CY 2015 formulary updates (including an Ombudsman Technical Assistance Program award here), are posted here; (2) Colorado – The state’s Ombudsman Technical Assistance Program award is posted here; (3) Illinois – A revised CY 2015 formulary list and updates to the state’s MMP 2015 Member Handbook, among other documents, are posted here; (4) Massachusetts – A revised CY 2015 formulary update and MMP Integrated Denial Notice are posted here; (5) Minnesota – A Summary of Benefits, Low Income Subsidy (LIS) Rider and Annual Notice of Change are posted here; (6) Ohio – A revised CY 2015 formulary list is posted here; (6) Texas – The Texas Readiness Review Tool is posted here; (7) New York – The CY 2015 Marketing Guidance for New York FIDA plans is posted here; and (8) Virginia – A revised CY 2015 formulary list is posted here.
In October, CMS posted here updated information for: (1) Illinois (Provider FAQs); (2) Michigan (CY15 Marketing Guidance; 2015 Member Handbook and other key documents); (3) New York (Spanish-language 2015 Member Handbook; 2015 Member Handbook updates and other key documents, including Part D Model Transition Letter); (4) South Carolina (three-way contract; 2015 Member Handbook updates and other key documents); (5) Texas (2015 Member Handbook and other key documents); and (6) Virginia (Continuity of Care Provisions). In addition, broadly speaking, in late Oct., CMS provided updated information for Medicare-Medicaid Capitated Financial Alignment Model plans regarding CY 2014 Model Core Reporting Requirements.
In Nov., key updates include: (1) Colorado – posting of the state’s Evaluation Design Plan here; (2) Illinois – posting of revisions to Ch. 9 of the MMP 2015 Member Handbook as well as other documents here; (3) Michigan – posting of updated dates as well as the state’s Evaluation Design Plan here; (4) New York – updated 2015 Marketing Guidance for the state’s FIDA plans here; and (5) Texas – posting of guidance for MMPs on New Marketing Codes and the Release of Model Marketing Materials here. Also of note, CMS posted the Capitated Financial Alignment Model Core 1.2 Reporting Requirements template (Pharmacy Rejected Claims) here.
In November, MACPAC made available (via RTI) the following report titled, “The Effect of State Medicaid Payment Policies for Medicare Cost Sharing on Access to Care for Dual Eligibles.”
Regarding CMS’ Financial Alignment initiative, updates are as follows: (1) Michigan – updated CY 2015 Marketing Guidance for MMPs here; and Michigan MMP State-Specific Enrollment Guidance and updated Delegated Notices (5a & 5b) posted here; (2) Ohio – revised CY 2014 MMP Capitated Model Reporting Requirements posted here; (3) New York – updated FIDA Plan State-Specific Enrollment Guidance and FIDA Plan Integrated Coverage Determination Notice (ICDN) models posted here; (4) South Carolina – the Spanish-language South Carolina MMP CY 2015 Member Handbook (Chapters 4, 5, 9 & 12), List of Covered Drugs, Summary of Benefits and Provider Pharmacy Directory posted here; (5) Texas – the executed three-way contract for the Texas Dual Eligible Integrated Care Project is available here, along with MMP CY 2015 Marketing Guidance, Member Handbook (Chapters 1 & 4), Delegated Notices (5a, 5b, 21, 27 & 29) and updated Member ID Card, as well as Texas Dual Eligible Integrated Care Project State-Specific Enrollment Guidance posted here; and (6) Washington – CY 2015 MMP Marketing Guidance posted here.
On Jan. 23, 2015, CMS issued an informational bulletin delineating existing options for states to assess Medicaid enrollees, including those in the new adult group, for Medicare Savings Programs (MSPs) when the enrollees become Medicare-eligible. The guidance also addresses ways through which states can “improve the stability and continuity” of MSP coverage.
On Feb. 19, CMS issued a request for input pertaining to the Provider and Pharmacy Directory model template here for which comments are due by 5pm ET on Mar. 5, 2105.
On Feb. 25, CMS posted the annual plan requirements for Medicare-Medicaid Plans (MMPs) for contract year (CY) 2016, which also includes timeframes of key dates for resubmission of annually required information (appendix I).CMS indicated that it “will provide additional guidance regarding the applicability of CY 2016 Final Call Letter guidance to MMPs following the release of the Final Call Letter.”
Regarding state-specific demonstration activity, we call your attention to these key developments: (1) New York – FIDA Plan Pharmacy and Provider FAQs posted here and here, respectively. See also information regarding FIDA Appeal and Grievances Notices here and updated Plan Delegated Notice (Exhibit 30) here; (2) Texas – Dual Eligible Integrated Care Project Home Health Provider FAQs posted here; (3) Ohio – MyCare Provider Outreach Letter posted here; Illinois – Medicare-Medicaid Alignment Initiative Plan Delegated Notice (Exhibit 17) posted here; and (4) South Carolina – Healthy Connections Prime Provider FAQs posted here.
On Mar. 26, CMS posted updated MMP Enrollment Technical Guidance (version 2.2); details here and here.
On Mar. 27, CMS posted its Mar. 6 memo delineating clarifying guidance to its existing Oct. 2014 reporting requirements for MMP plans that follow a capitated model.
On state-specific fronts, CMS: (1) published the Michigan MMP Integrated Denial Notice (IDN) here and MI Health Link Provider FAQs here, as well as updated MMP ID card information here; (2) posted certain denial notices plus updated Enrollment Guidance for Illinois here; (3) posted MMP Drug-Only EOB for Texas MMP, as well as select chapters of Spanish language Texas MMP CY 2015 Member Handbook updates and ID card information here
Key updates in Apr. include CMS’ posting here of: (1) the Applicability of the 2016 Final Call Letter for MMPs; (2) the Outreach to Demonstration Eligible Individuals Memo; (3) the CY 2016 Medication Therapy Management (MTM) Program Guidance and Submission Instructions; and (4) the MMP Submission of Plan Benefit Packages for CY 2016. On the state-specific front, CMS posted New York FIDA Plan Home Health Provider FAQs here and MMP Capitated Financial Alignment Model Reporting Requirements for New York here. CMS also posted updated information for Texas’ MMP Appendix 5: State-Specific Enrollment Guidance Requirements here.
Key updates in May include CMS’ posting of the CY 2016 MMP Provider and Pharmacy Directory National Model Template and memo; as well as updated CY 2015 Marketing Guidance for Texas MMPs here and updated Michigan Health Link Provider FAQs here.
Key updates in June include CMS’ posting here of: (1) CA, IL, NY, MI, OH, SC, TX, and VA – the CY 2016 MMP Member Handbook, ID card, Summary of Benefits, Delegated Notices, Integrated Denial Notice, List of Covered Drugs, Provider & Pharmacy Directory, and Annual Notice of Change templates; (2) MA – the CY 2016 MMP Provider & Pharmacy Directory template; and (3) MI – updated CY 15 MMP Integrated Denial, Appeal Denial Notice and Late Coverage Decision Notice models; and the CY 2015 Medicare-Medicaid Capitated Financial Alignment Model Reporting Requirements.
Key updates in July include CMS’ posting here of the Financial Alignment Extension Opportunity Memorandum (details; LOIs due by Sept. 1, 2015); and the Financial Alignment Initiative Enrollment, Age and Health Risk Assessment as of July 2015 (details). State-specific postings include: (1) the CY 16 MMP Member Handbook (Chapter 9), Appeal Denial Notice, Late Coverage Denial Notice and Integrated Denial Notice templates for MI (details); (2) the CY 2016 MMP Spanish-language Summary of Benefits templates for CA, IL, MA, NY, OH, SC, and TX (details); (3) the CY 2016 MMP Spanish-language List of Covered Drugs templates for CA, IL, MA, OH, SC, and TX (details); (4) the CY 2016 MMP Spanish-language Annual Notice of Change templates for CA, IL, MA, NY, OH, SC, and TX (details); (5) The MMP Quality Withhold Methodology for CA and IL (details); and (6) signed MMP agreement between CMS and RI (press release; additional details). Finally, on a related note, for details regarding ongoing funding to support State Health Insurance Programs (SHIP)/Aging and Disability Resource Centers (ADRC) providing options counseling to dual-eligibles, see here. Applications under the next round are due Aug. 14.
(1) California – updated CY 2016 MMP Exhibit 22 template; (2) South Carolina – Exhibit 5a/5b template and updated CY 2016 MMP Member Handbook (Chapter 4) template; (3) New York – updated CY 2016 MMP List of Covered Drugs (LOCD) template; 2016 MMP Provider and Pharmacy Directory templates; and updated CY 2016 MMP Member Handbook (Chapter 4) template; and (4) Minnesota – CY 2016 MMP Marketing Guidance. Finally, CMS also posted the CY 2016 MMP Explanation of Benefits (EOB) templates (Drug-only and Integrated)
Key updates include CMS’ posting of the Medicare-Medicaid Plan (MMP) Advisory Committee Stipends and Non-Monetary Incentives memo; and the CY 2015 MMP Model Reporting Requirements Memo, Guidance and Core Value Sets Workbook, and Capitated Model Requirements Core Measure 2.1 FAQs here. State-specific updates posted here include: (1) Illinois – Medicare-Medicaid Alignment Initiative (MMAI) Continuity of Care Provisions and Provider FAQs (here); (2) Michigan – CY 2015 MMP Year 1 Quality Withhold Methodology; (3) New York – Spanish-language CY 2016 model materials for the New York Fully Integrated Duals Advantage (FIDA) Intellectual and Developmental Disabilities (IDD) Medicare-Medicaid Plan (MMP), as well as the Member Handbook/Evidence of Coverage (EOC) (Chapters 1-3, 5-8, and 10-12); List of Covered Drugs (Formulary) and Summary of Benefit; and the CY 2016 MMP Appeal (01-08) and Grievance Notices (01 and 02), Member ID Card and Integrated Coverage Determination Notices (Models 1-3 and instructions); (4) Ohio – CY 2015 MMP Year 1 Quality Withhold Methodology; and (5) Washington – Preliminary evaluation report from Washington State’s Health Home demonstration under the Financial Alignment Initiative (CMS blog post)
Key updates include CMS’ posting of the Financial Alignment Initiative data regarding enrollment, age and health risk assessment (HRA) under the capitated model as of February 2016; as well as MMP capitated model core reporting requirement templates here. Additionally, for New York’s FIDA model, CMS posted the CY 2016 MMP Member Handbook/EOC Chapters 4 and 9 for the FIDA Intellectual and Developmental Disabilities (IDD) model, as well as CY 2015 reporting requirement templates here. For Virginia, CMS posted CY 2015 and 2016 model reporting templates here.
Key updates include CMS’ posting here and/or here of the CY 2017 MMP Annual Notice of Change (ANOC) for all national models. State-specific postings include: (1) California – CY 2017 MMP Marketing Guidance and Marketing Guidance Memo; (2) Massachusetts – the Spanish-language CY 2017 MMP Handbook/EOC (Chapter 9); (3) Michigan – CY 2016 MMP Capitated Financial Alignment Model Demonstration Year 1 Quality Withhold Methodology; Reporting Requirements; Reporting Requirements Memo; as well as a revision to the CY 2017 MMP Marketing Guidance and Marketing Guidance Memo; (4) New York – CY 2017 MMP Marketing Guidance and Marketing Guidance Memo; the Spanish-language CY 2017 MMP Handbook/Evidence of Coverage (EOC) (Chapter 9); and the CY 2017 MMP Marketing Guidance and Marketing Guidance Memo; (5) Rhode Island – CY 2017 MMP Marketing Guidance and Marketing Guidance Memo; (6) South Carolina – the Spanish-language CY 2017 MMP ANOC and Handbook/EOC (Chapter 9); (7) Virginia – revised CY 2017 MMP Marketing Guidance and Marketing Guidance Memo; and (8) Washington – the first annual report on the state’s Health Homes Managed Fee-for-Service (MFFS) Demonstration under the model.
Key updates include CMS’ posting here and/or here of the updated National Enrollment/Disenrollment Guidance for States and MMPs; the PowerPoint slides for the MMP Provider Pharmacy Directory (PPD) Technical Assistance Call that was held on Sept. 8, 2016; the CY 2017 MMP Drug Only and Integrated EOB Models; and the CY 2016 Reporting Requirements Core Measure 2.1 FAQs. State-specific postings include: (1) California – CY 2017 Member ID Card and DN; (2) New York – CY 2017 MMP Delegated Notices (P1, P2, P3, P4 & P5) for the New York FIDA IDD model, as well as the final State-Specific Reporting Requirements Appendix and Workbook for the FIDA IDD model; (3) Rhode Island – CY 2017 MMP Handbook/Evidence of Coverage (EOC) (Chapters 5-12); and (4) Texas – CY 2017 MMP Marketing Guidance and Marketing Guidance Memo. Also, on a related note, CMS seeks comments on long-term services and supports (LTSS) measures and those related to dual-eligibles. Comments are due Oct. 7, 2016.
Key updates include CMS’ posting here and/or here of: (1) MMP Enrollment Technical Guidance (Version 2.7); 2) CY 2017 National Medicare-Medicaid Plan (MMP) Enrollment Guidance and Exhibits; and (3) CY 2016 MMP Provider and Pharmacy Directory (PPD) FAQs. Key state-specific updates include: (1) California – CY 2017 MMP PPD for the California mode; and (2) Rhode Island – Integrated Care Initiative Continuity of Care Provisions. CMS also posted a number of state-specific updates to appendices.
2017
Key updates include CMS’ posting here and here of the CY 2017 MMP draft audit program protocols related to care coordination and quality improvement and service authorizations, appeals and grievances; CY 2017 MMP Health Service Delivery (HSD) Criteria Reference Table (Network Adequacy Standards Criteria File for all States); the CY 2017 MMP Capitated Financial Alignment Model Reporting Requirements, Memo, and Core Value Sets Workbook; and the CY 2018 MMP Service Area Expansion (SAE) Application. State specific updates include: (1) California; Illinois, Michigan, Massachusetts, Ohio, Rhode Island, South Carolina, Texas, and Virginia – the posting of the CY 2017 MMP Integrated Denial Notices (IDNs); (2) Virginia – the posting of the CY 2017 MMP Member Handbook Chapter 4 (revised 2/27/2017); and (3) Massachusetts, Minnesota, and Washington – a letter offering a two-year demonstration extension opportunity.
Key updates include CMS’ posting here and here of a number of state-specific transmittals, as well as broader guidance regarding: (1) retrospective processing services; and (2) recent webinar slides, including those pertaining to pharmacy and provider directories. Additionally, in May, CMS posted its FY 2016 report to Congress that provides an overview of the agency’s efforts to improve care for 11.4 million dual-eligibles.
Key updates during Q3 of 2017 include CMS’ posting here and here of a number of state-specific transmittals, as well as broader guidance regarding: (1) MMP Coordinating State Passive Enrollment with Medicare Prescription Drug Plan Reassignment for January 2018; (2) Contract Year (CY) 2018 MMP EOB Models (Drug-Only and Integrated guidance; and (3) MMP Encounter Submission Data FAQs for plans participating in the Financial Alignment initiative.
SEC. 2602 [42 U.S.C. 1315b]. PROVIDING FEDERAL COVERAGE AND PAYMENT COORDINATION FOR DUAL ELIGIBLE BENEFICIARIES. (a) ESTABLISHMENT OF FEDERAL COORDINATED HEALTH CARE OFFICE.— (1) IN GENERAL.—Not later than March 1, 2010, the Secretary of Health and Human Services (in this section referred to as the ‘‘Secretary’’) shall establish a Federal Coordinated Health Care Office. (2) ESTABLISHMENT AND REPORTING TO CMS ADMINISTRATOR.—The Federal Coordinated Health Care Office— (A) shall be established within the Centers for Medicare & Medicaid Services; and (B) have as the Office a Director who shall be appointed by, and be in direct line of authority to, the Administrator of the Centers for Medicare & Medicaid Services. (b) PURPOSE.—The purpose of the Federal Coordinated Health Care Office is to bring together officers and employees of the Medicare and Medicaid programs at the Centers for Medicare & Medicaid Services in order to— (1) more effectively integrate benefits under the Medicare program under title XVIII of the Social Security Act and the Medicaid program under title XIX of such Act; and (2) improve the coordination between the Federal Government and States for individuals eligible for benefits under both such programs in order to ensure that such individuals get full access to the items and services to which they are entitled under titles XVIII and XIX of the Social Security Act. (c) GOALS.—The goals of the Federal Coordinated Health Care Office are as follows: (1) Providing dual eligible individuals full access to the benefits to which such individuals are entitled under the Medicare and Medicaid programs. (2) Simplifying the processes for dual eligible individuals to access the items and services they are entitled to under the Medicare and Medicaid programs. (3) Improving the quality of health care and long-term services for dual eligible individuals. (4) Increasing dual eligible individuals’ understanding of and satisfaction with coverage under the Medicare and Medicaid programs. (5) Eliminating regulatory conflicts between rules under the Medicare and Medicaid programs. (6) Improving care continuity and ensuring safe and effective care transitions for dual eligible individuals. (7) Eliminating cost-shifting between the Medicare and Medicaid program and among related health care providers. (8) Improving the quality of performance of providers of services and suppliers under the Medicare and Medicaid programs. (d) SPECIFIC RESPONSIBILITIES.—The specific responsibilities of the Federal Coordinated Health Care Office are as follows: (1) Providing States, specialized MA plans for special needs individuals (as defined in section 1859(b)(6) of the Social Security Act (42 U.S.C. 1395w–28(b)(6))), physicians and other relevant entities or individuals with the education and tools necessary for developing programs that align benefits under the Medicare and Medicaid programs for dual eligible individuals. (2) Supporting State efforts to coordinate and align acute care and long-term care services for dual eligible individuals with other items and services furnished under the Medicare program. (3) Providing support for coordination of contracting and oversight by States and the Centers for Medicare & Medicaid Services with respect to the integration of the Medicare and Medicaid programs in a manner that is supportive of the goals described in paragraph (3). (4) To consult and coordinate with the Medicare Payment Advisory Commission established under section 1805 of the Social Security Act (42 U.S.C. 1395b–6) and the Medicaid and CHIP Payment and Access Commission established under section 1900 of such Act (42 U.S.C. 1396) with respect to policies relating to the enrollment in, and provision of, benefits to dual eligible individuals under the Medicare program under title XVIII of the Social Security Act and the Medicaid program under title XIX of such Act. (5) To study the provision of drug coverage for new full-benefit dual eligible individuals (as defined in section 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u–5(c)(6)), as well as to monitor and report annual total expenditures, health outcomes, and access to benefits for all dual eligible individuals. (e) REPORT.—The Secretary shall, as part of the budget transmitted under section 1105(a) of title 31, United States Code, submit to Congress an annual report containing recommendations for legislation that would improve care coordination and benefits for dual eligible individuals. (f) DUAL ELIGIBLE DEFINED.—In this section, the term ‘‘dual eligible individual’’ means an individual who is entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act, or enrolled for benefits under part B of title XVIII of such Act, and is eligible for medical assistance under a State plan under title XIX of such Act or under a waiver of such plan.
Key updates include CMS’ posting here of: (1) the Financial Alignment Initiative Early Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Results; (2) a memorandum addressing Submission of Plan Benefit Packages for Contract Year (CY) 2017, Applicability of Final Call Letter Provisions to Medicare-Medicaid Plans (MMPs) for CY 2017, CY 2017 Final Call Letter, including MMP Annual Requirements and the CY 2017 Medication Therapy Management Program Guidance and Submission Instructions; and (3) various guidance pertaining to the New York FIDA demonstration.
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