Arizona Medicare-Medicaid Dual Eligible Demonstration Proposal Comments

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1 1. 4/24/12 5/17/12 Multiple Arizona Nursing Facility Administrators 1 Recommend a public analysis, or study, of the economic impact of the Dual Demonstration on Arizona s skilled nursing facilities. For example what is the difference between traditional Medicare and Medicare Advantage rates, per member per month? How does the length of stay change impact facilities and plans? Passive enrollment restricts resident choice; recommend voluntary participation. Should passive enrollment occur, we request consideration of an extensive opt out period, with clear marketing guidelines and oversight for both the Plans and providers. We support the goal of administrative integration. This will require significant correction to the culture of operations. There is a rich repository of data and resources in the Minimum Data Set (MDS), currently completed for every nursing facility resident- both Medicare and Medicaid. Medicare Resource Utilization Groups or RUGS should be a baseline requirement for the DUAL MA Plans and will dramatically mitigate negative financial consequences of this Demonstration. It will allow you to focus on the full potential for clinical integration. Financial and clinical incentives should be aligned for the providers, as well as for the Plans and the State. It was indicated in the draft proposal that the State and the Plans will be sharing any savings, but the providers are the party at risk- from both a liability and The state is evaluating the data it has access to and whether this type of analysis can be done although any appropriate economic analysis should look at other issues like excess system capacity and efficiency opportunities. The Demonstration provides the greatest opportunity for alignment and coordination of services for dual eligible members. AHCCCS will continue an extensive education and engagement process for consumers and stakeholders. Members will have no less than 90 days advance notice to optout into Original Medicare. Arizona had a successful passive enrollment experience in AHCCCS agrees and will be notifying members of passive enrollment at least three months in advance. Marketing guidelines will be determined jointly by CMS and the State. AHCCCS agrees and is in full support of administrative integration and efficiencies for providers. Agree that yes this will be a change in culture which will need to be addressed during plan readiness. Plans will need to integrate operations under new Demonstration requirements. AHCCCS is taking this suggestion under consideration and may evaluate the impact of a change to the MDS tool under the Demonstration. AHCCCS is currently working with CMS to identify provider payment rate structure under the Demonstration. As the Demonstration is outlined by CMS, CMS and the State will share in the savings under the Demonstration. Additional incenting for providers and plans can continue to be discussed and evaluated. AHCCCS is also proposing that a portion of savings be reinvested back into the Demonstration in the

2 financial perspective. Is there some way to consider shared risk and reward? This would be especially important in the goal of reducing hospital readmissions. form of additional member benefits. AHCCCS has stated repeatedly that payment reform and gain sharing efforts between payers and providers are critical to reforming and improving the health care delivery system. 2. 5/11/12 Christie R. Boutte, PharmD., R.Ph. National Association of Chain Drug Stores 3. 5/15/12 Tanie Sherman, RN, MBA Arizona Hospital and Healthcare Association 4. 5/16/12 Jan Faiks 2 Including community pharmacists as a part of the coordinated care models for dual eligible beneficiaries is one of the many ways of using a pharmacist s clinical skills to improve patient outcomes. We urge the agency to obtain Medicare Parts A, B, and D data from CMS. Inclusion of Medication Therapy Management services The proposal does not modify the current separate appeals processes for the Medicare and Medicaid components of claims. Although AzHHA understands that CMS has expressed its preference for maintaining two separate appeals systems, we urge CMS to reconsider. Develop a policy to ensure that providers are not subject to separate audits on both Medicare and Medicaid for the same underlying claims. Modify the proposal so that hospitals will continue to receive reimbursement for crossover bad debt for dually eligible members who are moved into a unified plan. Provide information about whether dually eligible members who are now part of an ACO will be moved into unified plans; whether members moved into unified plans will be removed from ACOs; and how that removal will affect ACOs right to shared savings. Require MCOs participating in the Demonstration to either (1) become a Medicare Part D plan subject to all of the Part D Thank you for your comment. AHCCCS currently receives Medicare A and B data from crossover claims and is in the process of requesting Part D data from CMS. Given that 60% of the dual members are enrolled in managed care the Medicare A and B data is very limited. Plans will be held to all Part D MTM requirements. Currently, providers who are contracted with Medicare Advantage plans do not have appeal rights for the denial of claims. AHCCCS is working with CMS to identify if there are opportunities for changes to this regulation under the Demonstration and whether there could be a more integrated appeals process. AHCCCS will take this comment into account in discussions with CMS. CMS is currently evaluating the Medicare bad debt issue under the Demonstration. Yes, all dual eligible members will be passively enrolled into the Demonstration, regardless of ACO enrollment. It is our understanding that members must be enrolled in Original Medicare to be eligible for ACO enrollment so those enrolled in the Demonstration would not meet criteria. The affect on sharing savings would be a good question to direct to CMS. AHCCCS will be adopting the CMS preferred requirement that all Demonstration plans be required to meet all Medicare Part D requirements.

3 The Pharmaceutical Research and Manufacturers of America requirements or (2) contract with the patients Part D plan Ensure that Demonstration plans offer the same level of access to medicines covered through Medicare Part B as is offered by Medicare Advantage and in Fee-For-Service Medicare Demonstration plans will be required to cover all benefits currently covered by Medicare A, B, D and AHCCCS Significantly reduce planned enrollment in the Demonstration to avoid destabilizing Part D for non-dual beneficiaries and risking significant disruptions of care for beneficiaries in Arizona. Arizona is expanding this Demonstration to as many beneficiaries as possible to improve care and outcomes for the maximum number of individuals. Protect beneficiary choice and avoid disruptions in care during this Demonstration by exempting from passive enrollment in the Demonstration all beneficiaries who have made an affirmative choice to enroll in a Medicare Advantage or Special Needs Plans, or affirmatively chosen a Part D plan The Demonstration provides the greatest opportunity for alignment and coordination of services for dual eligible members. This proposal provides for additional coordination and improvements in efficiencies over what currently exists when members are enrolled in Medicare Advantage plans. Disruptions in care will be minimized as members will be enrolled for Medicare into their current Medicaid plan. The vast majority of members will continue to have a choice of plan to enroll in plus Original fee-for-service Medicare. Protect continuity of care by establishing a transition period of at least six months during which beneficiaries can access their current providers and maintain their current prescriptions. The Demonstration requirements will outline transition requirements for providers and medications. Arizona has previously transitioned over 30,000 dual members with very limited impact on beneficiaries. AHCCCS also has extensive experience in managing Medicaid member transitions for tens of thousands of members. Given the likelihood that Medicaid MCOs are unfamiliar with Medicare requirements related to coverage of medicines under Part B, it is important that guidance to plans should include specific detail on the Medicare Part B requirements relating to coverage of drugs. All current AHCCCS MCOs are also Medicare Advantage Dual Eligible Special Needs Plans and thus familiar with all Medicare Advantage requirements. Noted for new plans that are unfamiliar with Medicare requirements. The proposal seems to preclude beneficiaries from re-enrolling in their current MA plan. As such, beneficiaries will be barred from returning to the network of providers and plan policies that they purposely selected to suit their needs. Many Arizona dual eligible members are enrolled in dual SNPs which are also AHCCCS plans. These D-SNPs will become Demonstration plans so for the majority of beneficiaries, they would not have a Medicare Advantage plan to opt back in to. In addition, limiting enrollment to a Demonstration plan or Original Medicare minimizes beneficiary confusion and marketing from Medicare Advantage plans that cannot effectively coordinate AHCCCS benefits. 3

4 5. 5/17/12 Ted Williams Maricopa Consumers Advocates and Providers Persons with Serious Mental Illness will be automatically enrolled with the RHBA for all of their Medicaid funded services and members will no longer have choice of acute care plans. Members will be automatically enrolled in the RBHA Demonstration Plan and will no longer have choice of Medicare Advantage Plans. The only choice will be to select Original Medicare. AHCCCS has submitted a Waiver to CMS with this request Dual eligible members with Serious Mental Illness in Maricopa County will be passively enrolled into the RBHA for Medicare on January 1, Members will have no less than 90 days advance notice of this enrollment with the choice to opt-out to Original Medicare. Members will have a monthly opt-out to Original Medicare after January 1, Members will not have an opt-out for Medicaid benefits. For individuals who are seriously mentally ill the timing of the implementation for January 2014 presents certain concerns. Currently, in the last quarter of the year Medicare enrollees are allowed to change plans and are often confronted with a great deal of information about the various choices of plans. This would be occurring at the same time that they are being advised of the option of the Demonstration Plans. There is a risk of confusion and a great need for effective and targeted community education. If implementation is changed to coincide with implementation of the RBHA as the acute care plan on October 2013 than other issues are raised such as the notice period. It is important for stakeholders to see the proposed notices well in advance of implementation. This is a complicated delivery system. We are very concerned that the notices may not clearly explain the cost implications for opting out or not and the implications of losing the option of enrolling in a Medicare Advantage plan. It is not clear what the protocol is for opting out. At one point the proposal indicates that the individual can opt out at any time. Is this correct? It is also not clear what the protocol is for opting back in. Can a person re-enter at any time? Are there any limitations for opting in or out of the Demonstration? CMS prefers states to follow a January 1 implementation date to coincide with the Medicare timelines. Although dual eligible members are targeted during the last quarter of the year, they fall under a special enrollment period and may change Medicare enrollment monthly. This will continue under the Demonstration. We understand that a change of this magnitude has the potential to cause confusion and extensive and ongoing education and outreach will be conducted to mitigate any concerns in that regard The State is not exploring an October 2013 implementation date for the Medicare Demonstration. We agree that working the stakeholders will be important in development of the notices which will be sent to members. AHCCCS will work to highlight any cost implications. Yes, members can opt-out at any time to Original Medicare There are no limitations for re-enrolling into the Demonstration. AHCCCS will work with CMS to identify enrollment effective dates. 4

5 We are concerned that the proposal does not provide for a phase-in or process for handling vulnerable populations in other than the standard practice. We are concerned that this approach fails to: 1. Accommodate for the impact on individuals in the midst of a complicated or ongoing care plan; AHCCCS has undergone numerous member transitions including transitioning 11,500 ALTCS members in 2011 and This experience will aid in working with the Demonstration plans to have mechanisms in place to work with members care plans and current providers. 2. Address concerns about the proximity of the various providers to the member; 3. Assure the ability of the provider to respond to the cultural or linguist needs of the members. We are concerned with the reliance upon the SHIP office for assistance to all populations in understanding the multiple choices and their impact. While SHIP may do well with the majority of elderly Medicare recipients, it is not necessarily experienced in working with persons with serious mental illness. We would urge the development of additional resources from possibly the peer and family run organizations. The State will continue to work with stakeholders to identify additional resources and outlets for information, which may include peer and family run organizations. Arizona has chosen passive enrollment with the only option for an individual who chooses to opt-out enrollment in traditional fee for service Medicare. We support opt-in as a standard and in particular for population who are receiving intensive or ongoing care. Ongoing passive enrollment with opt-out, allows for a seamless enrollment process for dual eligible members. Demonstration plans will be held to high standards to work with members existing care plans and providers. Having all Medicare and Medicaid services coordinated by one entity will result in improved coordination of all services and member satisfaction and outcomes. Arizona had a successful experience with passive enrollment in 2006 for dual members. The two proposals (Medicare-Medicaid Demonstration Program and the Specialty RBHA) appear under development in silos with little plan for the cross over issues we think may happen. We recommend significantly longer transition times for possible changes in care from 30 days to 6 months. AHCCCS and ADHS/BHS are working collaboratively to address the integration of physical and behavioral health for members with Serious Mental Illness, including the coordination of Medicare. There are numerous documents that detail the significant coordination that is occurring between the agencies including the Dual Demonstration, RFI s and numerous stakeholder presentations and discussions. As noted above, the specialty RBHA in Maricopa County will be in its initial operational stage with new responsibilities which gives rise to concerns about the adequacy of the physical health network that will be identified and ready for service delivery. What back up AHCCCS and ADHS/BHS are currently reviewing transition guidelines. 5

6 procedures are planned? How will safeguards be put in place? Will AHCCCS require the specialty RBHA to bring the program fully operational for the Dual Demonstration Program at one time? Network adequacy will be a key point of emphasis for the Maricopa County RBHA and all Demonstration plans as it currently is with all AHCCCS plans. The Maricopa County RBHA contract will be awarded to an organization that has the capacity to be responsible for all requirements, including coordination of Medicare under the Duals Demonstration or as a D-SNP on January 1, SMI clients currently are not required to pay co-payments for their psychiatric care whether the primary payer is Medicare or Medicaid. How will this interface with the requirements for Medicare cost sharing responsibilities for non-psychiatric services? According to a March 29 th CMS memo demonstration plans must provide Medicare Parts A and B services at zero cost-sharing to plan enrollees under their integrated benefit package. Currently, and under the Demonstration, SMI members are exempt from AHCCCS co-payments. The only Medicare beneficiaries who are exempt from Part D co-pays are those who are institutionalized or receiving home and community- based services under the states 1115 waiver. SMI members enrolled in Acute care plans are currently excluded from co-pays for Medicaid covered drugs, but not from drugs they are receiving through Part D. Will there be any new prior authorization requirements imposed? How frequently will a member with a permanent disabling condition with ongoing treatment requirements be required to seek reauthorization? Will it be 90 days, 6 months or for a year? Prior authorization requirements will be outlined in the 3-way contracts between the Demonstration plan, CMS, and the State. At page 9, the AHCCCS Acute care contracts for the upcoming RFP will incorporate coordination requirements in its contracts with existing RBHAs. As outlined, this will be a requirement for non- Maricopa RBHAs. Will there be a consistent statewide approach to the coordination of care and data sharing across MCOs and RBHAs? The state is currently working to identify improvements to the coordination of behavioral health for all members, including those enrolled in the Duals Demonstration. As stated in the proposal, the Demonstration plans and RBHAs will be required to have a contract which outlines the responsibilities of each entity and how care will be coordinated. What steps will be taken in the coming weeks to assure a more meaningful inclusion in the design process of individuals with mental illness and their families? The State will continue stakeholder engagement with all dual eligible members which includes a targeted website, newsletter which is distributed at local facilities, and an upcoming public forum. Over the design and implementation phase, the State will continue to explore ways to engage consumers and other stakeholders. What type of data will be collected to demonstrate effectiveness and AHCCCS will require the collection and analysis of multiple data elements to 6

7 a decrease in health disparities for SMI clients? What measures beyond cost savings will be collected? report out on many performance measures for both behavioral and physical health to demonstrate the effectiveness of a more integrated health care service delivery program. At what point will any savings be dedicated to an expansion of services not traditionally covered by AHCCCS similar to Medicare Advantage plans? Who will be responsible for the design and selection of those services? AHCCCS is working with CMS to identify ways that benefits which can be currently offered by Medicare Advantage plans such as dental and vision can be offered by the Demonstration plans. AHCCCS has proposed that a portion of the savings be reinvested to allow for inclusion of these benefits. The State gained a large understanding of the importance of these benefits during the initial stakeholder focus groups. 6. 5/17/12 Asim Varma Arizona Center for Disability Law We believe enrollment should not be passive with an opt out provision. To preserve the choice of individual health care consumers, enrollment into the demonstration project should be opt in. In addition, there should be a 90 day transition period upon enrollment into the demonstration. Behavioral health services should be integrated with physical health care delivery behavioral health care should be integrated into all of the demonstration health plans. It is important that supplemental benefits are offered by demonstration MCOs, but it is also important that individuals are informed of the availability of supplemental benefits in demonstration health plans. We agree that as this process moves forward the people that will be most affected by this, i.e. dual eligible individuals, should be kept informed of the process. In addition, it would be helpful if dual eligible individuals could be given some basic education on the Medicare and Medicaid systems and how they interact for someone who is dual eligible. This type of education would not only inform consumers, but help them see the benefits of an integrated health plan and be more receptive to participating in the demonstration. AHCCCS will be pursuing passive enrollment with opt-out to ensure that the optimum number of members are receiving services from a coordinated plan. Members will be given advance notice and education of the passive enrollment with their option to opt-out to Original Medicare. Arizona had a positive experience with passive enrollment in Network adequacy and transition will be a key point of emphasis for all Demonstration plans as it currently is with all AHCCCS plans. AHCCCS is currently collaborating with ADHS/DBHS to integrate physical and behavioral health care for members in Maricopa County with Serious Mental Illness. This is the first step in improving the behavioral health service delivery. AHCCCS will continue to evaluate ways of improving and integrating behavioral and physical health. AHCCCS completely agrees and is working with CMS to include supplemental benefits currently offered by Medicare Advantage plans. AHCCCS agrees and will continue stakeholder engagement and education with dual eligible members and other affected by this Demonstration. 7

8 It is extremely important that the grievance and appeals process is streamlined and simplified for people who are dual eligible. The best situation would be if there can truly be one body to adjudicate appeals arising from both Medicare and Medicaid benefits. All member appeals will follow a coordinated process through the Demonstration plans. External reviews will be handled by separate entities initially. AHCCCS will continue to work with CMS to identify areas where the process can be more streamlined. 7. 5/17/12 Renee Waterstradt Cenpatico of Arizona When a person loses Medicaid coverage, would the MCOs serving as Demonstration plans continue to act as that individual s Medicare plan or would this require the member to choose a new Medicare plan? AHCCCS is waiting for additional guidance from CMS on enrollment under the Demonstration, but from current understanding, Demonstration plans can only serve members when they are Medicare and AHCCCS enrolled. It is our current understanding that yes if a member lost AHCCCS eligibility they would be required to choose new Medicare enrollment. 8 If they chose a new plan and then became Medicaid-eligible again, would they then be passively enrolled in the Demonstration plan unless they opted out to an Original Medicare plan? Need to standardize supplemental benefits to ensure individuals remain satisfied with being enrolled in a Demonstration plan. Behavioral health providers struggle with the lower rates paid by Medicare. Of particular concern is that Medicare does not pay a premium to cover the extra cost of telemed services. This is particularly an issue in rural and frontier areas. RBHAs reimburse telemedicine services at a higher rate. Another issue that is especially difficult for behavioral health providers in rural and frontier areas is the lack of recognition by Medicare of Licensed Professional Counselors (LPC), Licensed Independent Substance Abuse Counselors (LISAC) and Licensed Marriage and Family Therapists (LMFT). There is a shortage of Psychologists and Licensed Social Workers in rural Arizona. Consideration of higher rates adjusted to consider costs associated with RBHAs and Provider Agencies providing behavioral health services in rural and frontier areas. Enrollment in and out of Demonstration plans should be handled at a local level to ensure efficiency of updating eligibility information in both Medicaid and Medicare plans. If the decision is made to move forward with one identification card If a member becomes Medicaid-eligible again, thus becoming eligible for enrollment in the Demonstration, they would be passively enrolled in the Demonstration unless they choose to opt-out to Original Medicare. AHCCCS is exploring with CMS the inclusion of supplemental benefits and whether these would be standardized by plan. AHCCCS will take these comments under consideration as it works to establish provider payment reimbursement and adequate network access. Comment taken under consideration. AHCCCS agrees and plans to have dedicated staff to handle enrollment at the State level. AHCCCS agrees that one identification card is important and will take this

9 for participants in Demonstration plans, need to ensure that both AHCCCS and CIS IDs are included on card, as well as the RBHA information that a participant is auto-enrolled with when T19 benefits are established. suggestion of information into account. 8. 5/17/12 Chad Westover UniCare Health Plan of Arizona, Inc. 9 We recommend that the emphasis on the importance of a true Integrated Care Delivery System (ICDS) be a part of the request for Proposal (RFP) requirements and be reflected in scoring weights and criteria. AHCCCS should be the primary regulatory and compliance oversight agency in any three-way contract between AHCCCS, CMS, and the contracted health plan. Unicare recommends the current Medicaid application and enrollment process to be used to determine eligibility and enrollment of the dually eligible population in to health plans. We would like to recommend the use of a single Health Plan Identification number on the identification card. Unicare emphasizes that the ability to deliver the highest quality of care in the safest and most effective manner will only be achieved through a high quality and effective network of traditional and nontraditional providers. Unicare suggests that AHCCCS work with CMS to allow the AHCCCS to service as the regulatory approval entity for marketing materials to those that are dually eligible Using the state Medicaid marketing rules as a basis. These same rules should be used to allow health plans to market their dual eligible products to those that remain in Medicare Fee- For-Service. There will be no separate procurement for the Duals Demonstration. For the ALTCS population, Arizona will use its current ALTCS Contractors. For the Acute population, plan selection will be determined through the upcoming Acute RFP. There will be no separate plans who serve the dual eligible population only, thus to participate in the Duals Demonstration, bidders must bid on the entire Acute Medicaid population in Geographic Service Areas they choose. The RFP will outline whether all Acute plans will be required to all serve dual eligible members under the Demonstration or as Medicare Advantage Dual Eligible Special Needs Plans or whether there will be a choice to only serve Medicaid non-dual Acute members. AHCCCS and CMS will outline oversight responsibilities in a Memorandum of Understanding. This information will be included in the 3-way contracts with health plans. AHCCCS will continue to work with CMS to outline enrollment specifications, but agrees that enrollment should be handled at the State level. AHCCCS agrees with the importance of one identification card and will explore which identification numbers are needed for operational purposes. AHCCCS agrees and will continue to work with CMS to develop appropriate network requirements for Demonstration plans. AHCCCS will work with CMS to create a streamlined marketing policy and review process which meets the needs of the dual eligible population. AHCCCS will continue to evaluate rules on marketing to duals that have chosen to opt-out of the Demonstration.

10 Unicare has concerns with Medicare Opt-Out provisions, and we hope to work with the AHCCCS on reaching the goal of improving care coordination and delivering person-centered care for the dually eligible population. Solutions: 1. Structure the demonstration program so that the consumer has the same ICDS for both Medicare and Medicaid if they enroll in managed care 2. incent customers with enhanced or supplemental benefits if they enroll in the same managed care organization for both Medicare and Medicaid AHCCCS and CMS acknowledge the importance of beneficiary choice in the option to opt-out of the Demonstration to Original Medicare. Dual eligible members will be enrolled in Medicaid managed care even if they opt-out to Original Medicare. Members will not be able to have a different Medicare and Medicaid plan under the Demonstration. Members will not be able to enroll in Demonstration plans for Medicare only as they currently can in Medicare Advantage plans. Members will be in Original Medicare and an AHCCCS plan OR be enrolled in a Demonstration plan which serves their Medicare and AHCCCS plan. Set a minimum or basic level of supplemental benefits across all health plans, and allow individual health plans to layer on top of the basic supplemental benefit, additional benefits that are approved by AHCCCS. AHCCCS agrees that the inclusion of supplemental benefits is very important in the Demonstration and is exploring ways to have a level of supplemental benefits while still offering flexibility to Demonstration plans. 9. 5/17/12 Richard T. Clarke, Ph.D. Magellan Health Services of Arizona 10 While we are supportive and greatly appreciate the emphasis of the Request for Proposal (RFP) on a full risk integration (behavioral health and acute/primary care) this component of the RFP represents, based on preliminary numbers presented in the RFI, only 20% of the overall funding for the RBHA. We want to encourage both departments to emphasize, with more importance, the responsibilities within the RBHA for the larger populations [children, NT SMI, crisis system and the general mental health and substance abuse populations] and that the weighing and scoring reflect these components with equal force and importance. We believe that without a more detailed analysis of the risk adjustment necessary to ensure adequate resources for the SMI population (a high cost population) that this may be underfunded. We would like to suggest that given the complexities of the SMI population, higher acuity and relative size, that it might be more appropriate to continue the segregation of the Behavioral Health from the Physical Health Premiums in the Capitation Rate setting process. It appears that there will not be a reinsurance component for the fully integrated and dual eligible SMI populations; we suggest that this be reexamined as a safe guard to unusually high cost outliers Comment noted. The proposed integration of physical and behavioral health Medicaid benefits is outside the scope of this demonstration. However, this comment is noted for the purposes of those integration efforts AHCCCS will work with CMS to set adequate rates for the Duals Demonstration for the Medicare and Medicaid piece of payment. Comment noted. The proposed integration of physical and behavioral health Medicaid benefits is outside the scope of this demonstration. However, this comment is noted for the purposes of those integration efforts. Comment noted. The proposed integration of physical and behavioral health Medicaid benefits is outside the scope of this demonstration. However, this comment is noted for the purposes of those integration efforts.

11 until such time as a reliable and valid experience can be developed /17/12 Kent Monical UnitedHealthcare Based upon CMS guidance to use the eleven elements of the Special Needs Plan (SNP) model of care, we believe it is very important to weigh these elements against the long-standing foundation of Arizona s program and advocate for a model of care for MMEs (Medicare-Medicaid Enrollees) that does not undermine existing, proven models in Arizona. We believe integrated MME programs should include supplemental benefits that are complimentary to the plan s model of care and allows for a competitive market among participating plans. We recommend that the rate development for Arizona s integrated program include specific funding to support supplemental benefits that is additive to base Medicare and Medicaid funding. We encourage AHCCCS to reconsider the approach to maintaining a separate behavioral health structure for non-seriously Mentally Ill acute MMEs. We believe MMEs served in the acute program will benefit from fully integrated care similar to the experience in ALTCS. Allowing for ongoing access to historic providers, except in the case where the treatment plan specifically requires such maintenance, does not encourage full integration as envisioned in Arizona s integrated model. We encourage the State to advocate for Medicare risk adjustment methodology that is based upon existing structure, but evaluates the needs of individuals at the member level to appropriately find for the complexities of the population. We believe that it is imperative for states to advocate for a single [administrative] approach that is focused on improving the experience for the most complex individuals served by Medicare or Medicaid and maintaining separate and unique administrative requirements will undermine the effectiveness of integration. AHCCCS agrees. AHCCCS agrees that supplemental benefits are very important in the integrated duals model and is exploring ways to have a level of supplemental benefits while still offering flexibility to Demonstration plans. AHCCCS is currently working with CMS to identify payments to Demonstration plans, including funding of supplemental benefits. Due to current changes in the behavioral health system at time of implementation, behavioral health will not be included in the service delivery by Demonstration plans, but AHCCCS will continue to evaluate ways of improving and integrating behavioral health. Specific transition requirements will be outlined in the 3-way contracts between plans, CMS and the State. AHCCCS agrees that appropriate rate setting, including risk adjustment, is critical in this demonstration. AHCCCS supports this comment and will continue to work with CMS and stakeholders to identify areas of administrative alignment and improvement /17/12 Arizona providers need an opportunity to locally resolve disputes Currently, providers who are contracted with Medicare Advantage plans do 11

12 Susan L. Watchman Gammage & Burnham that arise from communication and coordination issues within a Dual plan. Without such a guaranteed process, providers will be financially disadvantaged and ultimately discouraged from participating in the program beyond the barest minimum. not have appeal rights for the denial of claims. AHCCCS is working with CMS to identify if there are opportunities for changes to this regulation under the Demonstration /17/12 Nicole A. Devore Fresenius Medical Care North America 13. 5/18/12 Deb Gullett Arizona Association of Health Plans, Inc. Request that AHCCCS give thoughtful consideration to how this costly, complex and vulnerable patient group [individuals with end stage renal disease (ESRD)] should be treated in the context of the dual eligible integrated care demonstration. We support your proposal to leave duals that are enrolled in Medicare Advantage (MA) or MA SNP plans outside of the demonstration project. The supplemental benefits offered through the plans will be of benefit to people with ESRD. Will AHCCCS identify members as Medicare eligible and then passively enroll the member into the demonstration, or will AHCCCS require the plan to interface with Medicare and enroll identified members into the demonstration? We think Medicaid should drive enrollment to include initial and ongoing passive enrollment. We suggest the continued use of the MARx system. We think that Medicare eligibility should be determined by Medicare since it is already established. Regarding the handling of a traditional MAPD Member that becomes dual eligible, if such a person was enrolled in a traditional MAPD plan and subsequently becomes dual eligible, how will the member be enrolled? Who will be interfacing with CMS to enroll the member AHCCCS or the health plan? Thank you for your comments in this area. This statement is incorrect. As is outlined the proposal, all members whether they are enrolled in Medicare Advantage plans or Original Medicare will be passively enrolled into the Demonstration. AHCCCS agrees. Enrollment specifics are still being determined, but AHCCCS anticipates enrollment being handled by State dedicated staff. This includes passive enrollment, ongoing enrollment, and disenrollments. AHCCCS is currently working with CMS to identify the use of the MARx system for enrollment. AHCCCS is proposing to adopt its current enrollment processes. Now that this member is eligible for AHCCCS and the Demonstration will be given an opportunity to select from the Demonstration plans available in their respective GSAs. Lack of selection at the time of eligibility determination will trigger passive enrollment into a Demonstration plan. At this time it is anticipated that AHCCCS will be the entity responsible for transmitting enrollment and disenrollment information to CMS. 12 Which unique CMS fields in the MMR will we have to carry over into the health plan enrollment record? Unknown at this time.

13 The health plans count on the enrollment record to reconcile payment for both AHCCCS and CMS. How will that enrollment record be constructed to ensure that integrated payment can be reconciled? Unknown at this time. We are seeking clarification concerning the ID card we are in favor of one card that will include a Medicare ID generated by the plan along with an AHCCCS ID. AHCCCS agrees that one ID card will be important and will continue to evaluate which information will be on the card. Will Health-E participation be required for the dual integration program? AHCCCS will be evaluating the use of Health-E as enrollment information is finalized. How will funding for these beneficiaries without full Medicare eligibility [without Medicare A and B] be secured? AHCCCS is working with CMS on this issue. Limiting this opt-out provision to Original Medicare is necessary to avoid a reduction in the level of integration for dual eligible members. AHCCCS agrees. AzAHP strongly supports the concept of a single benefit design and the elimination of the administration of cost-sharing. AHCCCS is working with CMS on this issue. We would like to better understand how these [supplemental benefits] will be financed under the demonstration model. AHCCCS agrees that supplemental benefits are very important in the integrated duals model and is exploring ways to have a level of supplemental benefits while still offering flexibility to Demonstration plans. AHCCCS is working with CMS to determine how these will be funded. We recommend that a single benefit plan be created. All services covered under Medicare A, B, D and AHCCCS will continue to be covered for dual eligible members and be coordinated by the Demonstration plans. Will demonstration plans be exempt from across the board cuts in Medicare Advantage rates? Will demonstration plans be exempt from requirements that require certain types of claims to be paid using either the prevailing Medicare or Medicaid payment methodology/fee schedule? Unknown at this time. AHCCCS is working with CMS on these issues. Will AHCCCS and CMS design a new integrated fee schedule or will AHCCCS and CMS continue to expect that the health plan s Unknown at this time. AHCCCS is working with CMS on these issues. 13

14 payment for Medicaid services be linked to a Medicaid fee schedule and Medicare services be linked to a Medicare fee schedule? Will AHCCCS expect the health plan to have a unified reimbursement rate in provider agreements? How will AHCCCS identify those members who are going to be passively enrolled? To be eligible for the demonstration, members must be enrolled in Medicare and AHCCCS. Members who are receiving cost sharing assistance from the State, but not enrolled in an AHCCCS health plan will not be enrolled in the demonstration. In the current system, Medicaid and Medicare allowable codes do not align. How will the disparities be addressed? Unknown at this time. Confirm if our understanding is correct that as part of the demonstration project, each participating plan needs to submit a unified Part D-like formulary that also includes drugs currently classed as Medicaid only. This is the current understanding of AHCCCS. More details will be released in future months. The providers included in CMS network adequacy standards are based on a traditional Medicare population. We recommend that the demonstration project uses AHCCCS standards for defining Network Adequacy Standards. AHCCCS agrees that network adequacy standards have been a challenge for local D-SNPs and will be working closely with CMS to identify network adequacy standards which are appropriate for the demonstration population. Will the required [behavioral health] coordination of care contracts be created between the MCO & RBHA or will AHCCCS create a template contract that will be consistent for all plans & RBHAs? Unknown at this time. AzAHP recommends that quality programs be integrated. AHCCCS agrees and will work with CMS to integrate quality requirements. We recommend that a new rating/quality mechanism be established for this program that adequately measures performance of the plans since STAR is not reflective of a plans performance as related to the intended Demonstration population and benefits. AHCCCS will be working with CMS to identify evaluation and performance measures. Will Medicare and Medicaid rates for the demonstration project be determined and coordinated by individual county? Unknown at this time, but AHCCCS anticipates rates being set by GSA. Will the Medicare risk adjustment process continue to apply to the dual eligible population? Will the demonstration project use the Unknown at this time. AHCCCS supports Medicare risk adjustment, but does not have details from CMS on rate setting at this time. 14

15 Medicare HCC process or us the State s current process? We are also seeking clarity on the proposed methodology that is contemplated and described as quality withholds. CMS has released guidance that there will be quality withholds for Demonstration plans. AHCCCS has no more details at this time. The dual eligible rate must be actuarially developed. AHCCCS agrees. There is a substantive difference between the requirements for encounter data submission and use by Medicare and Medicaid. How will this difference be reconciled? AHCCCS is proposing and will work with CMS to require all encounters under the Demonstration to be submitted to AHCCCS under one process. AzAHP supports a single government oversight of health plan compliance with Medicare and Medicaid rules. Oversight will be conducted jointly by CMS and AHCCCS. Specifics will be outlined in negotiations with CMS. Will Dual Demonstration Plans be allowed to conduct marketing and sales activities similar to current efforts to market and sell the D-SNP product to prospective members? Marketing rules will be negotiated and determined jointly between AHCCCS and CMS. There would be no D-SNP product to sell as there currently is. Members will not be allowed to enroll in a Demonstration plan for Medicare only. Members will be enrolled into their AHCCCS plan for Medicare and can only change plans yearly as it currently is under AHCCCS enrollment rules. How much marketing will be allowed to potential enrollees and existing enrollees during annual enrollment/opt out windows? Members will be able to opt out monthly to Original Medicare, but will only be able to change demonstration plans yearly on the anniversary of their AHCCCS enrollment. AHCCCS is considering an open enrollment for 2015 and would consider what marketing would be allowed for this time period. Can AHCCCS Dual Demo contractors actively work to recruit enrollees? Will there be a possibility of using brokers? Unknown at this time. AHCCCS anticipates implementing marketing rules that are close to what they are on for Medicaid. Will age ins with a certain Medicaid plan be passively enrolled, or need to be recruited and enrolled as currently done? AHCCCS members becoming eligible for Medicare would be passively enrolled into their current plan for Medicare and no recruitment would be necessary. Who is going to create the model language for the dual component and manage the turn around times for approval? AHCCCS and CMS will have a joint oversight team of marketing and member materials and will develop a process and material that is specific to the integrated model /18/12 Kathleen A. 15 Dual-eligible Medicare beneficiaries must maintain full access to Medicare fee-for-service benefits, including medical rehabilitation All Medicare A and B benefits will be included in the demonstration.

16 Moore HealthSouth Corporation services provided by IRFs (inpatient rehabilitation facilities) Providers should be reimbursed at no less than the current Medicare fee-for-service payment rates, adjustments, and payment policies for services provided to Medicare beneficiaries Provider payment rates under the demonstration are being discussed with CMS, but at this time, AHCCCS anticipates demonstration plans negotiating provider rates in contract. Networks must include a sufficient number of IRFs Demonstration plans will be held to high standards of network adequacy Sufficient safeguards are needed to permit an expedited appeals process that will resolve coverage disputes within three hours AHCCCS will work with CMS to develop a coordinated appeals process The program should establish a sufficient framework to evaluate the quality of care provided by post-acute care ( PAC ) rehabilitation providers Quality of care requirements will be determined jointly by CMS and AHCCCS The demonstration will require that all eligible beneficiaries enroll in a Managed Care Organization. Currently almost all dual eligible beneficiaries are enrolled in a MCO for AHCCCS benefits and will be passively enrolled into the same plan for Medicare. There will only be one MCO that will be responsible for coordinating care and providing oversight There will be multiple plans who are serving dual eligible members statewide as there are currently multiple AHCCCS plans. One plan will be responsible for coordinating both Medicare and Medicaid services. We support permitting enrollees to opt out of the demonstration for purposes of receiving their Medicare benefits through Medicare Parts A/B. AHCCCS agrees /18/12 Fred Karnas St. Luke s Health Initiatives 16 Ensuring that providers are adequately reimbursed Implications of the shift to Medicaid/Medicare managed care organizations on providers ability to be reimbursed for bad debt Making sure administrative efficiencies are realized. Another concern that we have is whether the administrative efficiencies that seem possible through such a model in theory are actually realized. How the proposed model affects the successful creation of and implementation of accountable care organizations in our state AHCCCS will be working with CMS on provider reimbursement under the Demonstration. CMS is currently evaluating the Medicare bad debt issue under the Demonstration. AHCCCS is working to identify areas of administrative efficiencies, but also understands that full efficiencies may not be guaranteed on Day 1 of implementation. AHCCCS will continue to work with CMS to create administrative simplification before and after implementation. All dual eligible members will be passively enrolled into the Demonstration, regardless of ACO enrollment. It is our understanding that members must be

17 enrolled in Original Medicare to eligible for ACO enrollment so those enrolled in the Demonstration would not meet criteria. How the proposed model might affect changes being contemplated by AHCCCS to pay providers differently to incentivize more efficient and effective service delivery As AHCCCS moves forward with provider payment initiatives, these may be considered under the Demonstration. We are also concerned how implementation of the proposed model might affect consumers in our state s behavioral health system. We worry that these additional systems changes will exacerbate consumer confusion and system disruptions that are likely to occur as we shift to a new behavioral healthcare delivery model. It will be very important for CMS and AHCCCS to pay attention to how adequate information and support such as training are provided so that consumers and providers can successfully navigate this transition. AHCCCS agrees that consumer, provider, and stakeholder education and information will be critical in the implementation of the Demonstration for all populations including those in the behavioral health community. AHCCCS will continue to explore methods to reach out to the dual eligible population in the next 18 months. It is also unclear to us how behavioral health consumers who choose to opt out of the proposed model will be assured adequate access to care. While the proposed model suggests that these consumers would be able to access services on a fee-for-service basis, it is unclear to us whether this change might have any impact on their access to a full array of health and behavioral health providers. All dual eligible members who are enrolled in the Demonstration or choose to opt out to Original Medicare will be entitled to Medicare Parts A, B, and D and Medicaid benefits, including behavioral health. For those members who remain enrolled in the Demonstration AHCCCS is working to provide additional supplemental benefits such as dental and vision. The only difference for those members opting out is that they will be receiving their Medicare benefits on a fee-for-service basis instead of through the Demonstration plan and will remain enrolled in their AHCCCS plan for Medicaid benefits. We are also unclear about how care will be managed and coordinated for those with a serious mental illness. The proposal suggests that their care will be managed by the Medicaid/Medicare managed care organization (MCO), with some coordination or relationship between the MCO and the specialty RBHA. The Maricopa County RBHA will also be a Medicare Demonstration plan which manages and coordinates Medicare benefits for members with Serious Mental Illness who are also eligible for Medicare. For members with Serious Mental Illness outside of Maricopa County, they will be enrolled with a Demonstration plan for Medicare and Medicaid and that plan will be required to coordinate their behavioral health needs with the RBHA. We also hope that CMS and AHCCCS (working with ADHS) ensure that duals with a serious mental illness continue to receive the full array of behavioral health services and community supports Demonstration plans will be required to coordinate all Medicare Part A, B, D and Medicaid benefits dual eligible members are eligible for. These benefits will be delivered through the existing RBHA and acute health plan structure 17

18 needed in a manner that is consistent with the culture, values and principles that have been identified and fostered in our state s behavioral health system over the years. outside of Maricopa County, and through the RBHA in Maricopa County. The culture, values and principles of the state's behavioral health system will remain central to the delivery of these services. The only change to benefits with implementation of this plan may be for members who were enrolled in Medicare Advantage plans. The level of supplemental benefits (dental, vision, fitness) that the member was getting through that plan may change in the Demonstration. Members will have full access to the behavioral health services and community supports. 18