Presented by Doug Goggin-Callahan, JD, on September 26, 2013 at the fourth annual Center for Health Literacy Conference: Plain Talk in Complex Times.

1. Acronyms, access, and appeals:
Taking the long view on
Medicare and Medicaid
care coordination

2. Introduction and
Learning Objectives

3. What is ICS?
- Independence Care System
- New York City based non-profit managed
long term care plan
- Serving older adults and people with disabilities
in four of the five boroughs of NYC
- Mission to help members live at home and
remain independent

4. What is covered in today’s
presentation?
– CMS and the states are undertaking financial
alignment demonstrations to change health care
delivery for dually eligible beneficiaries.
– Clear communication is needed around what
these programs are and how they affect people
with Medicare and Medicaid.
– Equally critical is communication regarding the
way in which the program works once a
beneficiary is enrolled.

5. Learning objectives
• In today’s presentation, you will learn and be
able to identify:
– Two key goals for the financial alignment
demonstration and how they affect dually eligible
beneficiaries.
– Three potential barriers to accessing the appeals
system.
– Two key stakeholders in the integrated appeals
process.

6. The Financial Alignment
Demonstrations

7. What are the Financial Alignment
Demonstrations?
• The opportunity was created under the
Affordable Care Act (ACA).
– The ACA created two new offices, the Medicare-
Medicaid Coordination Office (MMCO) and the
Center for Medicare Medicaid Innovation (CMMI).
• Broad charge for both offices to improve the ways in
which Medicare and Medicaid work together
• MMCO announced a financial alignment demonstration
opportunity in 2011.

8. What are the Financial Alignment
Demonstrations (cont’d)?
• The Financial Alignment Demonstrations
– States can apply for three-year demonstration
periods.
– There are two options for states:
• Fully capitated managed health care plans, or
• Managed fee-for-service.

9. What is a fully capitated managed
health care plan?
• Fully Capitated Managed Health Care Plans
– Health insurance companies that are responsible for
all Medicare, Medicaid, and long term care and
prescription medication needs
– These are different from Medicaid Advantage Plus
plans or other existing capitated plans.
– CMS expects greater coordination and to create
entirely new systems and processes that integrate
both Medicare and Medicaid in the fully capitated
health plans.

10. What is a managed fee-for-service
model?
• Managed fee-for-service model
– Uses the traditional fee-for-service model but
overlays some type of care management
infrastructure
• Accountable care organizations
• Health homes
• Patient-centered medical homes

11. Who is pursuing the Financial
Alignment Demonstrations?
• 23 states applied to move forward with
demonstrations.
– The majority applied to use fully capitated
managed health care plans.
– Washington State is moving forward with
managed fee-for-service, and New York may in
the outer years of the demonstration.

12. Why are states looking to move
forward with these models?
• Dually eligible beneficiaries are a relatively small
number of Medicare and Medicaid beneficiaries but
account a large portion of Medicare and Medicaid
spending.
– In New York, they account for 15% of the Medicaid
population and 45% of Medicaid spending.
• Dually eligible beneficiaries have health care
conditions that require greater intervention and
have higher needs for well-coordinated care.

13. Case example—Luz
• Hospitalized for cerebral vascular accident and has
aphasias and right hemiparesis
• History of diabetes, hypertension, and osteoarthritis
• Now, following her hospitalization, she is ready to be
discharged.
• Neither Luz nor her husband have a high school
education, and both state they have struggled with
speaking English.

14. Policy, Procedures, and
Stakeholders

15. With new systems come new
acronyms
• New York is pursuing a fully capitated
managed health care plan model called fully
integrated dual advantage or FIDA plans.
• Promisingly, New York has integrated its
appeals system for both Medicare and
Medicaid—one pathway.

16. How do you integrate these
systems?
• Internal appeal to the FIDA plan
• A state administrative law judge (ALJ) hearing
—new office created to handle these appeals
• The Medicare Appeals Council (Washington
DC)
• Federal Court

17. How do you integrate these
systems?
• Stakeholders in the appeals system
– At the table
• Community-based and advocacy organizations
• Health care providers
• Health plans
– Will be affected but not at the table
• Federal judges
• State law judges
• Primary care doctors
• Beneficiaries

18. Looking down the road: Getting it
right while in the planning process
• Consequences to unclear communication and
stakeholder disenfranchisement
– Beneficiaries cannot access needed services.
– Stakeholders do not participate in the implementation.
– Delays and backlogs happen in the process.
– Important elements of the process are not considered.
– The process and the key policy goals fail.

19. How to avoid the breakdown?
• Identify who is at the table and who needs to
be at the table early in the process.
– Bring in those groups who are not represented.
• Turn from policy to process.
– When policy is completed on paper, begin to drill
down on how it will be implemented.

20. How to avoid the breakdown
(cont’d)?
• The devil you know, versus the devil you don’t
– New and improved systems are still—new.
– Development of trainings for community-based
and advocacy organizations who can get the word
out
– Clear communications and model notices
– Simplicity of process
• Circle and sign appeals

21. Questions?

22. Additional resources
• National Senior Citizens Law Center
– www.dualsdemoadvocacy.org
• Community Catalyst
– www.communitycatalyst.org
• Medicare Rights Center
– www.medicarerights.org
• Medicare-Medicaid Coordination Office
– http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-
and-Medicaid-Coordination/Medicare-Medicaid-Coordination-
Office/FinancialModelstoSupportStatesEffortsinCareCoordination.htm
l

23. Contact Information
Doug Goggin-Callahan
Director of Compliance
(T): 646.653.6142
(E): dcallahan@icsny.org