Contracting as a Dual Eligible Special Needs Plan: Lessons Learned from Navigating the Medicare Program

1. Contracting as a Dual Eligible Special Needs Plan: Lessons Learned from Navigating the Medicare Program Janet Grant CareSource Management Group Executive Vice President Business Development and Regulatory Affairs Medicaid Conference September 24, 2008

2. CareSource Mission: Making a difference in the lives of underserved people by improving their health care • Medicaid focused non-profit health plans • Ohio: 625,000 Medicaid members • Michigan: 50,000 Medicaid members • 19 years of Medicaid managed care experience • SNP plans launched in both states January 2008

3. CareSource SNP Goals • Extend CareSource mission • Provide a continuum of care for Medicaid ABD members • Leverage plan Medicaid expertise; knowledge of Medicaid population needs • Invest in infrastructure to partner with states on highest acuity and cost populations • Vehicle for Medicare/Medicaid integration • Diversify product lines

4. SNP Launch Lessons Learned • Network, network, network….. • Time and resource commitments • Armed for provider questions/resistance • Use of consultants to jump start, provide technical assistance • Leadership to demonstrate priority, organizational commitment, recognition of resource requirements • Organizational involvement, need to learn MA and think through how to operate • Marketing, marketing, marketing…..

5. Competencies Required • Medicare regulatory requirements • Sales/marketing, enrollment • Financial/benefit bid: actuarial expertise • Risk adjustment management • Network development • Pursue state Medicaid integration

6. State Challenges

7. State Opportunities • Integration to increase quality of care and consumer satisfaction • Decrease provider administrative burden • Support rebalancing of facility based vs community based LTC • Savings associated with delay/prevention of facility based LTC

8. State Challenges • Knowledge of SNP and integration potential • Concern that savings accrue to Medicare • Other budget and policy priorities • Technology to support • Stakeholder resistance • Statewide SNP coverage • Statutory carve out of duals from Medicaid managed care • Voluntary MA enrollment • Operational challenges of integration

9. Ohio CMS SNP 101 SNP Work Group ABD seamless enrollment Technical assistance Expert consultation Savings analysis Michigan Plan for capitation ABD seamless enrollment Consumer education Tale of two states…

10. MI Consumer Education

11. Stakeholder Involvement • Disability advocates • Community Catalyst SNP Consumer Education Project • Area Agencies on Aging • Low income housing • Continuing Care Retirement Communities (CCRCs)

12. Stakeholder Shared Goals • Right care in the right place • Least restrictive environment • Case management as central strategy • Promote medical home • Quality outcomes and customer satisfaction • Coordinated care

13. Current Issues • SNP reauthorization • State contracting requirement and impact on service area expansion opportunities • Medicare/Medicaid integration • Identification and education of eligible dual consumers