Scott Leitz Assistant Commissioner for Health Care Minnesota Department of Human Services

1. Minnesota’s Approach: Integrated Medicare & Medicaid ProgramsAlliance for Health ReformBriefing on Dual EligiblesJune 3, 2011 Scott Leitz Assistant Commissioner for Health Care Minnesota Department of Human Services

2. MN’s Dually Eligible Population • 106,600 Minnesotans are fully eligible for both Medicare and Medicaid • 97% of seniors and 50% of people with disabilities on Medicaid are dually eligible • About 40% of MN’s total Medicaid spending is for duals • 68% of seniors and 41% of people with disabilities in MN Medicaid receive long-term care services • Most seniors served through managed care • Minnesota SeniorCare Plus (MSC+) • Minnesota Senior Health Options (MSHO): SNP program, voluntary alternative to MSC+ • Most people with disabilities served through FFS • Special Needs BasicCare (SNBC): SNP program, voluntary alternative to FFS

3. Key Service Needs of Duals • Aligned financial incentives between payers (Medicare and Medicaid) and providers • Primary and chronic care management strategies implemented across care settings • Improved coordination between primary, acute and long-term care services • Aligned networks across Medicare and Medicaid providers • Navigation assistance to get to right providers at the right time • Simplified paperwork and member materials that explain Medicare and Medicaid services and how they fit together • Coordination with behavioral and housing needs

4. Distinct Population Issues For seniors: • Many opportunities for reducing hospitalization but savings accrue to Medicare • Diversion strategies from nursing homes and high costs community settings (assisted living) For people with disabilities: • High use of specialty care but lack of access to basic primary and preventive care • Many primary care providers unwilling or lack expertise to serve people with disabilities • Majority have co-occurring mental health diagnoses • Not a static population: people with disabilities constantly becoming dual after Medicare waiting period results in continuity of care issues

5. Primary Issues Facing States • Medicare-paid providers drive primary and acute care. If poorly managed, Medicaid pays for the result (Higher need for long-term care services) • Increased pressure on State budgets due to high growth in dual eligible populations; need to prepare for both fiscal and care delivery challenges • Lack of financial equity for States for investment in aligned/integrated options (immediate savings accrue to Medicare) • Lack of stable scale-able platforms for alignment of Medicaid and Medicare for the future • Access to Medicare data for total cost of care requires State resource investment

6. Minnesota’s Approach • First state to integrate Medicare and Medicaid primary, acute and long-term care for seniors • Transitioned from Medicare demo to SNP status in 2005 • No complex waivers needed; we use existing state plan and home and community based service authorities under 1915 (a) and (c ). • Close working relationship and ongoing understanding and support from CMS (both Medicare and Medicaid) have been very important • Stakeholder involvement key in acceptance of managed care approach for people with disabilities

7. Where We’ve Succeeded • SNPs aligned with State long-term care goals for improved access and cost management • Majority of seniors now served in community • 98% of seniors on MSHO now receive annual primary/preventive care visits • State has leveraged integrated Medicare data and coverage of additional care coordination through contracts with Medicare SNPs • Continued enrollment growth in current integrated program for people with disabilities (SNBC) despite loss of some SNPs • Creative environment has produced some total cost of care models (virtual) that manage across payers and domains of care

8. Not Without Challenges • Limited opportunity for State to share any Medicare and Medicare SNP savings under current models • SNP bid process has resulted in premiums that duals cannot pay and thus lack of stability in SNP participation in integrated programs • Need to stabilize current SNP platform for integration and make it more attractive to States • Need for improvement in Medicare risk adjustment for frail seniors and people with disabilities • Integration of administrative processes: devil is in details, requires expertise and diligence

9. Moving Forward • Working to bring up PACE in Minnesota • Implementing statewide All Payer Health Care Home including CMS Medicare APC demo • Care Delivery System Payment Demo RFP will be issued soon; future steps expected to include FFS and MCO duals • Duals Demonstration Planning Contract with CMS • Development of performance metrics, risk adjustment, total cost of care payment models and provider feedback mechanisms specific to dual eligibles, consistent across managed care and FFS • Pursuing improvements in current SNP and/or new platforms for integrated financing and service delivery

10. Contact Information • Scott LeitzAssistant Commissioner for Health CareMinnesota Department of Human Servicesscott.leitz@state.mn.us(651) 431-2012 • Pam ParkerSpecial Needs PurchasingMinnesota Department of Human Servicespam.parker@state.mn.us(651) 431-2512

11. Seniors

12. People with Disabilities