Memorandum of Understanding (MOU)

1 Memorandum of Understanding (MOU) Between The Centers for Medicare & Medicaid Services (CMS) And The State of Rhode Island Regarding a Federal-State Partnership to Test a Capitated Financial Alignment Model for Medicare-Medicaid Enrollees Medicare-Medicaid Alignment Integrated Care Initiative Demonstration TABLE OF CONTENTS I. STATEMENT OF INITIATIVE .. 1 II. SPECIFIC PURPOSE OF THIS Memorandum OF Understanding .. 4 III. DEMONSTRATION DESIGN / OPERATIONAL PLAN .. 4 A. DEMONSTRATION AUTHORITY .. 4 B. CONTRACTING PROCESS .. 5 C. ENROLLMENT .. 7 D. DELIVERY SYSTEMS AND BENEFITS .. 10 E. ENROLLEE PROTECTIONS, PARTICIPATION, AND CUSTOMER SERVICE.

2 11 F. APPEALS AND GRIEVANCES .. 15 G. ADMINISTRATION AND REPORTING .. 15 H. QUALITY MANAGEMENT .. 17 I. FINANCING AND PAYMENT .. 18 J. EVALUATION .. 18 K. EXTENSION OF AGREEMENT .. 19 L. MODIFICATION OR TERMINATION OF MOU .. 19 M. SIGNATURES .. 22 Appendix 1: Definitions .. 23 Appendix 2: CMS Standards and Conditions and Supporting State Documentation .. 32 Appendix 3: Details of State Demonstration Area .. 37 Appendix 4: Medicare Authorities and Waivers .. 38 Appendix 5: Medicaid Authorities and Waivers .. 40 Appendix 6: Payments to MMPS .. 41 Appendix 7: Demonstration Parameters .. 63 1 I. STATEMENT OF INITIATIVE The Centers for Medicare & Medicaid Services (CMS) and the State of Rhode Island (RI) Executive Office of Health and Human Services (EOHHS) will establish a Federal-State partnership to implement the Medicare-Medicaid Alignment Integrated Care Initiative Demonstration ( ICI Demonstration or Demonstration ) to better serve individuals eligible for both Medicare and Medicaid ( Medicare-Medicaid Beneficiaries ).

3 The Federal-State partnership will include a Three-way Contract between CMS, the State, and one or more Medicare-Medicaid Plans ( MMPs) that will provide integrated benefits to those Medicare-Medicaid Beneficiaries who reside in the targeted geographic area(s) and who choose to participate ( Enrollees). The Demonstration will begin no sooner than December 1, 2015 and continue until December 31, 2018, unless terminated pursuant to Section L or continued pursuant to Section K of this Memorandum of Understanding (MOU). Meeting Enrollee needs, including the ability to self-direct care and perform self-care, and live independently in the community, are central goals of this Demonstration.

4 In meeting such needs, the ICI Demonstration will seek to test an innovative payment and service delivery model to alleviate fragmentation; improve coordination of services for Medicare-Medicaid Beneficiaries; enhance quality of care; reduce costs for both the State and the Federal government; meet Enrollees health and functional needs; improve transitions among care settings; and reduce health disparities. CMS and the State expect MMP and provider implementation of the independent living and recovery philosophy, wellness principles, and cultural competence to contribute to achieving these goals. (See Appendix 1 for definitions of terms and acronyms used in this MOU.)

5 Under this initiative, one or more MMPs will be required to provide for, either directly or through subcontracts, Medicare- and Medicaid-covered services, as well as additional items and services, under a capitated model of financing. CMS, the State, and the MMPs will ensure that Enrollees have access to an adequate network of medical and supportive services. The ICI Demonstration will be implemented as part of the State s broader Integrated Care Initiative, which aims to achieve improved health and well-being, and better health care, at lower costs for a segment of Rhode Island s Medicaid-only and Medicare-Medicaid Beneficiaries. In 2013, under Phase I of the Integrated Care Initiative, the State introduced an enhanced Primary Care Case Management model called Connect Care Choice Community Partners (CCCCP) and a Medicaid health plan model called the Rhody Health Options (RHO) program, available to Medicaid-only and Medicare-Medicaid Beneficiaries under the Rhode Island Comprehensive Section 1115(a) demonstration.

6 The one health plan participating in the RHO program is also the 2 only current prospective MMP for the ICI Demonstration. The ICI Demonstration is part of Phase II of the Integrated Care Initiative, and will require at least one MMP to provide both Medicare and Medicaid benefits to ICI Demonstration Enrollees, with the exception of certain developmental disability and other services (outlined in Appendix 7) that are also carved out of Phase I. These services will continue to be provided to ICI Demonstration Enrollees via the fee-for-service (FFS) system and will not be covered by the capitated rate. The individuals who receive those services will be eligible for Demonstration enrollment.

7 CMS and the State may seek to bring these services into the ICI Demonstration in the future. Medicare-Medicaid Beneficiaries will have the choice to opt out of the ICI Demonstration. For Medicaid benefits, individuals who opt out of the ICI Demonstration may enroll in or remain in RHO or any other Medicaid program that may be available to Medicare-Medicaid Beneficiaries for Medicaid services only. For Medicare benefits, individuals who opt out of the ICI Demonstration will have the choice to enroll in a Medicare Advantage plan, or receive FFS Medicare and enroll in a Prescription Drug Plan (PDP). Medicare-Medicaid Beneficiaries eligible for the ICI Demonstration may also be eligible to enroll in t he Program of All-Inclusive Care for the Elderly (PACE), if they choose not to enroll in the Demonstration.

8 Outreach and enrollment notices for the ICI Demonstration will inform Medicare-Medicaid Beneficiaries of all enrollment options. CMS and the State shall jointly select and monitor the MMPs. CMS and the State will implement the ICI Demonstration under Medicare Parts C and D and demonstration authority for Medicare, and State Plan and Rhode Island Comprehensive Section 1115(a) demonstration authority for Medicaid, as described in Section and detailed in Appendices 4 and 5. Consistent with the goals of the State s Comprehensive Section 1115(a) demonstration and the Integrated Care Initiative, key goals of the ICI Demonstration include: Enhancing person-centered care; Improving and maintaining Enrollee quality of life and care; Developing an integrated system of care and coordination of services; Increasing the proportion of individuals successfully residing in a community setting; Reducing long-term care costs by providing person-centered care in the most appropriate and cost-effective setting.

9 3 Decreasing avoidable hospitalizations, emergency room utilization and reducing nursing facility admissions and length of stay; Evaluating the effect of an integrated care and payment model on Medicare-Medicaid Beneficiaries who receive care and supports in the community and in institutions; and Promoting Alternative Payment Arrangements as a means to transform the delivery of high quality and cost-effective care within CMS requirements. The Demonstration will evaluate the effect of an integrated care and payment model on both community-based and institutional populations. In order to accomplish these objectives, comprehensive contract requirements will specify access, quality, network, financial solvency, and oversight standards as well as requirements.

10 Contract management, which will be jointly accomplished by the State and CMS, will focus on performance measurement and continuous quality improvement. Except as otherwise specified in this MOU, applicable Medicaid waiver or Section 1115(a) demonstration standards and conditions, State Plan Amendments, or the Three-way Contract, MMPs will be required to comply with all applicable existing Medicare and Medicaid laws, rules, and regulations as well as ICI Demonstration-specific and evaluation requirements, as will be further specified in the Three-way Contract to be executed among each MMP, the State, and CMS.