FUTURE OF INTEGRATED CARE - POTENTIAL PAYMENT PARAMETERS FOR DISCUSSION PURPOSES ONLY

  • Draft is also available in Portable Document Format (PDF)

DRAFT

MEDICARE PARTS A/B PAYMENT PARAMETERS

Rate Component Fully Integrated Duals Advantage (FIDA) Medicare Advantage (Applies to Medicare plans aligned with Medicaid Advantage Plus plans) Considerations
Baseline Rate
  • Rates based on costs absent the demo (MA payments and FFS county rates)
  • Plans do not bid
  • Same rate for all plans
  • Plans bid against benchmark
  • Rates are plan specific
  • Potential difference in standardized rate between current approach/bidding
  • Plan capacity/experience with bidding
  • Flexibilities in demonstration approach
  • Depending on bid, potential to use rebate dollars to fund supplemental benefits
Risk Adjustment
  • Hierarchical Condition Category (HCC) Risk Adjustment Model
  • HCC Risk Adjustment Model
  • Same approach
Frailty Adjustment
  • Currently built in to rates at county level for all MMPs, reflecting frailty that would have been paid in FIDESNPs
  • TBD approach going forward
  • Available for Fully Integrated Dual Eligible Special Needs Plans (FIDESNPs) that meet criteria
  • Plan specific
  • Frailty of target population
  • Benefits of different approaches different for different plans?
Quality Impact on Payment
  • Quality withhold applied to Medicare A/B and Medicaid rate components
  • MA star ratings built into MA component of FIDA plan rate, not plan specific
  • No quality withhold
  • Star rating impacts benchmarks and rebate amount
  • How to best incent quality
Bad Debt
  • Duals–specific bad debt load added to rates
  • Rates include standard Medicare beneficiary bad debt load
 

MEDICARE PARTS D PAYMENT PARAMETERS

Rate Component Fully Integrated Duals Advantage (FIDA) Medicare Advantage (Applies to Medicare plans aligned with Medicaid Advantage Plus plans) Considerations
Baseline Rate
  • National Average Monthly Bid Amount (NAMBA)
  • Plans bid
  • Potential difference in standardized rate between current approach/bidding
  • Plan capacity/experience with bidding
Risk Adjustment
  • RxHCC Model
  • RxHCC Model
  • Same approach
LICS and Reinsurance
  • Plans have option to attest for Low Income Cost Sharing (LICS) and reinsurance, 100% cost reconciled
  • Plans include prospective amounts in bid, 100% cost reconciled.
  • Same approach in effect for plans currently attesting in FIDA
Savings Percentage
  • Not applied
  • Not Applied
  • Same approach
Quality withhold
  • Not applied
  • Not Applied
  • Same approach
Risk Corridors
  • Standard Part D risk corridor applies
  • CMS sets administrative cost ratio
  • Part D risk corridor applies
  • Administrative cost ratio in plan bid
 

MEDICAID PAYMENT PARAMETERS

Rate Component Fully Integrated Duals Advantage (FIDA) Medicare Advantage (Applies to Medicare plans aligned with Medicaid Advantage Plus plans) Considerations
Baseline Rate
  • Must reflect costs absent demonstration. Builds off of existing long term care services. Current methodology aligns rate–setting parameters, and is acuity–adjusted for MLTC product lines (excl PACE).
  • Builds off of existing long–term care services. Current methodology aligns rate–setting parameters and is acuity adjusted for the MAP program.
Moving forward, is the "costs absent the demo structure" maintainable and relevant?
Administrative Costs
  • Must only reflect admin costs state would have otherwise born absent demo. Capped at $215.
  • Capped at $215
Are these costs adequately reimbursed 
Care Management Costs
  • Must only reflect care management costs state would have otherwise born absent demo
  • Includes care management costs based on expectations of plan expenditures/ care management model
Are these costs adequately reimbursed?
Savings Percentage
  • Applied equally to Medicare A/B and Medicaid rate components
  • Not applicable
 
Quality withhold
  • Applied to Medicare A/B and Medicaid rate components
  • Surplus component of rate reduced from 2% to 1%
 
Rate Cells and Risk Adjustment Currently 1 blended cell, which includes NH add–on. Risk Adjustment is plan–specific, based on UAS.
  • Currently 1 blended cell, which includes NH add–on. Risk Adjustment is plan–specific, based on UAS.
 

GENERAL PARAMETERS

Rate Component Fully Integrated Duals Advantage (FIDA) Medicare Advantage (Applies to Medicare plans aligned with Medicaid Advantage Plus plans) Considerations
Geographic Scope Currently only in downstate (NYC)
  • Expansion to move statewide 
  • How to address in rate cell approach
Population Served
  • NF eligible and receiving facility–based LTSS, NHTD waiver eligible, or receiving community–based LTSS
  • Expansion to include community well duals 
  • How to address in rate cell/risk adjustment approach
Medical Loss Ratio
  • Joint Medicaid and Medicare A/B MLR
  • Medicaid: applies for rating periods beginning on/after July 2017
  • Medicare: required for MA plans
  • Value of joint Medicaid/Medicare MLR

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