CMS, New York State testing new model of coordinated care for dual eligibles

Individuals who are eligible for both Medicare and Medicaid are often faced with challenges when navigating through the programs’ various rules, benefits, and providers. Some such individuals, known as “dual eligibles,” may also have intellectual or developmental disabilities and require access to various health care providers. In the attempt to provide a “more coordinated, person-centered experience” for such enrollees, CMS and New York State are teaming up to test a new model of providing care that focuses on coordinating acute care and long-term care needs.

New Model

CMS announced its partnership with the New York State Department of Health (NYSDOH) and the Office for People with Developmental Disabilities (OPWDD), that will create the Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD), which will be a demonstration project aimed at better serving dual eligible enrollees who have intellectual and developmental disabilities. According to CMS, the FIDA-IDD Demonstration will provide more opportunities for individuals to be involved in directing their own services and care planning while living as independently as possible in their communities.

Under the FIDA-IDD model, 20,000 dual eligible enrollees in the downstate New York region will be offered the opportunity to participate in the voluntary program. The program will be offered through Partners Health Plan in New York City, Long Island, and Rockland and Westchester Counties. Voluntary enrollment will begin after April 1, 2016.

ACA

Section 2602 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) established the Federal Coordinated Health Care Office, known as the Medicare-Medicaid Coordination Office (MMCO) to better coordinate the Medicare and Medicaid programs to ensure that dual eligibles receive the benefits to which they are entitled. The MMCO partners with states through CMS’ Financial Alignment Initiative to create demonstration projects to test methods of providing integrated benefits to dual eligibles. Demonstrations such as FIDA-IDD that are approved under the Financial Alignment Initiative are intended to provide better care through a person-centered, integrated care approach.

Structure

The new model shares the general structure and goals with the Fully Integrated Duals Advantage (FIDA) Demonstration project, which is already in operation in New York, but it involves different populations and Medicare-Medicaid plans. Additionally, the new model (FIDA-IDD) does not allow for passive enrollment and includes benefits that are tailored to providing support to individuals who have intellectual and developmental disabilities.

The FIDA-IDD is operated under the Capitated Model, through which states and CMS contract with health plans that receive prospective, blended payments in exchange for providing dual eligibles with coordinated care. In order to participate in the FIDA-IDD Demonstration, plans must meet core Medicare and Medicaid requirements and must pass a comprehensive readiness review.

How it Works

The FIDA-IDD Plan will provide enrollees with an interdisciplinary care team, which will be based on the enrollees’ individual preferences and goals so as to ensure that enrollees’ medical, behavioral health, long-term services and supports, and social needs are integrated. The demonstration will include performance metrics established by CMS and New York to ensure high quality care. The plan also includes continuity of care requirements so that enrollees can continue to see their current providers as they transition into the FIDA-IDD Plan. Additionally, New York created the Independent Consumer Advocacy Network (ICAN), which is a free Ombudsman program intended to assist enrollees with appeals and other plan issues. The program will support individual advocacy and will provide New York and CMS with feedback on the plan’s performance relating to community integration, independent living, and person-centered care.

External Evaluation

Each demonstration under CMS’ Financial Alignment Initiative, including the FIDA-IDD, will be externally evaluated to measure its quality, beneficiary care experience, care coordination, costs, and support of community living. FIDA-IDD will also have a specific evaluation that will use a comparison group to analyze the demonstration’s impact.