The Centers for Medicare & Medicaid Services (“CMS”) and the State of Rhode Island Executive Office of Health and Human Services (“EOHHS”) recently signed a Memorandum of Understanding regarding a Federal-State partnership to implement a Medicare-Medicaid Alignment Integrated Care Initiative Demonstration, under Rhode Island’s Section 1115 waiver (“Demonstration”).

The Section 1115 waiver allows the State to pursue innovations and improvements to the Medicaid Program. The State developed an Integrated Care Initiative under the waiver, which has two phases. In 2013, under Phase I, 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 program.

The Medicare-Medicaid Alignment Integrated Care Initiative Demonstration is Phase II of the Integrated Care Initiative, aimed at integrating benefits for individuals eligible for both Medicare and Medicaid (“dual-eligibles”).

Under the Demonstration, Medicare-Medicaid Plans (currently, Neighborhood Health Plan of RI, the “Plan”) will enter into a three-way contract with CMS and the State to provide integrated benefits to dual-eligibles. Medicare and Medicaid covered services, and additional items and services, will be paid to the Plan based on a capitated model of financing under the contract. CMS will make separate monthly, risk-adjusted payments to the Plan for the Medicare Parts A/B and Part D components of the rates and EOHHS will make a payment to the Plan for the Medicaid component of the rate. The Plan is encouraged to utilize alternative payment arrangements with providers. The Plan will have full accountability for managing the capitated payment to best meet the needs of dual-eligibles and will be required to comply with both Medicare and Medicaid existing laws and regulations.

Opt-in enrollments will be accepted from individuals eligible for the Demonstration no sooner than September 1, 2015 for coverage starting no sooner than December 1, 2015.

If individuals do not make an active choice to opt-in to the Demonstration, enrollment may be conducted using a passive enrollment process. The passive enrollment process must provide individuals the opportunity to make a voluntary choice to enroll or disenroll from the Plan on a monthly basis.

The goals of the 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;
  • 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 support 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.

Rhode Island’s participation in the Demonstration further exhibits its commitment to alleviate fragmentation; enhance quality of care; reduce costs; and improve transitions and coordination among care settings for dual-eligibles. But, Rhode Island isn’t alone. Other states are also partnering with CMS to test new models for providing dual-eligibles with a more coordinated, person-centered care experiences. In Rhode Island and elsewhere, these demonstrations will impact all stakeholders, including providers, health plans and individuals; who will need to understand their respective rights and obligations in order for the demonstrations to be effective and achieve their goals.

If you have questions related to the Demonstration or Medicare and Medicaid, please call Attorney Jillian Jagling at 401-824-5100 or email . We welcome your comments, questions and suggestions.