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Aging Initiative Minnesota Senior
Health Options (MSHO) MINNESOTA SENIOR HEALTH OPTIONS January, 2000 INTRODUCTION The Minnesota Department of Human Services (DHS) has developed a program called Minnesota Senior Health Options which combines Medicare and Medicaid financing and acute and long term care service delivery systems. This program was formerly known as the Long Term Care Options Project. (The name was changed after focus group research recommended a name which more accurately reflected the true nature of the program.) The program is authorized under Minnesota Statutes 256B.69 subd.23. The demonstration facilitates the integration of primary, acute and long term care services for persons over age 65 who are dually eligible for both Medicare and Medicaid. Out of about 550,000 persons over age 65 in Minnesota, about 48,000 receive Medicaid. Minnesota's Medicaid program is called Medical Assistance (MA). About 46,000 seniors are dually eligible for both Medicaid and Medicare. About 18,000 of these dually eligible seniors reside in the seven county metro area. Minnesota has received federal Medicare 222 and Medicaid 1115 waivers from the Health Care Financing Administration (HCFA) to put this demonstration into practice. The waivers allow the State to combine the purchase of both Medicare and Medicaid services into one contract managed by the state. Minnesota is the first state ever to be granted such a combination of waivers. The waivers also allow contracting with smaller HMOs and CISNs which are currently not eligible to be Medicare+Choice contractors. In addition, the federal waivers granted Minnesota a Medicare risk adjustment payment for frail elderly dual eligibles in the community as an incentive to prevent unnecessary institutionalization. The demonstration is being implemented in the seven county metro area and will cover a five year period. The Robert Wood Johnson Foundation (RWJF), which supported the planning stages for the demonstration, has provided a grant to cover the initial administration and implementation of the demonstration and this grant has been matched by Medicaid administrative funds from HCFA. The MSHO demonstration has generated much national attention from health care publishers and educators, providers, health plans, policy makers, and other state officials due to its unique nature and precedents set in its development. Minnesota's progress in implementing MSHO is being carefully watched by a large number of organizations and individuals across the country. For example, the Bipartisan Commission on Medicare Reform conducted a site visit to the project during the summer of 1998. The Robert Wood Johnson Foundation has just announced a new initiative to provide $8,000,000 in grants to up to 10 states to build on Minnesota's MSHO model. Problems with the Current System County and state health workers, providers who work with the elderly, and consumers have long identified conflicts between Medicare and Medicaid policy and financing. There are many stories from frustrated physicians, health plans and patients about the fragmented health care system seniors who are dually eligible for both Medicare and Medicaid experience today. It can be very difficult for seniors to access services from two or three different systems with different rules, case managers, telephone numbers, identification cards, etc. Seniors with chronic care needs may need a variety of services all at the same time. In reality, older persons' needs do not fit neatly into the separate acute and long term care financing and delivery boxes we have created. Specific problems with the current system include the following:
What an Integrated System Accomplishes Medicare policy and reimbursement drive clinical decisions that in turn affect Medicaid utilization and expenditures. For example, Medicare pays for hospital and physician care but decisions made by hospitals and physicians in response to Medicare payment incentives can affect Medicaid costs. Enrollment of dually eligible PMAP seniors in Medicare risk plans has recently become popular. However, this may provide incentives to institutionalize because these plans are paid higher payments from Medicare for persons in nursing homes and Medicare lacks payment adjustments for frail elders in the community. Yet, changes in either program may shift costs to the other, since many Medicare and Medicaid services substitute for each other. Cheaper services, primarily paid for by Medicaid such as nursing homes and home care, often substitute for more expensive Medicare services like hospitalization, shifting costs to the state. States have little incentive to help save Medicare dollars since they cannot share in any Medicare savings and because they fear this type of cost shifting. Integrated Medicare and Medicaid funding can provide better clinical and cost incentives for services to elderly dual eligibles. Integrated Medicare and Medicaid capitations provide the flexibility needed to reduce conflicts between Medicare and Medicaid policy. Integrated financing allows health plans and long term care providers to develop collaborative clinical delivery structures and strategies to improve quality and accountability for services to seniors. Once these financing barriers are eliminated, health plans and providers are free to coordinate their care management across the full range of acute and long term care services to seniors and address the clinical conflicts and problems outlined above. States are protected from cost shifting since one entity is responsible for the full range of services. MSHO FEATURES DHS has obtained federal waivers that allow the state to purchase both Medicare and Medicaid services in a combined package. Waivers include a combination of Medicare waivers under Section 222 of the Social Security Act and Medicaid waivers under Section 1115. Under the terms and conditions of the waivers granted by HCFA, the state is responsible for choosing contractors capable of providing a full range of integrated primary, acute and long term care services on a capitated risk basis. Administration of Minnesota Senior Health Options builds on the current administration, rules and statutes of the Prepaid Medical Assistance Program (PMAP). However, most requirements applied to Medicare risk plans also apply. Goals of the Demonstration
Current PMAP Program Since 1985, Minnesota has been enrolling recipients of public medical assistance programs, including seniors in managed care health plans. Under PMAP, persons eligible for Medicaid (MA) in the seven county Metro area and 49 out of 80 counties in Greater Minnesota are given a choice among several major health plans and/or a wide assortment of clinics and physicians with whom to enroll. Currently about 29,150 of Minnesota's 51,000 seniors who receive MA are enrolled in managed care plans through PMAP. About 15,200 of these PMAP enrollees live in nursing homes, and about 13,950 reside in the community. Some of these seniors are also voluntarily enrolled in a Medicare risk plan operated by their PMAP plan. Services provided through PMAP include: Medicare deductibles and co-insurance, physician visits, medical supplies and equipment, dental, hospitalization, therapies (PT, OT, ST, Psych), prescription drugs, medical transportation and some home care services. Although Medicare co-insurance and deductibles are paid through the health plans, Medicare pays providers directly for the remainder of the services. The nursing home per diem and home and community based waivered services are not the responsibility of the managed care plans under PMAP. For seniors enrolled in PMAP, these services are paid directly by the department on a fee for service basis. MSHO Services Under Minnesota Senior Health Options, enrollees are entitled to receive all Medicaid services provided under PMAP as described above, plus all Medicare services under Parts A and B. In addition, health plans will provide services available under the current home and community based waiver (Elderly Waiver), which consists mainly of extended home care benefits to frail elderly eligible for nursing home care. A unique feature of Minnesota Senior Health Options also requires health plans to be responsible for the first 180 days of care in a nursing facility for those who enroll in Minnesota Senior Health Options while living in the community. This feature maximizes the opportunity for innovation in non-institutional care and prevention of early institutional placement, especially for those who have chronic care needs. MSHO Administration The state negotiates contracts with Health Maintenance Organizations (HMOs) and/or Community Integrated Service Networks (CISNs) for capitated risk-based Medicare and Medicaid services. The state will manage these contracts for both Medicare and Medicaid services under an agreement with the Health Care Financing Administration (HCFA). Minnesota Senior Health Options allows Medicare risk contracting with smaller HMOs and CISNs who previously could not contract with Medicare on a risk basis. All MSHO plans must also have a PMAP contract in each county in which they offer MSHO. Contractors must meet most of the federal regulatory requirements of Medicare risk plans as well as most PMAP requirements. Operational requirements for MSHO are contained in an Operational Protocol, developed by DHS and approved by HCFA. MSHO staff did extensive analysis of Medicare+Choice Contract requirements, Medicaid managed care requirements, and Minnesota HMO and CISN licensing statutes and rules in order to develop one standard set of MSHO requirements which reduced conflicts and duplications between Medicare and Medicaid policies and state and federal oversight requirements. In addition, DHS and HCFA have entered into an agreement modeled after Medicare+Choice contracts, which outlines the state's responsibilities for oversight for the MSHO demonstration. A model MSHO contract between the state and the MSHO contractors also was developed and approved by HCFA prior to the negotiation process. RFP and Contract Negotiation Process DHS issued an RFP outlining all Medicaid and Medicare requirements for MSHO in February of 1996. All 5 PMAP plans serving seniors in the seven county metro area did respond. Proposals were given an extensive review process including county staff and county board review and comment. In addition, MSHO staff met with managed care, public health and social services staff in each of the seven Metro counties. Based on the review process, invitations for contract negotiations were extended to three PMAP plans: Medica, MHP and UCare Minnesota. After additional information was submitted, invitations for contract negotiations were also extended to Health Partners and Blue Plus. Contract negotiations with UCare Minnesota for Ramsey County and for MHP for Hennepin County were finalized in December, 1996. Contracts were effective January 1, 1997. MHP began enrollment began in Hennepin county and UCare began in Ramsey county in February, 1997. UCare expanded its network to Hennepin County effective June 1, 1997, and Anoka and Dakota Counties effective July 1, 1998. Medica's contract with MSHO was effective September, 1997 for Anoka, Dakota, Hennepin, and Ramsey Counties with Scott County added in June, 1999. UCare continues to indicate interest in serving counties outside the seven county metropolitan area as well as expanding to Washington County in the metro area. Health Plan Provider Networks Health plans participating in MSHO have been encouraged to develop new partnerships with long term care providers and counties in order to better serve seniors. Allina, the health system affiliated with Medica, was the first to issue RFPs in 1995 requesting subcontractors to form integrated care systems of long term care providers and clinics in order to serve PMAP seniors who have also elected to enroll in its Medicare+Choice plan. Medica subcontracts with these same care systems to serve its MSHO enrollees. As a result of a new awareness of the need for better coordination between acute and long term care and new methods of combining Medicare and Medicaid funding through MSHO and through enrollment of PMAP seniors in Medicare risk plans, a number of geriatric care networks or care systems have been developed in the Metro area in the last few years. These new business ventures vary in structure and risk sharing arrangements. The entities include an organization which brings physician services and care coordination by geriatric nurse practitioners directly to nursing home residents, a partnership between an HMO, hospitals, clinics and long term care facilities, a hospital entity partnered with a broad based long term care provider, a group of long term care providers who have created a joint venture for business arrangements with clinics and hospitals to manage a full spectrum of services on a subcapitated basis and a group of nursing homes which have formed a cooperative for more efficient contracting and purchasing arrangements. Entities include Evercare/Optage which merged in 1999 (the first care system to focus on nursing home residents), Columbia Park Medical Group, Creekside Family Physicians, University-Affiliated Family Physicians and Access Alliance. In addition, Metropolitan Health Plan (MHP), which is Hennepin County's HMO, has entered into a unique agreement with Hennepin County Public Health and Hennepin County Social Services to make available and manage home and community based services as part of a move to integrate services. Population Served Persons over age 65, dually eligible for both Medicare and Medicaid (including both institutional and community based), residing in the seven-county Metro area are eligible to enroll. The project may expand to other PMAP counties later depending on interest among plans and counties and adequate Medicare payment levels in those counties. Enrollment Minnesota Senior Health Options is offered as a voluntary option to the standard PMAP plan. There is a single enrollment process for both Medicare and Medicaid conducted through the county as a part of the PMAP enrollment process. Prior to January 1, 2000, plans could only market to their current PMAP enrollees. As of January 1, 2000, plans will be allowed to market to any MSHO eligible enrollee. All marketing materials used by the state or contracted health plans must be reviewed by HCFA and must meet Medicare risk requirements for marketing materials except for those items for which waivers were granted. Enrollees may disenroll on a monthly basis but will stay in the same plan's PMAP program. Projected enrollment over the life of the project was estimated to be 4,000 but MSHO has served about 5,700 enrollees in its three years of existence. As of January 1, 2000, MSHO had 3,420 seniors currently enrolled. Enrollment began in February 1997 in Hennepin and Ramsey counties. Other Metro counties will be added as health plans finalize networks in those areas. Clinical Delivery System and Providers Health systems participating in Minnesota Senior Health Options have been encouraged to create a network of providers that will accomplish the clinical integration that is at the heart of the demonstration. This may include the use of geriatricians, geriatric nurse practitioners and other professionals with geriatric experience. In addition to basic PMAP contract requirements, MSHO contracts contain provisions to address the needs of the chronically ill elderly population. Each enrollee has access to a care manager who conducts or arranges appropriate assessments and coordinates the overall continuing care of each enrollee. The contract outlines special procedures for access to home and community based services when needed. Plans must assure that the enrollee and family will be involved in care planning and treatment decisions. In addition to ensuring increased coordination and communication across all types and sites of health care, contracting health plans are asked to find ways to coordinate medical and social service needs with family caregivers as well as with local social service agencies and volunteer organizations. Within the contract requirements, each plan has the flexibility to create a clinical design that fits within their own system. Quality Assurance Several levels of quality assurance (QA) have been built into the demonstration. The Minnesota Department of Health (MDH) is responsible for licensing, oversight and monitoring of all HMOs and CISNs. DHS maintains an interagency agreement with MDH for coordination of oversight functions of PMAP and MSHO contractors. Under the MSHO demonstration waivers, the State incorporates quality assurance for Medicare services into its PMAP managed care quality assurance system and reports to HCFA periodically on plan compliance. Relevant portions of the national standard set of HEDIS utilization measures will be collected. Additional outcome measures more specific to elderly with chronic care needs have been developed by the MSHO Quality Assurance Subcommittee. Encounter level data will be collected and analyzed. A special client satisfaction survey will also be implemented as well as a disenrollment survey. Complaints and Appeals The current PMAP complaint and appeals system including access to the state PMAP ombudsman and county advocates and the fair hearings process is available to Minnesota Senior Health Options enrollees. Under the terms of the demonstration waivers, most Medicare complaints will also be handled through the PMAP process so that enrollees and health plans do not have to keep track of more than one grievance process. In addition, unlike Medicare's HMO grievance process which requires the enrollee to work though the HMO's internal process and sets certain dollar thresholds before the individual can access an independent review, Minnesota's current PMAP complaint and appeals process provides the enrollee the option of submitting an appeal directly to the state at any time without regard to the dollar amount involved. If a Medicare related appeal is not resolved through the current PMAP appeals process, the enrollee still has access to review by the Center for Health Dispute Resolution and an Administrative Law Judge at the federal level. Technical and Educational Program The department has subcontracted with the National Chronic Care Consortium (NCCC) for assistance in the development of a Technical and Educational Program (TEAP) which provides expert resources for enabling networks participating in MSHO to integrate acute and long term care services including concepts, clinical expertise and related tools. While a growing number of organizations and individuals are recognizing the need for integration, it is an evolving technology. The TEAP provides ongoing technical assistance to facilitate changes. The desired result is a process of ongoing collaboration regarding best practice models and a focal point for working on key issues in clinical care. The NCCC is a national organization based in the Twin Cities which includes sophisticated provider systems (hospitals, clinics, HMOs and long term care providers) throughout the country who are interested in better management of chronic care conditions. NCCC is known for its work in developing clinical integration tools such as assessment instruments and protocols, and for compiling information from all over the country on integration of acute and long term care. In addition to providing regular newsletters and research information to MSHO contractors and provider networks, NCCC facilitates educational forums on clinical integration topics and develops resources for use by MSHO clinicians based on input from an expert panel of clinicians and representatives from the integrated care systems participating in MSHO. Advisory Committee/Consumer Input During the five year development phase of the demonstration, several large public meetings and hundreds of smaller meetings were held to receive input from the public. A formal Advisory Committee comprised of 30 members meets quarterly for updates and input into Minnesota Senior Health Options. In addition, project staff maintain several ongoing committees with county managed care, county elderly waiver and public health staff. Research Design The state is responsible for ongoing monitoring and research based on encounter and other project data. HCFA has contracted with an independent entity, led by Dr. Robert Kane from the University of Minnesota's Division of Health Services Research and Policy to conduct the formal evaluation of Minnesota Senior Health Options. Rates DHS provides each Minnesota Senior Health Options contractor with a monthly per capita payment per enrollee which includes the PMAP capitation, a Medicaid Nursing Facility Add-on, and the Average Elderly Waiver payment as appropriate per Minnesota Senior Health Options policy. HCFA makes direct payment to each Minnesota Senior Health Options contractor for the monthly Adjusted Average Per Capita Costs (AAPCC) capitation. Minnesota Senior Health Options provides an increased Medicare capitation for frail elderly by applying an AAPCC risk adjustment factor. In exchange for these two Medicaid and Medicare capitation payments, Minnesota Senior Health Options contractors must provide all the medically necessary Medicaid, Medicare, Elderly Waiver and Nursing Facility services for the individuals enrolled in Minnesota Senior Health Options with the exception of long term nursing home per diems. (See attached chart for greater detail about rates.) For More Information Contact: |
