The following is a list of resources that are currently available to provide information and assistance when developing integrated Medicare and Medicaid models of care.  As new materials are developed they will be added to this list for reference.

"At-A-Glance" Guide to Medicaid Authorities for Integrated Programs

This chart provides a list and description of the authorities available to States that may be utilized in the development of an integrated care program.  The key flexibilities and/or limitations of each type of authority is provided.  This tool can be downloaded from the bottom of the page.

State Guide to Integrated Medicare and Medicaid Models

The State Guide to Integrated Medicare and Medicaid Models was developed to educate States and other stakeholders on the possible models that may be employed to better integrate Medicare and Medicaid services for dual eligibles.  New opportunities are available for States now that Medicare Advantage (MA) Organizations have the ability to target enrollment in plans to dual eligibles as authorized under Section 231 of the Medicare Modernization Act (MMA).  These MA Plans that are approved as MA - "Special Needs Plans" may offer an opportunity for better integrated Medicare and Medicaid coverage for dual eligible beneficiaries. The State Guide addresses some of the difficulties States face in attempting to integrate Medicare and Medicaid coverage for dual eligible beneficiaries and specifically identifies four models that have been used in recent years to integrate Medicare and Medicaid services.  This guide can be downloaded from the bottom of the page

Long Term Care Capitation Models

The purpose of this paper is to provide States with information on Medicaid and Medicare program authorities that can be used to implement capitated LTC models. On the Medicaid side, these include waiver and demonstration authorities and a new State plan option that became available through the Deficit Reduction Act (DRA) of 2005. The paper concludes by providing examples of programs that capitate LTC services and utilize different program authorities

Integrated Care Program Design, Rate Setting, and Risk Adjustment: A Checklist for States

This is a tool that was developed by the Center for Health Care Strategies, Inc. in consultation with a group of national experts.  It walks States through the steps for consideration, explains the importance of the issue and describes the implications of the decisions that States need to examine during the process of designing an integrated care program. The link to access this resource is provided at the bottom of the page under "Related Links Outside CMS".

"How To" Guides on Enrollment, Marketing and Quality

CMS has created "How To" Guides in the areas of Enrollment, Marketing and Quality which provide clarification on many Medicare and Medicaid rules and suggest streamlined processes that States and plans can use to fulfill Medicare and Medicaid requirements.  The documents are listed as downloads on the bottom of this page and are titled as follows:

• Enrollment "How To" Guide for Special Needs Plans
• Attachment A, Model MA Individual Enrollment Form
• Attachment B, Data Elements Required to Complete Enrollment Election
• Marketing "How To" Guide for Special Needs Plans
• Quality "How To" Guide for Special Needs Plans

Integrated Medicare and Medicaid Appeals Process

CMS has developed an optional model for the integration of the Medicare and Medicaid appeals processes for Special Needs Plans (SNPs) that serve dual eligibles.  This tool provides an explanation of the process flow as well as the advantages and disadvantages to utilizing this integrated appeals process.  Flowcharts of the standard appeal process and the expedited appeal process also provide a visual guide of how the model process would work.  These documents are listed as downloads on the bottom of this page and are titled as follows:

• Integrated Appeals Process
• Standard Appeal Flowchart
• Expedited Appeal Flowchart

State Medicaid Directors' Letter regarding the Subset Policy for Special Needs Plans

This letter provides information regarding the CMS policy that allows Medicare Advantage Special Needs Plans to target enrollment of dual eligible beneficiaries in States that are providing an integrated Medicaid benefit package.  Beginning with contract year 2008, SNPs may target enrollment of dual eligibles as long as the plan coordinates their efforts with the State Medicaid Agencies.  This letter is also found as a download at the bottom of the page.

CHCS Primer: Medicare Advantage Rate Setting and Risk Adjustment

This primer on Medicare managed care rate setting and risk-adjustment is aimed at helping State Medicaid agencies better understand how the Medicare rate setting system works so that States can work more effectively with Special Need Plans and other Medicare Advantage Plans to integrate Medicaid and Medicare services.  There is a link to the website provided in the "Related Links Outside CMS" at the bottom of this page. 

Medicare Advantage Application for Special Needs Plans

Each year CMS releases the application for Medicare Advantage Special Needs Plans that includes guidance to SNPs on issues such as allowable subsets, models of care, and the associated reporting and approval process.  This application can be found through the website for Special Needs Plans.  The link to this website can be found in the "Related Links Inside CMS" at the bottom of this page.  

Medicaid Obligations in Cost Sharing in Medicare Advantage Plans

Information regarding Medicaid's obligation to pay cost-sharing for individuals who are eligible for both Medicare and Medicaid (dual eligibles) and who are enrolled in a Medicare Advantage Plans is provided in a letter and chart.  This information is provided as a download at the bottom of this page.   

The purpose of this letter is to provide a compilation of pertinent information found in statute, regulation and guidance in a concise format for States, providers and Medicare Advantage Plans. Several factors determine whether or not Medicaid is liable for coverage of cost-sharing in MA Plans.  These factors include the dual eligibles coverage category, the type of cost-sharing, the options elected by the State and payment limitations specified in the State Plan.  The chart provided on the website is intended to clarify how these factors affect whether or not the State Medicaid program has a liability for cost-sharing for dual eligibles in MA plans.

Additional Guidance on the Medicare Advantage Program and Special Needs Plans

The Medicare Managed Care Manual provides additional information and guidance on the Medicare Advantage Program.  The link to this website can be found in the "Related Links Inside CMS" at the bottom of this page.  Information specific to Special Needs Plans can be accessed at the link provided in "Related Links Inside CMS" at the bottom of this page.

Downloads
"At-A-Glance" Guide to Medicaid Authorities for Integrated Programs [PDF, 45KB] State Guide to Integrated Medicare and Medicaid Models [PDF, 1,715 KB] Long Term Care Capitation Models [PDF, 170 KB] Enrollment "How To" Guide for Special Needs Plans [PDF, 55KB] Attachment A, Model MA Individual Enrollment Form [PDF, 114KB] Attachment B, Data Elements Required to Complete Enrollment Election [PDF, 38KB] Marketing "How To" Guide for Special Needs Plans [PDF, 105 KB] Quality "How To" Guide for Special Needs Plans [PDF, 159 KB] Integrated Appeals Process [PDF, 60 KB] Standard Appeal Flowchart [PDF, 44 KB] Expedited Appeal Flowchart [PDF, 44 KB] SMD Letter regarding Subset Policy for Special Needs Plans [PDF, 160 KB] Medicaid Obligations in Cost Sharing Letter [PDF, 772 KB] Medicaid Obligations in Cost Sharing Chart [PDF, 48 KB]
Related Links Inside CMS
Medicare Advantage Application for Special Needs Plans Additional Guidance on the Medicare Advantage Program and Special Needs Plans
Related Links Outside CMS
Integrated Care Program Design, Rate Setting, and Risk Adjustment CHCS Primer

Page Last Modified: 05/02/2008 8:47:49 AM
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