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

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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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