North Carolina S Response to CMS Questions on State Demonstration to Integrate Care For

North Carolina’s Response to CMS Questions on State Demonstration to Integrate Care for Dual Eligible Individuals, November 2012(Part 3)

1. Pages 8-15 of the State Demonstration Proposal to Integrate Care for Medicare-Medicaid Enrollees (“proposal”) describe the proposed integrated delivery model framework, including: primary care medical home infrastructure, independent assessment of need, functional need-based resource allocation, capacity incentives, and broader use of actionable data. Please identify the enhanced services that would be provided to Medicare-Medicaid enrollees who participate in the managed fee-for-service (FFS) demonstration that are not currently being provided.

The most immediate examples of enhancements will derive from the NC Division of Medical Assistance (DMA) partnership with CMS and the use of Medicare Data.

• Medicare claims data will be incorporated in beneficiaries’ medical home information files to further inform primary care medical home supports.
• Dual Eligible beneficiary medication therapy management targeting criteria will be applied to Medicare Part D claims data to help reduce medication missteps.
• Analyses of Medicare Part D data will help target needed nursing and adult care home facilities pharmacy supports and priorities for relationship building with existing Part D vendors and pharmacy consultants.
• Medicare claims data will be used with Medicaid claims data to refine risk stratification and targeting criteria to identify the most impactable beneficiaries, e.g. highest-risk dual eligible beneficiaries and facilities with the highest-proportion of high-risk dual-eligible residents.

o Risk stratification and targeting will guide deployment of care management and other Network and community resources to meet the needs of beneficiaries at greatest risk.

• Analyses of targeted high-risk beneficiaries and their needs will help establish priorities, beneficiaries that will benefit from population management interventions, implement team-based care, and build capacity and infrastructure within facilities and communities. Medicare claims data will also inform new integrated delivery system metrics and incorporateexisting quality metrics used to:

o assess the impact of medical homes for various beneficiaries sub-population and those living or moving among various settings

o identify needed program and policy adjustments

o inform rapid learning on challenges and opportunities encounteredduring implementation of the integrated delivery model

o guide performance improvement strategies

• Primary care medical home infrastructure will be extended to serve nursing home residents. This will include access to medical home supports including transitional care and medication therapy management, development of new tools and protocols with residential long term service and support providers, and improved behavioral support linkages for beneficiaries.
• Capacity development will include new access to information for beneficiaries and providers.
• Implementation resources are designated to capitalize on program transitions currently underway (as discussed below) to assure independence in the assessment of need, and access to electronic information in support of broader use of actionable data. With the refinement and integration of compatible functional need data across all Medicare-Medicaid enrollees, it will be possible to design and test a needs-based resource allocation process that supports greater flexibility in the use of public funds available to meet beneficiaries’ goals.

1. The proposal identifies a target population for the managed FFS demonstration of 176,050 full-benefit Medicare-Medicaid enrollees age 21 and older. Of these 176,050 beneficiaries:

1. How many are enrolled in the State’s primary care medical home (PCMH) model?

In North Carolina’s Dual Eligible Beneficiaries- Integrated Delivery Model Demonstration proposal submitted to CMS in May 2012, NC used monthly Medicaid claims data from December 2010 for estimations. More recent data are now available.

In June 2012, an estimated 169,752 full-benefitMedicare-Medicaidbeneficiaries were eligible to participate in the FFS Demonstration. Of these, 102,690Medicare-Medicaid beneficiaries are currently enrolled in the Medicaid support Primary Care Medical Homes (PCMH).This estimate excludes those under 21 years of age,those receiving PACE /Part C (20,573) and those receiving services primarily from the developing PIHP behavioral health system (36,598).

1. How many are enrolled in the 646 Demonstration

The model prescribed by the Centers for Medicare and Medicaid Services (CMS) uses ‘one touch’ logic to ‘attribute beneficiaries’ to North Carolina’s 646 Medicare Demonstration.The retrospective model has attribution assigned at the primary care physician level and is made to one of 1200 participating physicians in 200 physician group practices.Patients who are touched (one visit in the past 12 months) by one of the 646 providers are identified and attributed to the 646 Demonstration. This cohort of beneficiaries includes those who are both enrolled and unenrolled with a Primary Care Medical Home (PCMH) provider. For 646 Demonstration year 3(Jan-Dec 2012) cohort, 32,632Medicare beneficiaries were identified as Medicaid eligible and of them23,148(70.9%) were CCNC enrolled; 29.7% were not enrolled.

1. How many are nursing facility residents?

As of June 2012, there were 21,794 dual Nursing Facility residents who are eligible to participate in the FFS Demonstration. Nursing facility residents cannot be enrolled with Primary Care Medical Homes (PCMH) currently. As mentioned in the proposal, North Carolina will be submitting a State Plan Amendment (SPA) to address this issue.

1. What is the overlap of beneficiaries in 2.a, 2.b, and 2.c?

North Carolina is preparing to close out the 646 demonstration and transition all eligible dual beneficiaries into the statewide Medicare-Medicaid FFS Demonstration upon initiation of the Demonstration. CMS has been notified of this intention.

As mentioned above, at this time, nursing home residents are not eligible forenrollment in medical homes in North Carolina.Enrollment of nursing home residents in the FFS demonstration will begin following initiation of implementation and approval of therequisite state plan amendment (SPA). Eligible nursing home residents will be enrolled using the opt-out process currently in use for community-residing beneficiaries as described below in Question 6.b.

3. The State has indicated that it proposes to carve out from the managed FFS demonstration Medicare-Medicaid enrollees who receive behavioral health services. The response to Question #46 from Round 1 explained that the State will identify Medicare-Medicaid enrollees with behavioral health service needs who would be carved out of the managed FFS demonstration as follows: “Any service provided by mental health providers which include mental health hospitals, outpatient facilities, mental health centers, community support intervention, critical access behavioral health, therapeutic family services and waiver services can be identified through the Medicaid claims data (shadow claims). This data will then be combined with any service from encounter data from the specialty behavioral health plans to identify individuals receiving care from the specialty behavioral health MCOs. As the PIHP (pre-paid inpatient health plan) data becomes available through the Data Warehouse, these members will be tracked quarterly on a rolling year basis. Tracking elements will include the Medicaid client id and timeframe of service.”

Please see Appendix A, for a depiction of therelationships between North Carolina Division of Medical Assistance, theMedicaid supported pre-paid health plan (PIHP)Behavioral Health system (LME-MCOs) and Community Care of North Carolina (CCNC) medical home infrastructure.

a. Do the above criteria include beneficiaries using any type of behavioral health service or prescription drugs? Or, are some beneficiaries utilizing certain behavioral health services allowable (e.g., beneficiaries prescribed anti-depressants)?

In the FFS demonstration proposal submitted in May 2012, NC recommended a carve-out of all beneficiaries who are primarily receiving services through the still developing PIHP behavioral health system. This recommendation was due to concern that by January 2013, the system may not be able to provide accurate and valid data on service utilization. Beneficiaries receiving behavioral health services only through the PCMHs will be part of the FFS Demonstration. In discussions with CMS, we hope to identify a plan to bring these beneficiaries into the demonstration during the first year of implementation (2013).

Under the current carve out plan, all beneficiaries receiving behavioral health services from behavioral health providers within an LME-MCO will be identified in the manner described in Q46 in round 1 questions and left out of the evaluation cohort, irrespective of the service they receive.

b. Would beneficiaries who initially have no/limited behavioral health service needs continue to be eligible for the managed FFS demonstration if their behavioral health needs were to increase?

No. If beneficiaries move from receiving behavioral health services provided by Primary Care Medical Homes (PCMH) to services provided by behavioral health providers under the LME-MCOs due to their need for increased care, then they will be taken out of the FFS Demonstration evaluation cohort.

1. Would exclusion from the demonstration change the way these beneficiaries access services or interface with the delivery system? For example, does Community Care of North Carolina (CCNC) make a payment to the local management entity (LME) for every beneficiary (regardless of whether or not they receive behavioral health services) or only for beneficiaries who receive services?

No. Exclusion from the demonstration will not change the way these beneficiaries access care or interface with the delivery system. All beneficiaries will continue to receive the care they need from the venue they choose to seek services from, irrespective of whether this venue is a PCMH or a behavioral health provider within an LME-MCO. Community Care of North Carolina (CCNC) does not make any payments to LME-MCOs for any services. The LME- MCOs receive a capitated payment from Medicaid to oversee behavioral health services for Medicaid eligible beneficiaries and they also receive payment from the NC Division of Mental Health Developmental Disabilities and Substance Abuse Services (DMHDDSAS) for those services funded by the State. Please see Appendix A.

1. Page 23 of the State’s proposal and responses to Question #50 from Round 1 and Question #1 from Round 2 indicate that for behavioral health services the State is transitioning all counties from a fee-for-service delivery model to a pre-paid inpatient health plan (PIHP) contracted services delivery model. In the new delivery model, 11 LMEs would manage Medicaid-funded behavioral health services. The following questions ask for additional information on the timing of this transition and the linkages between CCNC and the LMEs to better understand whether it may be appropriate to include beneficiaries with behavioral health needs in the managed FFS demonstration.
2. Page 23 of the proposal indicates that all selected PIHP contractors must be fully operational by January 2013. In response to Question #50 from Round 1, the State included a link to a map of estimated LMEs, which assigns a LME to each county by January 2013. Does this information indicate that by January 2013 all Medicare-Medicaid enrollees would transition from the fee-for-service model to LME model for accessing behavioral health services? If not, what is the anticipated timeframe for the transition?

The progression to an LME-MCO model is contingent upon each LME-MCO passing multiple readiness reviews. At present about half of the state is under the LME-MCO model. The current plan is for the whole state to be under the model by January 2013, although implementation delays are anticipated. The legislation creating LME-MCOs requires that if statewide coverage by qualified LME-MCOs in incomplete by July 2013, uncovered recipients will be assigned to qualified LME-MCOs.

1. For Medicare-Medicaid enrollees with behavioral health needs, how would CCNC and LMEs work together to provide those services? For example:
2. Who conducts the assessment and using which protocols?

The assessment entity and protocol depends upon the point of entry. If a beneficiary receives services through their PCMH, at any point in time, if indicated, the PCMH could screen for behavioral health needs using the Alcohol Use Disorders Identification Test (AUDIT), the Drug Abuse Screen Test (DAST), the Patient Health Questionnaire (PHQ-9), etc. If the PCMH perceives that there are behavioral needs that can be managed through the PCMH, they will treat the beneficiary as part of the integrated care model. If they see that behavioral health needs exceed what can be managed in primary care, they may refer the beneficiary to the LME-MCO, refer directly to a behavioral health provider, or they may contact their local CCNC network Behavioral Health Coordinator for assistance in making these linkages. If a beneficiary comes to the attention of a CCNC care manager (whether through meeting CCNC priority criteria, or through a direct referral) then CCNC could conduct an initial screening and could refer to the PCMH or to any of the options listed above. Beneficiaries can contact the LME-MCO directly, in which case the LME-MCO staff may conduct an assessment. Or, the beneficiary could contact a behavioral health provider, in which case the provider would conduct the assessment.

1. Does a beneficiary have a choice of multiple behavioral health providers?

Yes, beneficiaries are always able to select a behavioral health provider or change providers.

1. What is the relationship between CCNC, the LME, and the behavioral health services provider?

The LME-MCO is responsible for enrolling, credentialing, authorizing services, and paying claims to behavioral health providers in the counties they oversee. Behavioral health providers provide direct behavioral health services to beneficiaries. Each CCNC network has a behavioral health coordinator and psychiatrist(s), primarily focused on working with primary care around early intervention and treatment of behavioral health needs that have not escalated to specialty behavioral health care. If needed, the behavioral health team at the CCNC networks can assist the PCMHs and beneficiaries in making connections with the specialty behavioral health system, whether through the LME-MCO ordirectly with a behavioral health provider. Particularly in instances where a beneficiaries needs are complex both medically and behaviorally, CCNC and the LME-MCOs bridge the gap between the two systems to ensure that all needs are being addressed.

1. What is the relationship between the CCNC network care manager and any care managers employed by the LME?

See above. CCNC Network Care Managers facilitate communication among all parties to ensure that needs of the beneficiary are being addressed. If needs are primarily medical, CCNC and the PCMH take the lead. If needs are primarily behavioral, the LME-MCO and behavioral health providers take the lead.

1. Would the role of the CCNC network care manager differ for nursing facility residents?

Nursing facility residents’ PCMH care management needs will mirror those available to community-dwelling beneficiaries with similar needs. There is no singularly defined role for CCNC network care managers.CCNC networks structure their staffing and deploy care management resources and other supports (pharmacy, psychiatry, palliative care, etc.)to meet the needs of beneficiaries. This is possible through the definition of expectations, vigilant monitoring of quality and performance metrics, and the population health information infrastructure that informs the delivery of PCMH and network operations. For example, in urban areas, care managers may work with a single practice, provide transitional supports working exclusively in one or more hospitals, or focus on the needs of one or more high-need enrollee population. In a rural area a care manager may serve all these functions and cover multiple practices.

1. Page 22 of the proposal and responses to Question 2 in Round 1 and Question 2 in Round 2 provide additional information about long-term supports and services under the proposed managed FFS demonstration. Please further describe the integration of long term supports and services. In particular:
2. Who conducts the assessment and using which protocols?

A summary of the programs, assessment entities and tools as of October 2012 is included in Appendix B: The current Long Term Supports and Services: Assessment Tools and Protocols.Please note, several programs are currently intransition.

• The NC Community Alternatives Program (CAP) for Disabled Adults (CAP/DA) waiver is working toward a total waiver redesign in 2013. Related features include
• Consideration of an inclusive waiver, expanding the target population to include recipients of the current Private Duty Nursing and other CAP programs, and
• Development of a new electronic information infrastructure in support of case management/care planning for recipients served through CAP waivers.
• CAP/MR/DD waiver is transitioning to LME-MCOs under the PIHP with a target date of early 2013 (discussed above under questions 3 and 4).

As policies and programs are finalized more specific updates regarding assessments and protocols will become available.