Slide 1: Leveraging State Capacity to Strengthen the Duals Model IC Presentation
Implementation Council Meeting
March 12, 2024
Slide 2: Brief #1
The Financial Alignment Initiative (FAI) Demonstration: How Four States Are Navigating the New Policy Landscape for Integrated Care Programs

State Medicaid Leaders and Disability Advocates from California, Rhode Island, South Carolina, and Washington Share Policy Priorities and Strategies

FEBRUARY 2024
Authors: 
Dennis Heaphy, MPH, MEd, MDiv, DMin, Disability Policy Consortium (DPC)
Ellen Breslin, MPP, former Disability Policy Consortium (DPC) Board member 
Leslie Diaz, BA, Disability Policy Consortium (DPC)

Partners: 
Leena Sharma, MPP, Community Catalyst 
Brandon Wilson, DrPH, MHA, Community Catalyst
Slide 3: The Brief’s Aims
The Financial Alignment Initiative (FAI) Demonstration: How Four States Are Navigating the New Policy Landscape for Integrated Care Programs 

This brief summarizes information for policymakers on how four Financial Alignment Initiative (FAI) demonstration states are designing, developing, and implementing new integrated care programs for individuals who are dually eligible covered under Medicare and Medicaid. In 2023, the authors interviewed FAI state Medicaid leaders in California, Rhode Island, South Carolina, and Washington. We also interviewed disability leaders and advocates dedicated to people's rights to live meaningful lives in the community in the three FAI states participating in the capitated model and operating Medicare-Medicaid Plans (MMPs). Of note, this brief presents information for four FAI states “as of a point in time,” with a significant emphasis on FAI states operating under a capitated model. 

To learn more about dually eligible individuals and the four FAI demonstration states including three FAI states with capitated models, see Figures 1-5, located at the end of this brief. To learn more about state Medicaid agency contracts (SMACs), see January 2024 resource prepared by the Integrated Care Resource Center (ICRC). The ICRC is a national initiative of Center for Medicare & Medicaid Services’ (CMS) Medicare-Medicaid Coordination Office (MMCO), established to help states develop integrated care programs for individuals who are dually eligible. CMS requires plans that are Medicare Advantage Dual Eligible Special Needs Plans (DSNPs) serving dually eligible individuals to hold a contract with the state Medicaid agency. The contract is referred to as a SMAC. To learn more about the flexibility that states have to leverage SMACs beyond the minimum requirements, readers may also review the January 2024 presentation prepared by the Medicaid and CHIP Payment Advisory Committee (MACPAC). MACPAC is a non-partisan legislative branch agency.
Slide 4: Three Key Takeaways
#1. State Medicaid leaders are at varying stages of navigating the new policy environment.

#2. State Medicaid programs are leveraging the SMACs to achieve alignment and integration.

#3. State-based disability leaders require more information to effectively engage in the FAI transitions.
Slide 5: Key Points and Quotes
State Capacity
State capacity is essential to advancing health equity and engaging the disability community.
Major Effort
One leader underscored the effort involved in launching programs that are so complex. This individual said, “It took us nearly three years to get up and running in a capacity where people knew what we were doing.”
Medical MOC
One state Medicaid leader said, “The Medicare model of care does not uphold the same goals as the Medicaid MOC. The Medicare model is medical, while the Medicaid MOC is not,” emphasizing the SMAC’s importance. Integrated care programs must have one model of care.
Disability Advocates
Across the states, disability leaders shared four major priorities:
1)	getting consistent actionable information,
2)	needing a “seat at the table,” 
3)	securing continued funding for the ombudsman program, and
4)	advancing community-based living and investing in non-medical services.
Slide 6: Six SMAC Recommendations
See Exhibit 2 for examples of the opportunities that states have to leverage SMAC and advance consumer protections. 

Exhibit 2. State Opportunities to Leverage the SMAC 

Note: the following information is shown in a table on the slide.

#1: State Opportunity 
•	Review the composition of each Medicaid and D-SNP plan’s Board of Directors. 
Benefit to Dually Eligible Individuals 
•	To ensure that potential influences over D-SNP policies and practices are aligned with state priorities and the model of care. 

#2: State Opportunity 
•	Require D-SNPs to adhere to regulations and policies. 
Benefit to Dually Eligible Individuals 
•	To ensure that D-SNP plans operate in accordance with state priorities and mitigate the use of harmful revenue maximizing practices. 
#3: State Opportunity 
•	Require D-SNPs to partner with disability organizations and social service organizations. This opportunity creates many opportunities. 
Benefit to Dually Eligible Individuals 
•	Two examples are as follows. Example #1: To ensure that D-SNPs produce reading materials for dually eligible individuals that are:
1)	clear,
2)	expressed in plain language in the translations of materials from English, and
3)	culturally and linguistically accurate, responsive to individuals’ needs, practices, and beliefs. 

Example #2: To ensure that D-SNPs provide benefits that consider the social determinants of health infused with the principles of independent living and recovery models of care. 
#4: State Opportunity 
•	Educate disability communities about Medicare fraud entities and health insurance counseling centers. 
Benefit to Dually Eligible Individuals 
•	To ensure that dually eligible individuals are protected from fraud and have access to a counselor to help them select the right program. 
#5: State Opportunity 
•	Require D-SNPs to create pathways for feedback with disability organizations and other trusted community-based organizations. 
Benefit to Dually Eligible Individuals 
•	To ensure that dually eligible individuals can report and address access to care issues with support from experts. 
#6: State Opportunity 
•	Connect with the national Medicare coverage protection groups. 
Benefit to Dually Eligible Individuals 
•	To ensure that dually eligible individuals have access to resources from a trusted group.
Slide 7: Brief #2
A Call for Equity: Re-Committing to an Independent Living and Recovery-Centered Model of Care 

Key Recommendations for State Medicaid Programs in Preparing State Medicaid Agency Contracts (SMACs) for Integrated Care Programs for Dually Eligible Individuals 

FEBRUARY 2024 

Authors: 
Dennis Heaphy, MPH, MEd, MDiv, Dymin, Disability Policy Consortium (DPC) 
Ellen Breslin, MPP, former Disability Policy Consortium (DPC) Board member 
Partners: 
Leena Sharma, MPP, Community Catalyst 
Brandon Wilson, DrPH, MHA, Community Catalyst
Slide 8: The Brief’s Aims
A Dignity-Based Independent Living and Recovery Centered Model of Care This brief aims to assist policy advocates and policymakers in their development of state Medicaid agency contracts (SMACs), as they strive to ensure dually eligible enrollees in Dual Eligible Special Needs Plans (D-SNPs) have full access to benefits available under Medicare and state Medicaid policies. It strives to address gaps in the Centers for Medicare and Medicaid Services (CMS) rule changes by strengthening state SMACs. While not all-encompassing, the brief introduces a whole, person-centered framework of healthcare delivery that advances health equity and the dignity of the individual. It recommends ways to strengthen opportunities for enrollees to access needed services to live meaningful lives in the community. 

A dignity-based model of care (MOC) is based on the independent living (IL) civil rights and recovery movements, which led to the creation of home and community-based services (HCBS), the deinstitutionalization of persons with mental health diagnoses, and the ongoing shift in our understanding of substance misuse to a more whole-person understanding of addiction. Foundational to the independent living (IL) and recovery movements is the core belief that all people with disabilities across the lifespan are endowed with basic dignity and rights articulated under the Americans with Disabilities Act (ADA). For many people with disabilities, a high percentage of whom are dually eligible, these rights can only be realized if provided access to community-based long-term services and supports (LTSS) and recovery services, embracing the principles that include consumer choice, control, dignity of risk, and hope.
Slide 9: Three Key Takeaways
#1. In contrast to Community Medical Alliance (CMA), a Medicare Advantage (MA) platform is grounded in a medical Model of Care (MOC), with evidence of practices that are antithetical to a person-centered approach.

#2. State SMACs should be grounded in trust-based and collaborative relationships with disability advocacy groups and groups serving minoritized populations with disproportionate percentages of persons with disabilities.

#3. The future success of D-SNPs depends on a care coordination model grounded in relationships based on trust and expertise.

Slide 10: Ten Key Features, of CMA’s MOC
Exhibit 1. Ten Key Features of CMA’s Model of Care 

Note: the following information is shown in a table on the slide.
CMA’s Model of Care (MOC) 
1	The MOC was grounded in trust, with the full support of the disability community. 
2	Home was the locus of care. 
3	A home-based integrated care team that included paramedics. 
4	CMA ensured consistency of staff in the home. 
5	Individuals had direct, personalized, streamlined communication and access to care coordinators. 
6	The individual’s care coordinator was part of the care team. 
7	The care coordinator was integrated into the care team seamlessly. 
8	Care coordinators had real-time decision-making authority over needed services. 
9	Individuals had ultimate choice over the care coordinator. 
10	CMA used care planning processes over utilization management (UM) processes.
Slide 11: Three Key Rules for Plans: Dr. Robert Master
Figure 2. Dr. Robert Master: Three Key Rules for Plans (2023) 

Dr. Robert Master outlines three important rules for plans serving dually eligible individuals residing in the community with the highest medical and LTSS needs, leveraging his expertise and experiences in Massachusetts. 

Rule #1: Plans should allocate LTSS based on care plans. State SMACs must require plans that serve enrollees with complex care needs to allocate LTSS based on individual care plans developed by enrollees with their care coordinators and care teams. Care plans should ideally be developed in a setting of the enrollee’s choice, such as their home, or at a minimum, using communication preferences, as determined by the enrollee. Communication preferences may include but not be limited to virtual, phone, relay service, or primary language. Care plans should include both medical and non-medical goals. 

Rule #2: Plans should be transparent about their LTSS allocation policies. States should develop transparency requirements for all plans to ensure that data reported back to the state is consistent and provide the state information that enables it to hold D-SNPs accountable, maximizing enrollee access to Medicaid and Medicare benefits in a person-centered way. It is important that allocation policies require D-SNPs to rebalance allocation of resources to LTSS and other upstream preventative services. SMACs should protect enrollees from care plan development and determination of LTSS need via non-transparent, member-anonymous payer developed criteria. This D-SNP practice is antithetical to the goals of promoting independence. It reduces access to services and causes delays, grievances, and unnecessary appeals. 

Rule #3. Plans should promote effective, responsive primary care. The primary care ecosystem in Massachusetts is collapsing with practices closing, clinicians exiting and even for the healthy, long waits to find a primary care provider (PCP). For those with complex needs, and mobility impairments, the current state is potentially an existential threat for those with the greatest needs. 
Slide 12: 17 Recommendations to Advance Sustainable, Integrated Programs for Dually Eligible Individuals 
A CALL TO EQUITY TOOLKIT: 
Re-Committing to an Independent Living and Recovery Centered Model of Care 

In recognition of the importance of integrated care programs to the ability of dually eligible individuals to live, this toolkit is designed to help stakeholders create better programs. This outlines recommendations for policymakers to consider in preparing their state Medicaid agency contracts (SMACs). SMACs are a powerful policy tool used by states, typically amended annually, to improve integrated care programs. States can translate these recommendations into contract language to operationalize the recommendation. According to a January 2024 presentation by the Medicaid and CHIP Payment Advisory Committee (MACPAC), “CMS officials said states are free to include any requirements as long as they do not conflict with federal law.” That said, some states may not understand how much flexibility they have with SMACs, while other states may lack the staff capacity or lack Medicaid knowledge to take full advantage of the opportunity to create better programs. To learn more about SMACs and sample language, follow this link to the Integrated Care Resource Center (ICRC). 

Exhibit 1 provides an overview of the toolkit’s pillars, followed by recommendations organized by four key pillars. 

Note: the following information is shown in an organization chart on the slide.

Exhibit 1. 
Key Pillars to Advance Sustainable, Integrated Programs for Dually Eligible Individuals 

•	Pillar 1. Health Equity 
•	Recommendations = 4 

•	Pillar 2. Engagement & Access 
•	Recommendations = 4 

•	Pillar 3. Investment Upstream 
•	Recommendations = 2 

•	Pillar 4. Data & Transparency 
•	Recommendations = 7

Slide 13: 17 Recommendations by Pillar

Pillar 1 (4)
Pillar 1. Health Equity 
1.1 Independent Living and Recovery
1.2 Intersectional Approach 
1.3 Root Causes 
1.4 Impact of Voices 

Pillar 2 (4)
Pillar 2. Engagement & Access 
2.1 Implementation Councils
2.2 Oversight Role
2.3 Policy Frame 
2.4 Advertising and Outreach 

Pillar 3 (2)
Pillar 3. Investment Upstream 
3.1 Payment Policy 
3.2 Investment Plan 

Pillar 4 (7)
Pillar 4. Data & Transparency 
4.1 Data Collection
4.2 Artificial Intelligence and Utilization Management 
4.3 Care Coordinators; Care Planning and Care Teams 
(2 in 4.3)
4.4. Key Performance Indicators 
4.5 Dashboard 
4.6 Transparency Guidelines 
4.7 Plan Practices 

Slide 14: Ten Recommendations to Advance the Independent Living and Recovery MOC
A CALL TO EQUITY TOOLKIT: 
Re-Committing to an Independent Living and Recovery-Centered MOC (ILR-MOC) 

Ten Ways to Leverage the SMAC to Advance the ILR-MOC 

Exhibit 2 presents ten SMAC recommendations for state leadership consideration, to advance the ILR-MOC.

1.	Conflict-free care coordination 
2.	Low caseloads and Health Homes
3.	In-home visits 
4.	Diverse staffing model and paramedics
5.	Whole-person care team planning
6.	Non-medical care plan goals  
7.	Flexible benefits
8.	Equity: Robust disparity plan 
9.	Equity: An intersectional approach 
10.	Performance Measurement