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Janet GrantCareSource Management Group
Executive Vice President Business Development and Regulatory Affairs
Medicaid ConferenceSeptember 24, 2008
Contracting as a Dual Eligible Special Needs Plan:
Lessons Learned from Navigating the Medicare
Program
2
CareSource
Mission: Making a difference in the lives of underserved people by improving their health care
• Medicaid focused non-profit health plans
– Ohio: 625,000 Medicaid members
– Michigan: 50,000 Medicaid members
• 19 years of Medicaid managed care experience
• SNP plans launched in both states January 2008
3
CareSource SNP Goals
• Extend CareSource mission • Provide a continuum of care for Medicaid
ABD members • Leverage plan Medicaid expertise; knowledge
of Medicaid population needs• Invest in infrastructure to partner with states
on highest acuity and cost populations• Vehicle for Medicare/Medicaid integration• Diversify product lines
4
SNP Launch Lessons Learned
• Network, network, network…..– Time and resource commitments– Armed for provider questions/resistance
• Use of consultants to jump start, provide technical assistance
• Leadership to demonstrate priority, organizational commitment, recognition of resource requirements
• Organizational involvement, need to learn MA and think through how to operate
• Marketing, marketing, marketing…..
5
Competencies Required
• Medicare regulatory requirements• Sales/marketing, enrollment• Financial/benefit bid: actuarial expertise• Risk adjustment management• Network development• Pursue state Medicaid integration
6
State Challenges
7
State Opportunities
• Integration to increase quality of care and consumer satisfaction
• Decrease provider administrative burden• Support rebalancing of facility based vs
community based LTC• Savings associated with delay/prevention of
facility based LTC
8
State Challenges
• Knowledge of SNP and integration potential• Concern that savings accrue to Medicare• Other budget and policy priorities• Technology to support• Stakeholder resistance • Statewide SNP coverage• Statutory carve out of duals from Medicaid managed
care• Voluntary MA enrollment • Operational challenges of integration
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Tale of two states…
Ohio• CMS SNP 101• SNP Work Group• ABD seamless
enrollment• Technical assistance
– Expert consultation– Savings analysis
Michigan• Plan for capitation• ABD seamless
enrollment• Consumer education
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MI Consumer Education
11
Stakeholder Involvement
• Disability advocates – Community Catalyst SNP Consumer Education
Project
• Area Agencies on Aging• Low income housing• Continuing Care Retirement Communities
(CCRCs)
12
Stakeholder Shared Goals
• Right care in the right place• Least restrictive environment• Case management as central strategy• Promote medical home • Quality outcomes and customer satisfaction• Coordinated care
13
Current Issues
• SNP reauthorization • State contracting requirement and impact on
service area expansion opportunities• Medicare/Medicaid integration• Identification and education of eligible dual
consumers