On December 12, Ohio became the third state to move forward with a demonstration project aimed at integrating care for people eligible for both Medicare and Medicaid (“dual eligibles”).

Under the Memorandum of Understanding signed with the Centers for Medicare & Medicaid Services (CMS), Ohio will use its newly created Integrated Care Delivery System (ICDS) health plans to deliver Medicare and Medicaid services to nearly 115,000 of the state’s dual eligibles. ICDS plans will be responsible for providing person-centered care following a comprehensive assessment process that takes into account the medical, behavioral health, long-term services and supports, and social needs of enrollees. Dual eligibles will be able to voluntarily enroll into an ICDS plan as of September 1, 2013. Those that do not opt-in will be passively enrolled in three phases by region starting on October 1, 2013. The state intends to use an “intelligent assignment” process that will take into account beneficiaries’ previous managed care enrollment and provider use.

Promising Features:

The Ohio MOU contains some very positive features, including some improvements over the previously released MOUs (Massachusetts and Washington). Here are a few examples:

• • Ombudsman: Ohio will use its current Long-term Care (LTC) Ombudsman program to advocate on behalf of beneficiaries and provide systematic oversight of plans’ support for home- and community-based care. This is a welcome expansion of the LTC Ombudsman duties, though much work needs to be done to put the systems in place by the time the project launches.
• • Enrollment Assistance and Options Counseling: Ohio will work with the state’s Senior Health Insurance Information Program (SHIIP), Aging and Disability Resource Networks (ADRN), and other local partners to provide ongoing outreach, education and counseling to beneficiaries. And CMS will provide support to SHIIPs and ADRNs. While this is a step in the right direction, it’s essential that support from CMS comes prior to the launch of the demonstration and also is available to other local aging and disability organizations.
• • ADA Compliance: ICDS plans and their providers will be expected to comply with the Americans with Disabilities Act. For example, providers must demonstrate their ability to accommodate the physical access and flexible scheduling needs of their patients. In addition, plans and providers must communicate in a way that meets the needs of patients, including those who are hard of hearing, those with cognitive limitations or those who do not speak English.
• • Consumer Engagement: Each ICDS plan must establish at least one beneficiary advisory committee and a process for that committee to provide input on the plan to its governing board. The committee’s membership must reflect the diversity of the dual eligible population. The plans must also include people with disabilities within their governance structure.
• • Area Agencies on Aging: Ohio will maintain the longstanding role of the Area Agencies on Aging (AAAs) in its existing Medicaid waivers by requiring ICDS plans to contract with AAAs for waiver service coordination for those enrollees that are age 60 and older. Plans can — and should — contract with other qualified community organizations to provide this service to those under 60.
• • Waiver Service Coordinator: If the beneficiary is receiving home- and community-based waiver services, then a waiver services coordinator must be part of the care team.
• • Continuity of Care: Plans must allow enrollees to continue seeing existing medical and non-medical providers for reasonable lengths of time; in some cases, up to a year.

Work Left to be Done:

The above provisions addressed many consumer and advocate concerns raised during the proposal development process. However, much work remains to be done to ensure the demonstration provides higher quality and more person‐centered care.

• • Adequacy of payment: As currently designed, it is unclear that the structure under the capitated financing model provides the right incentives for plans to cover the cost of health care services, especially for the highest-cost dual eligibles. In addition, the basis for the savings expectations—1 percent in the first year, 2 percent in the second and 4 percent in the third—is not entirely clear. The analysis conducted by CMS and the state should be transparent so that all stakeholders understand the factors taken into consideration in developing the savings expectations.
• • Oversight: Oversight of the demonstration is largely left in the hands of the state and CMS. While the state will engage stakeholders through public meetings and focus groups, this does not replace the more formal role that stakeholders, including beneficiaries and advocates, should play in oversight. In Massachusetts, for example, the state is creating an Implementation Council, at least half of whose members will be beneficiaries or family members.
• • To be decided: Many details are being left to the three-way contract between CMS, the state and the ICDS, the development of which appears out of reach of consumers and other stakeholders.

Even with these concerns, the Ohio MOU represents a great improvement over the state’s proposal submitted last spring. But now the hard work begins. Among the next critical steps, the ICDS plans, most of which have limited experience serving the dual eligible population, will need to pass a rigorous readiness review process to demonstrate they have the right provider networks and systems in place to meet their enrollees’ needs. Still, the road to better care for Ohio’s dual eligibles is under construction. Ongoing, transparent collaboration among the state, plans, providers and consumers and their advocates will be the key to avoiding many of the potholes and detours along the way.

- Leena Sharma, State Advocacy Manager, and Renée Markus Hodin, Director, Integrated Care Advocacy Project