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SCDuE Weekly Update | July 3, 2013

The proposed model of the South Carolina Dual Eligible (SCDuE) Demonstration has been changed to reflect a carve-in of home and community based services (HCBS). These changes will be outlined in the Memorandum of Understanding (MOU) between the State and CMS (e.g., transition of HCBS authority to the Coordinated and Integrated Care Organization (CICO) during the Demonstration period). Some implementation details are subject to change pending a fully executed MOU; therefore, the State will not issue a procurement solicitation until such time.  The State is in the process of negotiating the details of the Demonstration’s MOU with CMS.

PLAN SELECTION AND PAST PERFORMANCE

The joint selection process will take into account the previous performance in both Medicare and Medicaid of interested organizations.  Specifically, previous performance in the Medicare program will be used to determine an organization’s eligibility for receiving passively enrolled beneficiaries.  CMS policies described in the January 9, 2013 guidance to interested organizationsis considered the minimum demonstration standard.  The State may establish higher standards for plan selection or stricter eligibility requirements for receiving passive enrollment.  CMS and the State may establish additional requirements such as demonstrating sufficient capacity during readiness review and meeting implementation milestones for those beneficiaries who are already enrolled.  These requirements can be established at any time prior to or during the Demonstration.  Below is a brief summary of the policies related to plan selection and passive enrollment outlined in the January 9, 2013 guidance to interested organizations.

  • Sanctions:  Organizations will be ineligible to participate in the Demonstration if they are under sanction, as described in 42 CFR 422.750 and 42 CFR 423.750, at the time CMS and the State seek to execute the three-way contract.  An organization that is sanctioned after the execution of a contract will be unable to enroll any new members – either through passive or opt-in enrollment – until the sanction is lifted.

  • Past Performance Review and “Consistently Low Performing” Icon (LPI):  Past performance outlier status is based on an organization’s performance in 11 categories including, but not limited to compliance, multiple ad hoc corrective action plans (CAPS), and failure to maintain fiscally sound  operation.  LPI designation is given to entities with poor or below average Medicare plan ratings (i.e., less than three stars for three or more consecutive years).

Although an interested organization that is an outlier in CMS’ past performance analysis for Contract Year 2014 and/or has an LPI on the Medicare Plan Finder website for CY 2014 may qualify to participate in the Demonstration, the organization is ineligible for passive enrollment until it no longer has the past performance outlier or LPI designation.

CMS and/or the State will determine whether a Medicare-Medicaid Plan (MMP) is eligible to accept passive enrollment prior to the scheduled date of execution of the three-way contract.  An organization that is ineligible to receive passive enrollment will only be able to enroll: 1) individuals who are currently enrolled in another Medicare or Medicaid managed care plan sponsored by the same organization; and 2) individuals who opt into the organization’s MMP. When an organization is no longer considered by CMS to be a past performance outlier and/or no longer has an LPI on Medicare Plan Finder, it may be eligible to receive passive enrollment.

Some interested organizations that have little or no experience in the Medicare program may have a parent or sibling organization with previous Medicare experience. For these entities, CMS’ past performance and LPI methodologies consider information about the parent and sibling organizations’ previous Medicare past performance.

Phasing enrollment will enable CMS and the State to assess a plan’s ability to serve its currently enrolled beneficiaries before allowing it to enroll new beneficiaries. The process will also spread MMPs’ intensive intake and assessment efforts over several periods of passive enrollment.

The details of the State’s enrollment strategy, which includes a voluntary enrollment followed by passive enrollment, will be outlined in its executed MOU.

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Medicare-Medicaid FAQs (Frequently Asked Questions) | PDF

Contact CMS for any questions or concerns regarding the meetings, guidance, or the MMP application. Emails can be directed to MMCOcapsmodel@cms.hhs.gov

Contact the SCDuE Team for more information, questions, and/or comments related to the SCDuE Demonstration by email at scdue@scdhhs.gov.

For additional assistance, please contact the SCDuE Program Coordinator, Teeshla Curtis by email at curtist@scdhhs.govor by telephone at (803) 898-0070.

Visit the SCDuE Website at https://msp.scdhhs.gov/scdue/

Visit the CMS-MMCO Website at https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/index.html

 

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