ManagedCareSupplement3

GENERATIONS – Journal of the American Society on Aging

One large MA plan in the Northeast is dis- cussing a pilot program to identify high-risk enrollees who would benefit from significantly more care coordination, complex case manage- ment, and LTSS supports than most MA enroll- ees need. These members would be referred to a PACE plan for some services, and PACE prac- titioners would coordinate with the individual’s community healthcare providers. In another example, in Ypsilanti, Michigan, the Huron Valley PACE (HVP), which opened four years ago, is pursuing strategies to expand Figure 1. Huron Valley PACE Supplemental Services Packages Proposed for Private- Pay, Not-Enrolled, Clients

through PACE and Part D waivers presented to CMS. Also HVP and Altarum are exploring pol- icy options for FFS Medicare-only beneficiaries whose incomes are slightly too high for enroll- ment in Medicaid, and who are unable to pay the full cost of needed LTSS. Below are two figures illustrating how PACE organizations could partner with MA plans. In Model Number 1, the PACE organization takes on comprehensive responsibility for Medi- care-covered services, supplemental benefits, and supportive services for selected chronically ill enrollees referred by the MA plan. This MA plan would receive a capitation payment for each enrollee, but all health-related services (medical, supplemental, and supportive services) would be the responsibility of the PACE organization. The payment and risk-bearing terms would be negotiated and agreed upon in a contract. In this model, the MA plan collects the Medicare per member, per month payment, maintains the interface of reporting and regulatory compliance with Medicare, and performs other administra- tive functions, while the chronically ill Medicare beneficiary and his or her family view the PACE organization as their primary locus of care plan- ning and service provision.

and scale to serve FFS Medicare-only beneficia- ries with LTSS needs. Toward that end and under the leadership of Executive Director Sonja Love Felton, HVP is developing supplemental LTSS services packages to offer to FFS Medicare-only beneficiaries. The three services packages (see Figure 1, above) are geared to varying needs, and include a baseline assessment. These packages also will inform discussions of possible LTSS ser- vices that could be offered to interested MA plans. Development of the HVP supplemental ser- vices packages has experienced some challenges. To address these, HVP partnered with Altarum’s Program to Improve Eldercare (tinyurl.com/ ybn7kdb6). HVP and Altarum have identified the cost of prescription drug coverage as a major barrier in enrollment of FFS Medicare-only par- ticipants. Altarum is working to resolve these barriers for HVP and for other PACE plans,

Figure 2. Model 1: PACE Responsible for Medicare-Covered Services

50 | Spring 2019

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