1. 2015 National Training Program
Dual Eligible Options:
SNPs, PACE, & MMP
The CMS National Training Program provides this as an informational resource for our partners. It’s not a legal document or intended for press purposes.

2. Session Objectives This session should help you to
Define Dual Eligible
Review Cost of dual eligible population
Recognize types of health plans available to dual eligible beneficiaries
Explain eligibility requirements and enrollment
Identify which states in our regions offer MMP’s
Review Financial Alignment Initiatives
This session should help you to
Define Dual Eligible
Review Cost of dual eligible population
Recognize types of health plans available to dual eligible beneficiaries
Explain eligibility requirements and enrollment
Identify which states in our regions offer MMP’s
Review Financial Alignment Initiatives
07/01/2015
Dual Eligible

3. Lesson 1-Dual Eligible Define Dual Eligible
Review costs of dual eligible beneficiaries
Lesson 1 will provide you with the following information:
Define Dual Eligible
Review costs of dual eligible beneficiaries
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Dual Eligible

4. Dual Eligible
Dual eligible beneficiaries include individuals who receive full Medicaid benefits as well as those who only receive assistance with Medicare premiums or cost sharing.
They must meet certain income and resource requirements and be entitled to Medicare Part A and/or Part B
Dual Eligible Beneficiaries
Dual eligible beneficiaries include individuals who receive full Medicaid benefits as well as those who only receive assistance with Medicare premiums or cost sharing. They must meet certain income and resource requirements and be entitled to Medicare Part A and/or Part B
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

5. Must be Entitled to One of the Following:
Full Medicaid
Medicare Savings Programs
Four Programs
Qualified Medicare Beneficiary (QMB) Program;
Specified Low-Income Medicare Beneficiary (SLMB) Program;
Qualifying Individual (QI) Program; and
Qualified Disabled Working Individual (QDWI) Program.
Full Medicaid; or
Medicare Savings Programs, which include the following four programs: Qualified Medicare Beneficiary (QMB) Program;
Specified Low-Income Medicare Beneficiary (SLMB) Program;
Qualifying Individual (QI) Program; and
Qualified Disabled Working Individual (QDWI) Program.
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

6. Medicare Savings Programs
Enrollment into a MSP results in automatic eligibility for the Part D Low-income subsidy (Extra Help)
SLMB, QI and QDWI
They pay Medicare premiums
The do NOT pay Medicare Cost Sharing
Enrollment into a MSP results in automatic eligibility for the Part D Low-income subsidy (Extra Help)
SLMB, QI and QDWI
They pay Medicare premiums
The do NOT pay Medicare Cost Sharing
Additional Information can be found at: Education/Training/CMSNationalTrainingProgram/Downloads/2015-Medicare-Savings- Program-Job-Aid.pdf
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

7. Medicare Savings Program Income Limits
Qualified Medicare Beneficiary
If you qualify for the Qualified Medicare Beneficiary (QMB) program, you get help paying your Part A and Part B premiums, deductibles, coinsurance, and copayments. To qualify for QMB you must be eligible for Medicare Part A, and have an income not exceeding 100% of the federal poverty level (FPL). This will be effective the first month following the month QMB eligibility is approved. Eligibility can’t be retroactive.
Specified Low-Income Medicare Beneficiary
To qualify for the Specified Low-Income Medicare Beneficiary (SLMB) program, you must be eligible for Medicare Part A and have an income that is at least 100%, but doesn’t exceed 120% of the FPL. If you qualify for SLMB, you get help paying for your Part B premium.
Qualified Individual
To qualify for the Qualified Individual (QI) program, you must be eligible for Medicare Part A, and have an income not exceeding 135% of the FPL. This program was fully renewed with federal funds in spring of 2015.
Qualified Disabled and Working Individual
To qualify for the Qualified Disabled and Working Individual program (QDWI), you must be entitled to Medicare Part A because of a loss of disability-based Part A due to earnings exceeding Substantial Gainful Activity; have an income not higher than 200% of the FPL, and resources not exceeding twice the maximum for Supplemental Security Income ($4,000 for an individual, and $6,000 for married couple in 2015); and not be otherwise eligible for Medicaid. If you qualify, you get help paying your Part A premium. If your income is between 150% and 200% of the FPL, the state can ask you to pay a part of your Medicare Part A premium. In 2015, the resource limits for the QMB, SLMB, and QI programs are $7,280 for a single person and $10,930 (doesn’t include $1,500 burial fund disregard) for a married person living with a spouse and no other dependents. These resource limits are adjusted on January 1 of each year, based on the change in the annual consumer price index since September of the previous year.
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

8. Cost of Dual Eligible
Dual-eligible beneficiaries account for a disproportionate share of Medicare FFS expenditures.
As 19 percent of the Medicare FFS population, they represented 34 percent of aggregate Medicare FFS spending in 2010.
Dual-eligible beneficiaries account for a disproportionate share of Medicare FFS expenditures. As 19 percent of the Medicare FFS population, they represented 34 percent of aggregate Medicare FFS spending in data-book-section-4-dual-eligible-beneficiaries.pdf
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

9. Cost continued…
On average, Medicare FFS per capita spending is more than twice as high for dual-eligible beneficiaries compared to non-dual-eligible beneficiaries
In 2010, $19,418 was spent per dual-eligible beneficiary, and $8,789 was spent per non- dual-eligible beneficiary.
On average, Medicare FFS per capita spending is more than twice as high for dual-eligible beneficiaries compared to non-dual-eligible beneficiaries: In 2010, $19,418 was spent per dual-eligible beneficiary, and $8,789 was spent per non-dual-eligible beneficiary. eligible-beneficiaries.pdf
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

10. Cost continued…
In 2010, average total spending which includes Medicare, Medicaid, supplemental insurance, and out-of-pocket spending across all payers for dual-eligible beneficiaries was about $31,600 per beneficiary, more than twice the amount for other Medicare beneficiaries.
In 2010, average total spending⎯which includes Medicare, Medicaid, supplemental insurance, and out-of-pocket spending across all payers⎯for dual-eligible beneficiaries was about $31,600 per beneficiary, more than twice the amount for other Medicare beneficiaries. eligible-beneficiaries.pdf
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

11. Lesson 2—Medicare Health Plans for Duals
Special Needs Plans
Programs of All-inclusive Care for the Elderly (PACE)
MMPs
Lesson 2, “Other Medicare Health Plans,” provides information on the following:
Special Needs
Programs of All-inclusive Care for the Elderly (or “PACE”)
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Dual Eligible

12. Coverage Options
Dual eligible beneficiaries may choose coverage under FFS Medicare or a Medicare Advantage (MA or MAPD) Plan.
Medicare-covered services are paid first by Medicare because Medicaid is always the payer of last resort.
Medicaid may cover the cost of prescription drugs and other care that Medicare does not cover.
Dual eligible beneficiaries may choose coverage under FFS Medicare or a MA Plan. Medicare- covered services are paid first by Medicare because Medicaid is always the payer of last resort. Medicaid may cover the cost of prescription drugs and other care that Medicare does not cover.
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

13. Medicare Special Needs Plans (SNPs)
Can you get your health care from any doctor or hospital?
You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out‑of‑area dialysis).
Are prescription drugs covered?
Yes. All SNPs must provide Medicare prescription drug coverage (Part D).
Do you need to choose a primary care doctor?
Generally, yes.
Do you need a referral to see a specialist?
In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.
Medicare Special Needs Plans (SNPs) are Medicare Advantage Plans designed to provide focused care management, special expertise of the plan’s providers, and benefits tailored to enrollee conditions.
You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out‑of‑area dialysis).
All SNPs must provide Medicare prescription drug coverage (Part D).
You generally need to choose a primary care doctor.
In most cases, you need a referral to see a specialist. Certain services, like yearly screening mammograms, don’t require a referral.
07/01/2015
Dual Eligible

14. Medicare Special Needs Plans (SNPs) Continued
What else do you need to know about this type of plan?
A plan must limit plan membership to people in one of the following groups:
Those living in certain institutions (like a nursing home), or who require nursing care at home
Those eligible for both Medicare and Medicaid
Those with specific chronic or disabling conditions
Plan may further limit membership
Plan should coordinate your needed services and providers
Plan should make sure providers that you use accept Medicaid if you have Medicare and Medicaid
Plan should make sure that plan’s providers serve people where you live, if you live in an institution
There are other things you need to know about Medicare Special Needs Plans (SNPs):
A plan must limit plan membership to people in one of the following groups:
People who live in certain institutions (like a nursing home), or who require nursing care at home
People who are eligible for both Medicare and Medicaid
People who have specific chronic or disabling conditions (like diabetes, End- Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia)
Plans may further limit membership.
Plans should coordinate the services and providers you need to help you stay healthy and follow your doctor’s orders.
If you have Medicare and Medicaid, your plan should make sure that all of the doctors or other health care providers you use accept Medicaid.
If you live in an institution, make sure that the plan’s doctors or other health care providers serve people where you live.
Medicare Advantage Plans can vary. Read individual plan materials carefully to make sure that you understand the plan’s rules. You may want to contact the plan to find out if the service you need is covered and how much it costs.
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Dual Eligible

15. Plan Finder Medicare.gov Find Health and Drug Plans. 07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

16. Plan Finder: Refine Your Search
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

17. Medicare Program of All-inclusive Care for the Elderly (PACE) Plans
Combines services for frail, elderly people
Medical, social, and long-term care services
Include prescription drug coverage
Alternative to nursing home care
Only in states that offer it under Medicaid
Qualifications vary from state to state
Contact state Medical Assistance (Medicaid) office for information
Can be private pay or Medicare Only
Programs of All-inclusive Care for the Elderly (PACE) combine medical, social, and long-term care services for frail elderly people who live in and get health care in the community. PACE provides all medically necessary services, including prescription drugs. Based on the circumstances, PACE might be a better choice for some people instead of getting care through a nursing home. PACE is a joint Medicare and Medicaid program that may be available in states that have chosen it as an optional Medicaid benefit. The qualifications for PACE vary from state to state.
Call your state Medical Assistance (Medicaid) office to find out about eligibility and if a PACE site is near you. Visit Medicare.gov/contacts for the Medicaid office phone number in your state.
NOTE: Instructor may highlight local plans.
07/01/2015
Dual Eligible

18. PACE Plans By Region V and VII
Region V (12 total)
1 –  Indiana
9 – Michigan (1 New plan effective August 1st)
1  – Ohio
1 - Wisconsin
Region VII (6 total)
1 – Nebraska
2 – Iowa
1 – Missouri
2 - Kansas
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Dual Eligible

19. Medicare-Medicaid
Medicare-Medicaid enrollees must navigate two separate programs:
Medicare for the coverage of basic acute health care services and drugs
Medicaid for the coverage of long-term care supports and services, certain behavioral health services, and to help with Medicare premiums and cost-sharing.
Medicare-Medicaid enrollees must navigate two separate programs: Medicare for the coverage of basic acute health care services and drugs, and Medicaid for the coverage of long-term care supports and services, certain behavioral health services, and to help with Medicare premiums and cost-sharing.
Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

20. Medicare-Medicaid Enrollee Delivery System Transformation
CURRENT STATE
Provider and Payor-Centered
Fragmented Care
Volume-Driven
Complicated Benefit Overlap
FUTURE STATE
Person-Centered
Coordinated Care
Outcomes-Driven
Simplified Processes 20

21. Medicare-Medicaid Plans
A longstanding barrier to coordinating care for Medicare-Medicaid enrollees has been the financial misalignment between Medicare and Medicaid.
To begin to address this issue, the Centers for Medicare & Medicaid Services (CMS) will test models with States to better align the financing of these two programs and integrate primary, acute, behavioral health and long-term services and supports for their Medicare-Medicaid enrollees.
07/01/2015
Dual Eligible

22. Model Types
Capitated Model: A State, CMS, and a health plan enter into a three-way contract, and the plan receives a prospective blended payment to provide comprehensive, coordinated care.
Managed Fee-for-Service (FFS) Model: A State and CMS enter into an agreement by which the state would be eligible to benefit from a portion of savings from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid.
Capitated Model: A State, CMS, and a health plan enter into a three-way contract, and the plan receives a prospective blended payment to provide comprehensive, coordinated care.
Managed Fee-for-Service (FFS) Model: A State and CMS enter into an agreement by which the state would be eligible to benefit from a portion of savings from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid.
Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordinatio n.html
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

23. Medicare-Medicaid Plans
RO V
Has 3 Medicare-Medicaid Plans
Illinois: MMAI
Coordinated care to >135,000 enrollment began 2014
Ohio: ICDS
Coordinated Care >180,000 enrollment began 2014
Michigan (NEW)
Enrollment began 2015
RO VII
No MMPs
Illinois MMAI:
On February 22, 2013, the Department of Health and Human Services announced that the State of Illinois will partner with the Centers for Medicare & Medicaid Services (CMS) to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience.
Under the demonstration, also called the "Medicare-Medicaid Alignment Initiative," Illinois and CMS will contract with health plans to coordinate the delivery of and be accountable for all covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees
On February 22, 2013, the Illinois Department of Healthcare and Family Services (HFS) received approval from the federal Centers for Medicare and Medicaid Services (CMS) to jointly implement the Medicare-Medicaid Alignment Initiative (MMAI). The MMAI is a groundbreaking joint effort to reform the way care is delivered to clients eligible for both Medicare and Medicaid Services (called “dual eligibles”). The MMAI demonstration project will provide coordinated care to more than 135,000 Medicare-Medicaid enrollees in the Chicagoland area and throughout central Illinois beginning January 2014.
Ohio: Integrated Care Delivery System (ICDS)
On December 12, 2012, the Department of Health and Human Services announced that the State of Ohio will partner with the Centers for Medicare & Medicaid Services (CMS) in the Financial Alignment Demonstration to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience. 
Under the Demonstration, Ohio and CMS will contract with Integrated Care Delivery System (ICDS) plans that will coordinate the delivery of and be accountable for all covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees.
Michigan
MI Health Link is a new program that will allow you to get health care and services covered by Medicare and Medicaid. MI Health Link lets you use one plan and one card for health care, behavioral health care, home and community-based services, nursing home care and medications
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

24. Lesson 3: Medicare-Medicaid
Explain Medicare-Medicaid Coordination Office
Review Updates on the Financial Alignment Initiative
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Dual Eligible

25. MEDICARE-MEDICAID COORDINATION OFFICE.
Created by the Affordable Care Act, the Medicare-Medicaid Coordination Office works to improve coordination between the federal government and states for Medicare- Medicaid enrollees in order to ensure full access to covered services and high quality care in both programs.
The Office is moving forward on improving access, coordination, and cost of care with a focus in three major areas: program alignment, data and analytics, and models and demonstrations.
MEDICARE-MEDICAID COORDINATION OFFICE. Created by the Affordable Care Act, the Medicare-Medicaid Coordination Office5 works to improve coordination between the federal government and states for Medicare- Medicaid enrollees in order to ensure full access to covered services and high quality care in both programs. The Office is moving forward on improving access, coordination, and cost of care with a focus in three major areas: program alignment, data and analytics, and models and demonstrations. To date, the Medicare- Medicaid Coordination Office has:
• Launched the Alignment Initiative, with the goal of eliminating unnecessary and inefficient conflicts in the regulatory, statutory, and policy requirements of the two programs, where feasible.
Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

26. Medicare-Medicaid Coordination Office
Launched the Alignment Initiative, with the goal of eliminating unnecessary and inefficient conflicts in the regulatory, statutory, and policy requirements of the two programs, where feasible.
Launched the Alignment Initiative, with the goal of eliminating unnecessary and inefficient conflicts in the regulatory, statutory, and policy requirements of the two programs, where feasible. Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

27. Medicare-Medicaid Alignment Initiative
Alignment efforts in process. Since its development, the Alignment Initiative has served as CMS’ guide for streamlining Medicare and Medicaid program rules, requirements, and policies.
This Initiative includes support and involvement from a variety of components across CMS, primarily the Center for Medicare and the Center for Medicaid and CHIP Services.
Over the past few years, CMS has begun addressing the twenty-nine alignment opportunities listed in the Federal Register. For some, solutions have been identified that can be effectuated through rulemaking or policy changes.
Alignment efforts in process. Since its development, the Alignment Initiative has served as CMS’ guide for streamlining Medicare and Medicaid program rules, requirements, and policies.
This Initiative includes support and involvement from a variety of components across CMS, primarily the Center for Medicare and the Center for Medicaid and CHIP Services.
Over the past few years, CMS has begun addressing the twenty-nine alignment opportunities listed in the Federal Register. For some, solutions have been identified that can be effectuated through rulemaking or policy changes.
Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordinatio n.html
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

28. Prohibited Billing
Under Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997:
Medicare and Medicaid payments you receive for furnishing services to a QMB are considered payments in full.
You may not balance bill QMBs for any Medicare cost sharing (including deductibles, coinsurance, and copayments) for these services.
You are subject to sanctions if you bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing).
Additional Resource: Network-MLN/MLNMattersArticles/downloads/SE1128.pdf
Prohibited Billing
Under Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, Medicare and Medicaid payments you receive for furnishing services to a QMB are considered payments in full. You may not balance bill QMBs for any Medicare cost sharing (including deductibles, coinsurance, and copayments) for these services. You are subject to sanctions if you bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing).
07/01/2015
Dual Eligible
Medicare Advantage and Other Medicare Plans

29. Medicare Advantage and Other Medicare Plans Resource Guide
Resources
Medicare Products
Centers for Medicare &
Medicaid Services (CMS)
1-800-MEDICARE ( ). TTY users should call
Medicare.gov
CMS.gov
Social Security
1‑800‑772‑1213. TTY users should call 1‑800‑325‑0778.
socialsecurity.gov
Railroad Retirement Board
TTY users should call
RRB.gov
Manuals/Guidance (continued)
2015 Medicare Marketing Guidelines
CMS.gov/Regulations-and- Guidance/Guidance/Manual s/Downloads/mc86c03.pdf
Medicare Managed Care Manual
CMS.gov/Regulations-and- Guidance/Guidance/Manual s/Internet-Only-Manuals- IOMs- Items/CMS html
State Health Insurance Assistance Programs For telephone numbers call CMS
1-800-MEDICARE ( ). TTY users should call
Affordable Care Act
HealthCare.gov/law/full/index.htm
“Medicare & You Handbook”
CMS Product No
“Have You Done Your Yearly
Medicare Plan Review?”
CMS Product No
“Medicare Supplement Insurance, Getting Started”
CMS Product No
“Your Guide to Medicare Private Fee-for-Service Plans”
CMS Product No
“Understanding Medicare Enrollment Periods”
CMS Product No
“Your Guide to Medicare Savings Account Plans”
CMS Product No
“Your Guide to Special Needs Plans”
CMS Product No
To access these products
View and order single copies at
Medicare.gov/publications.
Order multiple copies (partners only) at productordering.cms.hhs.gov. You must register your organization.
Resources
Medicare Products
Centers for Medicare &
Medicaid Services (CMS)
1-800-MEDICARE ( ) TTY users should call
Medicare.gov
CMS.gov
Social Security
1‑800‑772‑1213. TTY users should call 1‑800‑325‑0778
socialsecurity.gov
Railroad Retirement Board
TTY users should call
RRB.gov
State Health Insurance Assistance Programs For telephone numbers call CMS
1-800-MEDICARE ( ). TTY users should call
2015 Medicare Marketing Guidelines
CMS.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/mc86c03.p df
Medicare Managed Care Manual
CMS.gov/Regulations-and- Guidance/Guidance/Manuals/Internet-Only-Manuals- IOMs-Items/CMS html
Affordable Care Act
HealthCare.gov/law/full/index.htm
MLN Dual Eligible
2015 Medicare Savings Program Income Limits Job Aid
“Medicare & You Handbook”
CMS Product No
“Have You Done Your Yearly
Medicare Plan Review?”
CMS Product No
“Medicare Supplement Insurance, Getting Started”
CMS Product No
“Your Guide to Medicare Private Fee-for-Service Plans”
CMS Product No
“Understanding Medicare Enrollment Periods”
CMS Product No
“Your Guide to Medicare Savings Account Plans”
CMS Product No
“Your Guide to Special Needs Plans”
CMS Product No
To access these products
View and order single copies at
Medicare.gov/publications
Order multiple copies (partners only)
at productordering.cms.hhs.gov. You must register your organization
07/01/2015
Dual Eligible

30. CMS National Training Program
To view all available NTP training materials, or to subscribe to our list, visit CMS.gov/Outreach-and-Education/Training/ CMSNationalTrainingProgram/index.html For questions about training products
This training module is provided by the CMS National Training Program (NTP).
To view all available CMS NTP materials, including additional training modules, job aids, educational activities, and webinar and workshop schedules, or to subscribe to our list, visit CMS.gov/outreach-and-education/training/cmsnationaltrainingprogram. For questions about these training products,