Response to Comments on Integrated Care 2008

Response to Comments on the Integrated Care Preprint

January 8, 2008

Comment	Response
There were a total of three letters commenting on the Integrated Care Preprint. All of the commenters support CMS’ stated goals for the State Plan Preprint, which are to allow States that choose to use the Preprint to highlight their arrangements with integrated SNPs and provide an opportunity for these States to confirm that their integrated care models comply with both federal statutory and regulatory requirements.The commenters believe that issuance of the Preprint can be a positive step and urged CMS to continue with its development.	CMS agrees. (No changes are needed)
One commenter strongly recommended that CMS take additional action to promote opportunities for Medicare-Medicaid integration that are important to facilitating MA SNP implementation and recommends that CMS draw upon the experience of the demonstration plans that have played a leadership role in Medicare-Medicaid integration efforts.	CMS agrees. (No changes are needed)
The draft State Medicaid Director’s Letter that accompanies the draft SPA Preprint template indicates that the agency intends to also issue instructions for State use. Because the instructions are necessary for parties commenting on the Preprint to understand how it will be used and the time and resources necessary to complete it, the commenter recommended that in the future, the draft Preprint instructions be issued along with proposed Preprints.	The Instructions are part of the Preprint. (Clarifying changes were made in the Instructions and Preprint)
A commenter recommends that the State Plan include a date certain on which the State expects to implement the State Plan amendment addressed in the new Preprint.	We did not agree with requiring a date certain on the Preprint since it is voluntary. States must work around other federal and state requirements to implement Integrated Programs which would affect the accuracy of implementation date. (No changes are needed)
One commenter explained that since there is wide variation among States in the specific services provided under the categories of “Acute” and “Long Term Care” services, states should provide a detailed list of the services and check those that apply.	CMS does not agree with this suggestion, since the Preprint is an optional vehicle for States to explain how the integrated care programs will operate in their state. States are able to add additional information as they feel is necessary to explain their program. More specific details on each service are also included under contracts and/or waivers submitted by States. States may reference other documents where this information would be provided. (Changes are not needed)
In addition to establishing payment methodologies for Medicaid covered benefits provided by integrated SNPs, States also have specified obligations for paying cost sharing for Medicare covered benefits provided to SNP enrollees who are Qualified Medicare Beneficiaries (QMBs). One commenter recommended that items addressing State cost sharing obligations be added to the Payment section of the Preprint.	CMS does not agree. States are already required to explain Cost-Sharing requirements in another section in their State Plan. (No changes needed)
One commenter recommends that CMS specify in the Pre-print whether the dual eligible populations selected by the State are subject to a voluntary or mandatory enrollment process under the State’s Medicaid managed care program.	States may include this information in the Preprint but it is not a requirement. (No changes needed)
A commenter indicated that the subheadings in the Preprint have been mislabeled because there are two items labeled “E” (“Geographic Area” and “Target Dual Eligible Population”).	CMS corrected the items labeled incorrectly. (Changes were made to Preprint)
One commenter expressed appreciation for CMS’ initiatives to date to move toward availability of integrated pre- and post-enrollment marketing materials for beneficiaries who are considering enrolling or who are already enrolled in integrated SNPs. In addition to developing the Preprint, they encouraged CMS to intensify efforts to collaborate with States, integrated SNPs, and other key stakeholders to promote development of such materials in the future and issue additional guidance to supplement the “Marketing How to Guide”.	CMS has been working with States and other stakeholders and will continue to outreach to States to encourage integrated care arrangements. CMS has updated its website to include a roadmap with resources that can assist interested States in pursuing integrated care arrangements. (Changes were made to the Instructions to add the Website)
A commenter recommended that CMS add to the list of assurances an item that addresses the cost sharing obligations of States for QMBs enrolled in integrated SNPs.	States are already required to provide cost sharing requirements in their State Plan as stated previously. (No changes are needed)
Two commenters strongly support the voluntary nature of the proposed State Plan Preprint for Integrated Medicare and Medicaid Programs and oppose mandating the preprint.	CMS supports offering the Integrated Care Preprint on a voluntary basis. (No changes are needed)
One commenter offered corrective language at section F, item (5), the word “as” should be deleted from the following sentence: “The Medicaid agency or its designee will allow an authorized representative to enroll Medicaid beneficiaries in a SNP”. At section H, under Integrated Performance Improvement Projects: a closed parenthesis should be inserted at the end of the first paragraph.	CMS agrees with the comments. (Changes were made to the Preprint)
One commenter asked questions about the voluntary nature and the impact on an approved waiver to implement an integrated care program.	The Preprint is voluntary/optional document. CMS would not prevent a State from implementing an approved waiver application if an Integrated Care SPA was not submitted. The Preprint is a tool that States may use to explain their integrated care arrangements. As stated in the Preprint instructions the Preprint does not replace the need for States to operate under the appropriate statutory authorities and to be in compliance with federal requirements. (No changes are needed)
One commenter asked about the expected timeline for submitting the integrated care SPA and how it would coincide with the waiver submission.	CMS has indicated that the Integrated Care Preprint is voluntary. States are not required to fill it out prior to submitting or implementing an integrated care waiver program. (No changes are needed)
One commenter indicated that it would be helpful in Sections F (enrollment) and Sections G (Marketing) if there could be another response under the existing options.	States are able to add additional information as they feel is necessary to explain their program. (Changes were made)
One comment was made about the term “authorized representative” and whether this refers to enrolling Medicaid beneficiaries in a SNP for Medicaid services or for Medicare services.	This provision allows the authorized representative to enroll Medicaid beneficiaries in a SNP for Medicaid services. (No change needed)
One commenter indicated that according to NCQA HEDIS is now referred to as “Healthcare Effectiveness Data and Information Set”	CMS agrees. (Correction to Preprint was made)