Rhode Island Executive Office of Health and Human Services ...€¦ · practice that functions as a patient centered medical home (as recognized by EOHHS). 1 RI’s Office of the

1

Rhode Island Executive Office of Health and Human Services (EOHHS)

Medicaid Program Accountable Entity Roadmap Document

DateofSubmissionforCenterforMedicareandMedicaidServices(CMS) ReviewandApproval:___date______

2

TableofContents

I. RoadmapOverviewandPurpose....................................................................................3

II. RhodeIsland’sVision,GoalsandObjectives....................................................................4

III. OurApproach.................................................................................................................7

IV. ProgresstoDate............................................................................................................11

V. AEProgramStructure....................................................................................................16

VI. AECertificationRequirements.......................................................................................18

VII. AlternativePaymentMethodologies..............................................................................22

VIII.MedicaidInfrastructureIncentiveProgram(MIIP).........................................................25

IX. ProgramMonitoring,Reporting,&EvaluationPlan........................................................34

AppendixA:DRAFTCertificationStandards..........................................................................38

AppendixB:StakeholderMeetingsandFeedback.................................................................55

AppendixC:RoadmapRequiredComponents.......................................................................58

3

I. RoadmapOverviewandPurpose ThisAccountableEntity(AE)RoadmapisbeingsubmittedbytheRIEOHHS,asthesinglestateMedicaidagencyinRhodeIsland,toCMSforreviewandapprovalinaccordancewithSpecialTermandCondition(STC)48ofRhodeIsland’sHealthSystemTransformationProject(HSTP)Amendmenttothestate’s1115MedicaidDemonstrationWaiver.Thepurposeofthisdocumentisto:• DocumenttheState’svision,goalsandobjectivesundertheWaiverAmendment.• Detailthestate’sintendedpathtowardachievingthetransformationtoanaccountable,

comprehensive,integratedcross-providerhealthcaredeliverysystemforMedicaidenrollees,anddetailtheintendedoutcomesofthattransformeddeliverysystem.

• RequestreviewandapprovalbyCMS,asisrequiredbeforethestatecanbeginpaymentsoffederalIncentiveFundsundertheWaiverAmendment

TheAccountableEntity”Roadmap”isarequirementoftheSpecialTermsandConditions(STCs)ofRI’sHealthSystemTransformationWaiver(STC48).TheStatemustdevelopanAccountableEntityRoadmapfortheHealthSystemTransformationProjecttobesubmittedtoCMSforCMS’s60-dayprocessofreviewandapproval.TheStatemaynotclaimFFPforHealthSystemTransformationProjectsuntilafterCMShasapprovedtheRoadmap.OnceapprovedbyCMS,thisdocumentwillbeincorporatedasAttachmentNoftheSTCs,andonceincorporatedmaybealteredonlywithCMSapproval,andonlytotheextentconsistentwiththeapprovedwaivers,expenditureauthoritiesandSTCs.(Changestotheprotocolwillapplyprospectively,unlessotherwiseindicatedintheprotocols.)

TheAccountableEntityRoadmapwillbeaconceptualizedlivingdocumentthatwillbeupdatedannuallytoensurethatbestpracticesandlessonsthatarelearnedthroughoutimplementationcanbeleveragedandincorporatedintotheState’soverallvisionofdeliverysystemreform.ThisRoadmapisnotablueprint;butratheranattempttodemonstratetheState’sambitionsfordeliverysystemsreformandtooutlinewhattheStateanditsstakeholdersconsiderthepaymentreformsrequiredforahighqualityandafinanciallysustainableMedicaiddeliverysystem.ThisroadmaphasbeendevelopedwithinputfromparticipatingMCOs,AccountableEntitiesandstakeholders.AdraftroadmapwaspostedforpublicinputinDecember2016.Twenty-four(24)commentswerereceivedfromavarietyofstakeholdersrepresentingprovider,insurers,andadvocates.Thirteen(13)publicinputsessionswereheldbetweenJanuaryandMarch2017toinformthefinalroadmap.AfulllistofpublicsessionscanbefoundinAppendixB.AdetailedlistoftherequiredRoadmapelements,andthelocationofeachelementinthisdocument,isprovidedinAppendixC.

4

II. RhodeIsland’sVision,GoalsandObjectivesRhodeIsland’sMedicaidprogramisanessentialpartofthefabricofRhodeIsland’shealthcaresystemservingoneoutoffourRhodeIslandersinagivenyearandclosertothirtypercentoverathreeyearperiod.Theprogramhasachievednationalrecognitionforthequalityofservicesprovided,withMedicaidMCOsthatareconsistentlyrankedinthetopteninnationalNCQArankingsforMedicaidMCOs.

However,thereareimportantlimitationstoourcurrentsystemofcare–recognizedhereinRhodeIslandandnationally:• Itisgenerallyfeebasedratherthanvaluebased,• Itdoesnotgenerallyfocusonaccountabilityforhealthoutcomes,• ThereislimitedemphasisonaPopulationHealthapproach,and• Thereisanopportunitytobettermeettheneedsofthosewithcomplexhealthneedsand

exacerbatingsocialdeterminants.

Assuch,thecurrentsystemofcare,bothinRhodeIslandandnationally,focusespredominantlyonhighqualitymedicalcaretreatmentofindividualconditions–asisencouragedandreinforcedbyourfeeforservice(FFS)paymentmodel.Asaresultofthismodel,thereisoftensiloedand/orfragmentedcare,withhighreadmissionsandmissedopportunitiesforintervention.Specifically:

• WithinMedicalCare:Thereislimitedfocusontransitions,discharges,carecoordination,andmedicationmanagementacrossandbetweenhospitals,specialistsandprimarycareproviders.

• BetweenMedicalCareandBehavioralHealthcare:Thereislimitedeffectivecoordinationbetweenmedicalandbehavioralproviders,oftenactingastwodistinctsystemsofcare.

• Complicatedbygrowingneedsofanagingpopulation:Thiswillchallengemedicalmodelsofcareandrequirebroaderdefinitionsofcare(e.g.,dementia,cognitiveissues).

• BetweenMedicalCareandSocialDeterminants:ThereislimitedrecognitionandadaptationofamedicalmodelthatrecognizescommonfactorsimpactinghealthofMedicaidpopulations–suchaschildhoodtraumaanditslongtermimpacts,mistrustofthehealthcaresystem,etc.Thereisalsolimitedcapacitytoaddressbroadersocialneeds,whichoftenovershadowandexacerbatemedicalneeds–e.g.,housing/housingsecurity,foodsecurity,domesticviolence/sexualviolence.

Asaresult,althoughindividualprovidersareoftenhighperforming,nosingleentity“owns”serviceintegration,andnosingleentityisaccountableforoveralloutcomes-onlyspecificservices.Effectiveinterventionsmust“breakthrough”thefinancinganddeliverysystemdisconnects,tobuildpartnershipsacrosspaymentsystems,deliverysystemsandmedical/socialsupportsystemsthateffectivelyalignfinancialincentivesandmoreeffectivelymeetthereallifeneedsofindividualsandtheirfamilies.

5

TheseissuesareparticularlyproblematicwhenservingthemostcomplexMedicaidpopulations--thesixpercentofMedicaiduserswiththemostcomplexneedsandhighestcoststhataccountforalmosttwothirds(65%)ofMedicaidclaimsexpenditure.Specifically:

• PopulationsreceivinginstitutionalandresidentialservicesNearlyhalf(45%)ofclaimsexpenditureonhighcostusersisonnursingfacilitiesfortheelderlyanddisabled,andonresidentialandrehabilitationservicesforpersonswithdevelopmentaldisabilities.

• PopulationswithintegratedphysicalandbehavioralhealthcareneedsFortypercent(40%)ofclaimsexpenditureonhighcostusersisforindividualslivinginthecommunity,most(82%)ofwhomhavemultipleco-morbidities,withbothphysicalandmentalhealthorsubstanceabuseneedsthatrequireanintegratedapproach.

Thevision,asexpressedintheReinventingMedicaidreportisfor“…areinventedMedicaidinwhichourMedicaidmanagedcareorganizations(MCOs)contractwithAccountableEntities(AEs),integratedproviderorganizationsthatwillberesponsibleforthetotalcostofcareandhealthcarequalityandoutcomesofanattributedpopulation.”Thegoalsareconsistentwithinitiativestakingholdacrossthecountry–amovementtowardAccountableCareOrganizations,includingvaluebasedpayment,newformsoforganization,andincreasedcareintegration.Specificgoalsofthisinitiative,developedinalignmentwithSIMandotherongoinginitiativesinourRIenvironmentinclude:1

• Transitionfromfeeforservicetovaluebasedpurchasing• FocusonTotalCostofCare(TCOC)• Createpopulationbasedaccountabilityforanattributedpopulation• Buildinterdisciplinarycarecapacitythatextendsbeyondtraditionalhealthcareproviders• Deploynewformsoforganizationtocreatesharedincentivesacrossacommonenterprise• Applyemergingdatacapabilitiestorefineandenhancecaremanagement,pathways,

coordination,andtimelyresponsivenesstoemergentneedsAsaresultofthistransformationoftheRhodeIslandMedicaidprogram(andinpartnershipwithothereffortssuchasSIM),RIanticipatesthatby2022,RhodeIslandwillhaveachievedthefollowingobjectives:• Improvementsinthebalanceoflongtermcareutilizationandexpenditures,awayfrom

institutionalandintocommunity-basedcare;• Decreasesinreadmissionrates,preventablehospitalizationsandpreventableEDvisits;• Increaseintheprovisionofcoordinatedprimarycareandbehavioralhealthservicesinthe

samesetting;and• IncreasednumbersofMedicaidmemberswhochooseorareassignedtoaprimarycare

practicethatfunctionsasapatientcenteredmedicalhome(asrecognizedbyEOHHS).

1RI’sOfficeoftheHealthInsuranceCommissioner(OHIC)receivedaSIM(StateInnovationModel)grantfromCMStotesthealthcarepaymentandservicedeliveryreformmodelsoverthenextfouryears,inaprojectcalledHealthyRhodeIsland.

6

ThisdocumentestablishestheRoadmaptoachievethevision,goalsandobjectivesdescribedhere.

7

III. OurApproach Asstatedabove,theRhodeIslandAccountableEntityProgramisintendedto“breakthroughthefinancinganddeliverysystemdisconnects,tobuildpartnershipsacrosspaymentsystems,deliverysystemsandmedical/socialsupportsystemsthateffectivelyalignfinancialincentivesandmoreeffectivelymeetthereallifeneedsofindividualsandtheirfamilies.”TheAccountableEntityprogramshallbedevelopedwithin,andinpartnershipwith,RhodeIsland’sexistingmanagedcaremodel,buildingonitsexistingstrengths.TheAEprogramwillenhancethecapacityofMCOstoservehigh-riskpopulationsbyincreasingdeliverysystemintegrationandimprovinginformationexchange/clinicalintegrationacrossthecontinuum.Structurally,theAccountableEntityprogramincludesthreecore“pillars”:(1)EOHHSCertifiedAccountableEntitiesandPopulationHealth,(2)ProgressiveMovementtowardEOHHSapprovedAlternativePaymentMethodologies,(3)InfrastructureIncentivePaymentsforEOHHSCertifiedAEs,asdepictedbelow:

Notallprovidersareatthesamelevelofreadinessfortheinterdisciplinaryintegrationandtransitiontoalternativepaymentmethodologiesenvisionedbythisprogram.Assuch,EOHHSistakingamulti-prongedstrategy,inordertoeffectively“meetproviderswheretheyare”andenablethenecessarysystemtransformation.EOHHSanticipatesatleastthreespecificprograms:

Phase1:ComprehensiveAEProgramEOHHSviewsthefulldevelopmentofhighperformingComprehensiveAEsasthecoreobjectiveofitsHealthSystemTransformationProgram.TheComprehensiveAEPilotalreadyunderwayshallbeexpandedandenhancedforfullimplementation.TheComprehensiveAE

8

representsaninterdisciplinarypartnershipofproviderswithastrongfoundationinprimarycareandinclusiveofotherservices,mostnotablybehavioralhealthandsocialsupportservices.TheAEwillbeaccountableforthecoordinationofcareforattributedpopulationsandwillberequiredtoadoptadefinedpopulationhealthapproach.

Phase2:SpecializedLTSSAEPilotProgramEOHHSisworkingwithstakeholderstodevelopandimplementanLTSSAEpilotprogram,intendedtoencourageparticipatingLTSSproviderstobuildcollaborativeLTSS-focusedintegratedcaredeliverysystemsthatincludeacontinuumofcare,asshownbelow.TheabilityofanLTSSAEtoaddresspersonswithbehavioralhealthneedsanddementiawillbecritical.

MultipleprovidersandgroupsofprovidersofLTSSserviceshaveexpressedstronginterestinthispilot.However,RhodeIsland’sLTSSsystemofcareisfragmentedanddominatedbyspecializedproviderswhoaregeographicallyand/orservicespecific.Significantinfrastructuredevelopmentisrequiredtobuildthenecessarycapacityandcapabilitiesfortheseproviderstoeffectivelymanageapopulationunderatotalcostofcaremodel.

Phase3:MedicaidPre-EligiblesPilotProgramEOHHSisseekingMedicaidprevention/deferralstrategiestoenableandencourageagingpopulationstolivesuccessfullyinthecommunity.Tobeeffective,EOHHSmustwork“upstream”,andsupportpeopleinthecommunitywhoarenotyetMedicaideligiblebutareathighriskofbecomingsowhen/iffacedwithacriticalincidentordepletionofresources.Effectiveprogramsinthisarenamust“breakthrough”thefinancingsystemdisconnectsshownbelowtocreatefinancialincentivesforparticipatingproviders.

9

Assuch,EOHHSisintheprocessofdevelopingapilotprogramintendedtoengagehighvolumeMedicareprovidersinthedevelopmentandimplementationoftargetedinterventionsforMedicaidPre-eligibles,especiallyatriskpopulationsresidinginthecommunity.Thispilotisstillinthedesignphase–tobeimplementedsubjecttoapprovalbyCMSinfutureiterationsofthisroadmap.

EOHHSanticipatesthatadditionalprogramsmaybeaddedovertime,basedonlearningsfromthecurrentprogramsandpilots.EOHHSistakingaphasedapproachtoimplementation,withaprocessandtimelinethatallowsfortheincorporationofongoinglearnings,asshownbelow:

NotethattheComprehensiveAEprogramisalreadyunderway,asPilotAEswerecertifiedinthefallof2015andAPMcontractswereinplacebetweenMCOsandPilotAEsin2016.EOHHSplanstomovetheComprehensiveAEprogramtofullcertificationinCY2017withthefirstfullprogramperformanceperiodbeginninginCY2018.Thetwonewpilotprograms(SpecializedLTSSAEandMedicaidPre-Eligibles)willfollowasimilartrajectory,withstagedimplementationdatesandtargetedpilotperformanceperiodsinCY2018andCY2019respectively.EOHHSiscommittedtosupportingthissystemtransformationthroughourMedicaidInfrastructureIncentiveProgram(MIIP).Anestimated$76.8MillioninHealthSystemTransformationFundswillbeallocatedtotheMIIP,supportingMCOsandAEsinbuildingthecapacityandtoolsrequiredforeffectivesystemtransformation.2Thesefundsmustbeusedto

2 SubjecttoavailablefundscapturedinaccordancewithCMSapprovedclaimingprotocols.

10

supportstatedefinedpriorities,inspecifiedallowableexpenditureareas,andwillbetiedtotheachievementofAEandMCOspecificmilestones.Effectiveimplementationofthisprogramwillmeanthatby2022atleastonethird(33%)ofeligibleswillbeattributedtoanEOHHSAccountableEntity,participatinginanEOHHSapprovedAlternativePaymentMethodology(APM).Thisgoalwillbeaccomplishedinaccordancewiththefollowingprogression:PercentofMedicaidcoveredlivesattributedtoanEOHHSapprovedAPM

PerformanceYear TargetDY10CY2018 10%CY2019 15%CY2020 20%CY2021 25%CY2022 33%

Beyondthisroadmap,fourcoreguidancedocumentswillgovernthisprogram,specifyingrequirementsforEOHHS,MCOsandparticipatingAEs:

CoreDocuments TargetedCMSSubmission

Description

1. AEApplicationandCertificationStandards

Spring2017 • AEcertificationstandards• Applicantevaluationandselectioncriteria• Submissionguidelines

2. APMGuidance Fall2017 • RequiredcomponentsandspecificationsforeachallowableAPMstructure

• AEScorecard• Areasofrequiredconsistency,flexibility

3. AttributionGuidance Fall2017 • RequiredprocessesforAEattribution,hierarchy4. AEIncentiveProgram

GuidanceFall2017 • Additionaldetailsonfundingallocation,required

priorities,allowableareasofexpenditure,milestones

NotethatkeyelementsofthesecoreprogrammaticguidancedocumentswerepostedaspartofthedraftRoadmapinDecember2016,leveragingthelearningsfromtheComprehensiveAEpilotprogramplusongoinglearningsfromnationalresearchandadvicefromindustryexperts.Stakeholdersandparticipantsprovidedmanyvaluablecommentsonthesekeyelementswhichwillbeincludedinthefinalguidance.Additionally,EOHHSshallholdpublicinputsessionsandparticipantworkingsessionswithkeystakeholdersandinterestedpublicparticipantstorefineeachguidancedocument.Draftguidanceshallbeposted,commentsreceivedwillbereviewed,anddocumentswillberevisedinconsiderationofpubliccommentsbeforefinalsubmissiontoCMSforapproval.

11

IV. ProgresstoDate EOHHShasmadesignificantprogressalongseveralaspectsoftheAccountableEntitystrategy.Keyactionstakentodateinclude:1. ComprehensiveAEPilotProgramImplementation2. SpecializedAEPilotProgramDevelopment3. EstablishmentoffundingmechanismforInfrastructureIncentivepaymentsKeyactionstepstodateineachoftheseareasarehighlightedbelow.1. ComprehensiveAEPilotProgramImplementation

RhodeIslandhasalreadybegunmovingforwardwiththecreationandsupportofAccountableEntities(AEs),whilesimultaneouslytestingcriticalprogramdesignelements.ToapproachthetaskofhowtobestadvancesuchmodelsinRhodeIsland,EOHHSissuedanRFIinAugust2015andreceived14responseswithmanythoughtfulcommentsandrecommendations.BasedonfeedbackfromtheRFIandexperienceinotherstates,thestateimplementedanAccountableEntityPilotProgramasafast-trackpathandanopportunityforearlylearningsinlatefall2015.EOHHSthenprovisionallycertifiedPilotAEsandissuedcompaniondocumentsspecifyingattributionrulesandtotalcostofcareguidance.Pilotswerecertifiedwiththeunderstandingthat:

• ThestatewouldbeproceedingtomovepastthePilotphaseand,basedonexperiencesandlearningsfromRIandacrossthecountry,woulddevelopmoreextensiveandrefinedcertificationstandards.Applicantsforpilotcertificationwouldbeexpectedtocomplywiththosenewstandards.

• Thestatewouldpursueopportunitieswiththefederalgovernmentthat,ifsuccessful,wouldenablestateinvestmentsinthefurtherdevelopmentofAEcapabilities.

Todate,therehavebeenthreeroundsofpilotAEapplications.Applicantshadtodemonstratereadinessacrossthreekeydesigndomains,includinggovernance,organizationalcapability,anddata/analyticcapability.Qualifiedpilotapplicantswere“ProvisionallyCertifiedwithConditions”,whichspecifiedlimitationstotheircontractingauthorityandconfirmedrequireddevelopmentalstepsandtimelines.Thefollowingsixprovider-basedentitieshavebeendesignatedasProvisionallyCertifiedPilotAEs,eligibletoenterintoTotalCostofCare-basedsharedsavingsprogramswithMedicaidMCOsbeginninginJanuary2016:

• BlackstoneValleyCommunityHealthCenter’sHealthKeyAccountableEntity• CoastalMedical,Inc.

12

• CommunityHealthCenterAccountableCareOrganization(CHCACO)3• IntegraCommunityCareNetwork,LLC• ProvidenceCommunityHealthCenters,Inc.’sProvidenceChoiceCareAE• ProspectHealthServicesRhodeIsland,Inc.(PHSRI)ThesesixAEswerecertifiedas“Type1”AEs,meaningtheyarecertifiedtocontractforallservicesforatotalattributedpopulation.AsofJuly2016,morethanonethird(1/3)oftotalMedicaidliveswereattributedtoparticipatingpilotAEsunderTotalCostofCarepilotterms,asshownbelow:AEPilot:AttributedLives

Type1AttributedLives United NHP TotalMCOsBlackstoneValley(BVCHC) 8,933 8,933Integra(CNE,SCH&RIPCP) 19,011 20,140 39,151PHSRI 5,350 5,411 10,761PCHCProvidenceChoiceCareAE 25,037 25,037CHCACO+ 28,160 28,160TotalType1 24,361 87,681 112,042

SourcesandNotes:UnitedandNHPattributedlivesfromQ42016snapshotreports.CoastalwasprovisionallycertifiedinJuly2016andhasnotyetcontractedwiththeMCOs.TheseAEpilotparticipantsprovidethreedifferentmodelsofComprehensiveAccountableCare,whichwillallowsignificantopportunitiesforevaluationgoingforward.Therearetwohospitalbasedentities,onemultispecialtygrouppractice,andthreeFQHCbasedmodels,allofwhichdemonstrateacommitmenttoprimarycareinfrastructureandaninterdisciplinaryapproach.2. SpecializedAEPilotProgramDevelopment

“Specialized”AEsaregenerallyintendedasaninterimarrangementtoenableproviderstoformnetworksthatwillbuildthecapacityandinfrastructureneededtomanagespecializedpopulationsacrossproviders.Overtime,EOHHSintendsthattheseSpecializedAEswouldpartnerwithaComprehensiveAE.InconjunctionwiththeComprehensiveAEPilotProgramimplementedinlatefall,2015,EOHHSincludedanopportunityforprovisionalcertificationofspecialized“Type2”AccountableEntities.Specifically,theSpecializedPilotType2AEswasintendedtoencourageandenhanceintegratedcareforpersonswithSPMI/SMI(Serious&PersistentMentalIllness/SeriousMentalIllness),consistentwithEOHHS’goalofintegratingphysicaland

3CommunityHealthCenterAccountableCareOrganization(CHCACO)currentlyincludesEastBayCommunityActionProgram(EBCAP),ComprehensiveCommunityAction,Inc.(CCAP),ThundermistHealthCenter,Tri-TownCommunityActionAgency,WellOnePrimaryMedical&DentalCare,andWoodRiverHealthServices.

13

behavioralhealthservices.Assuch,organizationswithattributedSPMI/SMIpopulationswereeligibletobecome“Type2”AEs,eligibletoparticipateinatotalcostofcarebasedsharedsavingsarrangementwithparticipatingMedicaidMCOs.Inpractice,theimplementationofthistypeofSpecializedAEresultedinthealignmentofSpecializedAEswithComprehensiveAEs.Assuch,EOHHSintendstosunsettheType2SPMISpecializedAccountableEntity,insteadencouragingintegrationofSPMIpopulationswithcomprehensiveAEs,ashasalreadyoccurredinthemarket.EOHHSremainscommittedtocontinuedimprovementsandenhancementsinintegratedcareforpersonswithSPMI/SMI.EOHHSisalsoworkingcloselywithstakeholderstodevelopaSpecializedLTSSAEPilotProgramtofocusonprovidersoflongtermservicesandsupports(LTSS).Activitiestosupportthisinitiativesofarinclude:

• Establishmentofkeyprogramgoals• Multiplediscussionswithkeystakeholdersandpublicmeetings• Researchandevaluationofsimilarprogramsinotherstates• Detaileddiscussionswithkeystakeholdersregardingpotentialprogramstructure,

includingattributionmethods,APMmodelsandperformancemetricsSpecializedLTSS-focusedAEsareintendedtoachievetherebalancinggoalsofReinventingMedicaidbyeffectivelyenablingandencouragingagingpopulationstolivesuccessfullyinthecommunity.ThisrequirescreatingsufficientfinancialincentivesforcurrentLTSSproviders–nursingfacilities,homeandcommunitybasedproviders--toworktogethertochangethewaycareisdeliveredtoouragingpopulation.Assuch,theSpecializedLTSSfocusedAEprogramshall:

• Supportfocusedinvestmentstobuildcapacityandfillingapsininfrastructuretomoreeffectivelyaddresstheneedsofvulnerableseniors,supportingtheirabilitytosuccessfullyremaininthecommunity.

• Encourageandinvestinthedevelopmentofintegratedcaredeliverymodels,suchthatprovidersbuildcollaborativeLTSSfocusedintegratedcaredeliverysystemsthatincludeacontinuumofcare.Abilitytoaddresspersonswithbehavioralhealthneedsanddementiawillbecritical.

• Encourage/requirealternativepaymentmethodologiesthatsupportthisintegratedsystemandthatalignfinancialincentivesbothacrosspayorsandbetweenthestate,MCOsandproviders.

• ChangefinancialincentivesforNursingFacilities–encouragethemtoreducelengthofstay,increasequality,andsendpeoplehomequicker.

EOHHSisalsobeginningtodesignaMedicaidPre-EligiblesPilotProgram.TheconceptualdesignastestedwithstakeholdersinthedraftroadmapinJanuary2017wasmetwithstrong

14

interestandpositivefeedback,andinitialdesigndiscussionshavealreadybegunwithinterestedstakeholders.Overthecomingmonths,EOHHSintendstoworkwithCMSandlocalpartiestodesignpotentialpathwaysforthisinnovativeapproach.3. EstablishmentoffundingmechanismforInfrastructureIncentivepayments Beginninginlate2015,EOHHSbeganpursuingMedicaidwaiverfinancingtoprovidesupportforAEsbycreatingapooloffundsprimarilyfocusedonassistinginthedesign,developmentandimplementationoftheinfrastructureneededtosupportAccountableEntities.RIsubmittedanapplicationforsuchfundinginearly2016asanamendmenttoRI’scurrentGlobalMedicaid1115Waiver.InOctober2016CMSapprovedthiswaiveramendment,bringing$129.8milliontoRIfromNovember2016throughDecember2020.4ThisfundingisbasedontheestablishmentofaninnovativeHealthWorkforcePartnershipwithRI’sthreepublichighereducationinstitutions:UniversityofRhodeIsland(URI),RhodeIslandCollege(RIC),andtheCommunityCollegeofRhodeIsland(CCRI),asillustratedbelow.HealthSystemTransformationProject

ThemajorityofthefinancingfromthiswaiveramendmentwillbeprovidedtoAEsasincentive-basedinfrastructurefundingviathestate’smanagedcarecontracts.OtherCMS-fundedcomponentsinclude:

4ThecurrentRhodeIsland1115Waiverisa5-yeardemonstration,endingin2018.TheSTCsincludeDSHPfundingauthoritythrough2018,withacommitmentarticulatedinthecoverlettertoextendthisauthoritythru2020uponwaiverrenewalforatotalfundingopportunityof$129Million.

15

• InvestmentsinpartnershipswithInstitutionsofHigherEducation(IHEs)forstatewidehealthworkforcedevelopment;and,

• One-timetransitionalfundingtosupporthospitalsandnursingfacilitiesinthetransitiontonewAEstructures5asshowninthechartbelow.

*HealthWorkforcePartnershipsincludes$5.4MforWorkforceDevelopmentand$2.4MforProgramOperations.**OtherProgramsincludes:ConsumerAssistance,WavemakerFellowship,TBClinic,RIChildAudiologyCenter,andCtrforAcuteInfectiousDiseaseEpidemiology.Includessomeunavailablefunding. Asmentionedabove,thecurrentRI1115WaiverexpiresDecember31,2018.TheSTCsofthewaiveramendmentincludeexpenditureauthorityforthisprogramupto$79.9millionFFPthroughtheenddateofthecurrentwaiver.Theremaining$49.9millioninfundingisanticipatedtobeavailableupontherenewalofthewaiverwithanextensionofDSHPauthoritythrough2020.

5TheSTCslimitthisprogramtobeone-timeonlyandtonotexceed$20.5million,paidonorbeforeDecember31,2017.

16

V. AEProgramStructure EOHHSintendstoexpandandrefinethecurrentPilotAccountableEntityProgramtofurthersupportandencouragethedevelopmentofAccountableEntities.Assuch,theAccountableEntityProgramwillincludethreecore“pillars”asshownanddescribedbelow.EachofthesepillarswillbearticulatedthroughspecifiedarrangementswithcertifiedAEs.ThesethreepillarsarenotedbrieflyhereanddescribedmorefullylaterinthisRoadmap.

ThevehicleforimplementingtheAEinitiativewillbecontractualrelationshipsbetweentheAEanditsmanagedcarepartners.MedicaidMCOsarecontractuallyrequiredtoincreasinglyenterintoEOHHSapprovedvaluebasedAPMcontractarrangements.CertifiedAEsmustenterintovaluebasedAPMcontractsincompliancewithEOHHSguidelinesinordertoparticipateinmemberattribution,sharedsavingsarrangements,andtobeeligibletoreceiveincentive-basedinfrastructurepaymentsthroughtheHealthSystemTransformationProgram.CorePillarsofEOHHSAccountableEntityProgram

1. EOHHSCertifiedAccountableEntitiesandPopulationHealthThefoundationoftheEOHHSprogramisthecertificationofAccountableEntities(AEs)responsibleforthehealthofapopulationofmembers.

2. ProgressiveMovementtowardEOHHSapprovedAlternativePaymentMethodologiesFundamentaltoEOHHS’initiativeisprogressivemovementfromvolumebasedtovaluebasedpaymentarrangementsandmovementfromsharedsavingstoincreasedriskandresponsibility.OnceanAEiscertified,theAEmustpursuevalue-basedAlternativePaymentMethodologies(APMs)withmanagedcarepartnersinaccordancewithEOHHSdefinedguidance.

3. InfrastructureIncentivePaymentsforEOHHSCertifiedAEsIncentive-basedinfrastructurefundingwillbeavailabletostatecertifiedAEswhohaveenteredintoqualifyingAPMcontractualagreementswithmanagedcarepartners.Aspartoftheseagreements,AEsmayearnincentive-basedinfrastructurefundingunderstate-specifiedrequirements.

Notethateachofthesepillarswasdevelopedwithanefforttobalancethefollowingkeyprinciples:

17

• EvidenceBased,leveraginglearningsfromourpilot,otherMedicaidACOsandnationalMedicare/Commercialexperience

• FlexibleenoughtoencourageInnovation,ACOs,andparticularlyMedicaidACOs,arerelativelynew,andinmanydevelopmentalareasclearevidenceisnotavailable

• Robustenoughtoaccomplishmeaningfulchange,andfosterorganizationalcommitmentsandtrueinvestments

• Specificenoughtoensureclarityandconsistency,recognizingthatconsistentguidelinesprovideclaritytoparticipants

Thefollowingsectionsprovidefurtherdetailoneachofthethreepillars.

18

VI. AECertificationRequirementsDuringthespring/summerof2017,EOHHSwillbeformalizingtheCertificationStandardsforAccountableEntities.Interestedpartieswillthenbeinvitedtosubmitapplicationsforcertificationandparticipationintheprogram.TheissuanceofAECertificationStandards,aswellasthevariousstagesoftheapplicationandapprovalprocess,willbemanageddirectlybyEOHHS.Thefinalcertificationstandardsandapplicationrequirementswillbebasedonacombinationofthefollowing:

• LearningstodatefromtheexistingAEPilotprogram• National/emerginglessonsfromotherstatesimplementingMedicaidACOs• EOHHSmulti-yearparticipationinaMedicaidACOLearningCollaborativefacilitatedbythe

CenterforHealthCareStrategies(CHCS)andsponsoredbytheCommonwealthFoundation• LessonslearnedfromtheexistingMedicareACOprograms• AlignmentwithSIMandtheACOstandardsasdevelopedbytheRhodeIslandOfficeofthe

HealthInsuranceCommissioner(OHIC)• FeedbackandcommentsfromstakeholdersonthedraftCertificationStandardsaspostedin

December2016• Feedbackandcommentsfromstakeholdersgatheredinpublicmeetings/discussionsduring

thebeginningof2017

EOHHSrecognizesthatpotentialapplicantsmayhavedifferingstagesofreadiness.Assuch,AEswillbeannuallycertified,andEOHHSanticipatesthatmostwillbe“ProvisionallyCertifiedwithConditions”.DeficiencieswillneedtobeaddressedinaccordancewithanagreeduponprojectplaninorderfortheAEtocontinuetobeeligibleforInfrastructureIncentivefunds.Eventually,AEswhohavedemonstratedthatallofthedomainrequirementswerefullymetwillbedesignatedas“FullyCertified”.“Full”certificationisnotrequiredtobeeligibleforincentivefunds.

EOHHSintendstocertifythreetypesofAEs:1. ComprehensiveAEs2. SpecializedLTSSPilotAEs3. SpecializedMedicaidPre-EligiblesPilotAEsNotethattheseAEswillservedistinctpopulations.Assuch,entitiesmayapplytoparticipateinoneormoreprograms,aslongasreadinesscanbeappropriatelyandspecificallydemonstrated.

1. ComprehensiveAECertificationStandardsEOHHShasidentifiedthecriticaldomainsconsideredinstrumentaltothesuccessofComprehensiveAEsinmeetingtheneedsoftheMedicaidpopulationthroughsystemtransformation.Notethattheserequirementsdonotspecifyaparticularorganizationalstructure.EOHHSvaluesmultiplemodelsofAEandencouragesentitieswithdifferent

19

structurestoapply(underthecurrentpilotthereareFQHCbased,hospitalbasedandprimarycarebasedPilotAEs).AEApplicantsmustmeetminimumrequirementsinordertobeconsideredforcertification.Preliminaryminimumrequirementsinclude:

• Minimumattributedlives• MinimumMedicaidshareoflives• Demonstratedabilitytocollect,share,andreportdata• Demonstratedlevelofbehavioralhealthintegrationwithprimarycare,withan

establishedbehavioralhealthproviderorganizationwithatleast10yearsofexperience• DemonstratedaffiliationorworkingarrangementwithanSUDtreatmentproviderwith

atleast10yearsofexperience • Demonstratedaffiliationorworkingarrangementwithcommunitybasedorganizations

toaddressbroadersocialcontextsimpactinghealth,outcomes

FinalrequirementsforqualifiedapplicantsshallbeincludedintheAEapplication.

QualifiedAEapplicantswillthenberequiredtodemonstratetheirspecificcapacitytoservetherequestedpopulationsbymeetingrequirementsacrossthefollowingdomains.PreliminarydetailedrequirementsforeachofthesedomainsareincludedinAppendixA.• Domain1:BreadthandCharacteristicsofParticipatingProviders

Interdisciplinarywithdemonstratedabilitytoserveabroadcontinuumofneedsincludingsocialdeterminantsforattributedpopulations.Mustincludeadefinedaffiliationorworkingarrangementwithcommunitybasedorganizationstoaddressbroadersocialcontextsimpactinghealth,outcomes.

• Domain2:CorporateStructureandGovernanceAnadequateandappropriategovernancestructuretoaccomplishtheprogramgoals

• Domain3:LeadershipandManagementAleadershipstructure,withcommitmentofseniorleaders,backedbytherequiredresourcestoimplementandsupportasingle,unifiedvision

• Domain4:ITInfrastructure:DataAnalyticCapacity&DeploymentAcorefunctionalITcapacitytoreceive,collect,integrate,andutilizeinformation

• Domain5:CommitmenttoPopulationHealthandSystemTransformationAconcertedprogrambuiltonpopulationhealthprinciplesandsystematicallyfocusedonthehealthoftheentireattributedpopulation.Asystematicpopulationhealthmodelthatworkstoimprovethehealthstatusoftheentireattributedpopulationwhilesystematicallysegmentingsubpopulationriskgroupswithcomplexneedsinordertoimplementfocusedstrategiestoimprovetheirhealthstatus.

• Domain6:IntegratedCareManagementAcomprehensiveintegratedcaremanagementprogram,includingsystematicprocesses

20

andspecializedexpertisetoidentifyandtargetpopulations.Anorganizationalapproachandstrategytointegrateperson-centeredmedical,behavioral,andsocialservicesforindividualsatriskforpooroutcomesandavoidablehighcosts.

• Domain7:MemberEngagement&AccessCapacityforeffectivememberengagement,includingstrategiestomaximizeoutreach,engagement,andcommunicationwithmembersinaculturallycompetentmanner

• Domain8:QualityManagementAbilitytointernallyreportonqualityandcostmetrics;tousethosemetricstomonitorperformance,emergingtrends,andqualityofcareissues;andtouseresultstoimprovecare

ItisEOHHS’expectationisthattheAEshallbestructuredandorganizedtoprovidecareforallpopulations,includingadultsandchildren.However,EOHHSrecognizesthatthenecessaryskillsandcapacitiesofanAEwillvaryconsiderablyacrosspopulations.Specifically,

• Children,includingchildrenwithspecialhealthcareneeds(CSHCN)andchildrenwithhigh,risingandlowrisk

• Adults,includingadultswithcomplexmedicalneeds,co-occurringBH/medical,Homeless,SubstanceUseDisorders,AdultswithDisabilities,DevelopmentallyDisabledadults.

Assuch,AECertificationmaybespecifictoanapprovedpopulation–Children,Adults–withattributionlimitedtotheapprovedpopulation.AEapplicantswillneedtodemonstratetheabilitytomeetthebroadrangeofneedspresentineachidentifiedpopulation.NotethatinsomeinstancesthesecapacitiesmaybedemonstratedbytheAEitself,orthroughitsrelationshipwithparticipatingMCOs.Toensurethatincentivesaremeaningfullyandadequatelysized,thiswillbeacompetitiveprogram,withstricterrequirementsforcertificationbeginninginyeartwo,therebylimitingthenumberofCertifiedAEs,subjecttoavailablefunding.Preliminaryevaluationandselectioncriteriaareasfollows:

• DemonstratedcommitmenttoEOHHSprioritiesandMedicaidpopulationsDemonstratedcapabilitiesandcapacitiestoservetheuniqueneedsoftheMedicaidpopulation,andtoaddressthegoalsandprioritiesdescribedinSection2.

• EvidenceofReadiness(Domains1-3)Specificevidenceofstronginterdisciplinarynetworkcapacity,andaneffectivegovernancemodelandleadershipteam.

• Data&AnalyticCapacity(Domain4)Demonstratedcapacitytocollect,integrateandutilizedatatosupportdecision-making.

• SystemTransformation(Domains5-8)Demonstratedcommitmentto,andcapacityfor,populationhealthandsystemtransformation,includingacomprehensive,integratedandinterdisciplinarycare

21

managementprogram,effectivememberengagementstrategiesandastrongqualitymanagementprogram.

FinalevaluationandselectioncriteriashallbeincludedintheAEapplication.

2. SpecializedAECertificationStandards:LTSSPilotCertifiedAETheobjectiveofanLTSSPilotAEwillbetobuildintegratedsystemsofcareinclusiveofacontinuumofservicesforpeople,asappropriate,tobeabletosafelyandsuccessfullyresideinacommunitysetting.Eligibleentitiesmustdemonstratereadinessacrossthefollowingdomains:

• Domain1:BreadthandCharacteristicsofParticipatingProvidersAdequatecapacityandpartnershipsacrosstheLTSScontinuumofcare,includingspecializedbehavioralhealthcarecapacity.MustincludeHomeandCommunityBasedCareProviders(e.g.,adultday,homecare,alternativelivingcapacity).MayincludeNursingFacilitieswhomeetminimumqualitystandards,haveahighshareofbedsdedicatedtoMedicaid,andexisting/plannedspecializedbehavioralhealthcapacity

• Domain2:Governance,LeadershipandManagementCapabilitiesSufficientcapabilitiestoaccomplishtheprogramgoals,enablesharedoperationalandfinancialresponsibility,andsupportqualitymeasurement/monitoring

• Domain3:IntegratedCareManagementMusthavesufficientcaremanagementprocessesandteamstosupportanintegratedapproachtoLTSS

• Domain4:ProgramCommitmentMustcommittoengageinalonger-termplanningprocesswithEOHHS

NotethatthePilotcertificationstandardsareintendedasastartingpointtoengageindividualprovidersinthechallengingtasksofpartnershipdevelopment.EOHHSanticipatestheremaybemultiplepilotLTSSAEswithdifferentcombinationsofparticipatingprovidersanddifferentgovernanceandcaremanagementmodels.SimilartotheComprehensiveAEprogram,EOHHSintendstoallowformultiplemodelsunderthepilotandwillleveragelearningsfromthepilottoestablishmorerigorousstandardsforfullimplementation.

Toensurethatincentivesaremeaningfullyandadequatelysized,thiswillbeacompetitivepilotprogram,withalimitednumberofselectedparticipants,subjecttoavailablefunding.

3.SpecializedAECertificationStandards:MedicaidPre-EligiblesPilotCertifiedAEsCertifiedComprehensiveAEsmayalsobeeligibletoparticipateintheMedicaidPre-EligiblesPilotprogramiftheymeetEOHHSspecifiedcriteria,tobedevelopedinthecomingmonths.ComprehensiveAEswhoarealreadyworkingwithMedicarepopulations(eitherthroughMedicareAdvantageorMedicareACOarrangements)arelikelytoprovidethefoundationforsuchaprogram.

22

VII. AlternativePaymentMethodologies FundamentaltoEOHHS’initiativeisprogressivemovementtoEOHHS-approvedAlternativePaymentMethodologies(APMs),incorporatingclearmigrationfromvolumebasedtovaluebasedpaymentarrangementsandmovementfromsharedsavingstoincreasedriskandresponsibility.TheAEinitiativewillbeimplementedthroughmanagedcare.AEsmustenterintomanagedcarecontractsinordertoparticipateinmemberattributionandsharedsavingswithinTCOCarrangements.TheseAEswillalsobeeligibletoreceiveinfrastructureincentivepaymentsfromtheirmanagedcarepartnerthroughtheHealthSystemTransformationProgram.AstheprimarycontractorwithEOHHS,theMCOswillretainaccountabilityforensuringcompliancewithallcontractualrequirementsandrelatedFederalmanagedcareregulations.ItisanticipatedthatsuccessfuldevelopmentofanAEwillincludeadefinedyetdynamicdistributionofresponsibilitiesbetweentheMCOandtheAE,andthatthesewillbeidentifiedinthewrittenagreementbetweentheparties.ThedistributionofrolesandresponsibilitiesmayvaryamongAEsandMCOstoachievethemosteffectivecombination.PerformanceofcertainfunctionscanbedelegatedtoasubcontractingAE,butdelegationwillbewiththeexpressedobligationtoabidebymanagedcareregulations.EOHHSiscommittedtomaintainingmemberchoicewithintheAEprogramstructure.Membersmusthaveaccesstotherightcare,attherighttime,andintherightsetting.AEproviderrelationshipsmaynotimpactmemberchoiceand/orthemember'sabilitytoaccessproviderscontractedoraffiliatedwiththeMCO.WhileAEbasednetworklimits,restrictionsandfeesareprohibited,MCOsandAEsmayencourageutilizationofpreferrednetworksprovidedthatrewardsorpositivefinancialincentivesusedarenominalandspecificallylinkedwithhealth-promotingplansofcare.AllincentivesandmethodsofencouragementofpreferrednetworksmustbeconsistentwithCMSrequirementsforMedicaid.6EOHHSisalsocommittedtoensuringthattheproposedAEwillnotlimitMedicaidbeneficiaryaccesstoprovidersonthebasisofAEattribution.Itisnottheintentoftheaccountableentityprogramtocreatenewsiloesofcarewithineachsystem.Inparticular,AEaffiliatedhospitalsand/orspecialistsmaynotinanywaylimitaccesstoonlyAEparticipatingproviders.QualifiedAPMcontractsshallbeinaccordancewithEOHHSdefinedAPMguidance.Thisguidanceshallbedeveloped:

• leveraginglearningsfromthecurrentpilotprogramguidancedocumentsasimplementedin2016,

• inalignmentwithFederalMACRArules,

6NextGenerationACOsummaryonCMSwebsite:https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/index.html.NextGenerationACORFA,whichincludessectiononbeneficiarycoordinatedcarerewards:https://innovation.cms.gov/Files/x/nextgenacorfa.pdf

23

• inalignmentwithRhodeIslandcommercialrequirementsasestablishedbytheOfficeoftheHealthInsuranceCommissioner,and,

• consideringpublicandstakeholderinput.NotethattheallowableAPMsdoNOTrequireachangetheunderlyingstructureofpaymentbetweentheMCOsandtheAEs.Participatingprovidersmaycontinuetogetpaidastheyalwayshave.Paymentmodelsthatmaintaintheexistingfee-for-servicestructure,withatotalcostofcareoverlay(therebycreatinganopportunityforsharedsavingsandriskbetweenpayorsandproviders)wouldqualifyasanAPM.EachofthethreeAEProgramswillspecifyqualifyingAPMsthatwillbebasedonaspecifiedpopulationofattributedlives,asdefinedinthetablebelow.Withintheserespectivepopulations,attributiontoanAEshallbeimplementedinaconsistentmannerbyallparticipatingMCOsbaseduponEOHHSdefinedguidance,tobedevelopedwithinputfromstakeholdersthisspringandsubmittedforapprovalbyCMS.

AEAttributablePopulations

Program AttributablePopulations1. ComprehensiveAEs Medicaid-onlyeligibles2. SpecializedLTSSAEs LTSSeligible,includingdualsandnonduals3. SpecializedMedicaidPre-EligiblesAEs Medicare-onlyeligible

ThespecifictermsofthesavingsandrisktransfertotheAEareatthediscretionofthecontractingparties.EOHHSdoesnotintendtostipulatethetermsofthesearrangementsbutexpectstheywilloperatewithintheboundsofEOHHSdefinedAPMGuidance.Inaddition,EOHHSdoesreservetherighttoreviewandapprovesucharrangements.7,8

AdditionalprogramspecificAPMrequirementsareasfollows:

1. ComprehensiveAEAlternativePaymentMethodology:TotalCostofCareManagedCareContractswithComprehensiveAccountableEntitiesmustbebasedontotalcostofcare(TCOC).TheseTCOCarrangementsshallsupersedeandbeexclusiveofanyotherTCOC-relatedsharedsavingsarrangementswithanAEoranyofitsconstituentproviders.Qualifiedtotalcostofcare(TCOC)contractsmustincorporatetheEOHHSQualityScorecard.Acomprehensivequalityscorefactor,basedontheQualityScorecard,mustbeappliedtoanysharedsavingsand/orriskarrangementswhencalculatingthetotalcostofcare.Adraftversion

7InadditiontothisEOHHSrequirement,notethatincertaincircumstancestransparencyinsucharrangementsisspecificallyrequiredinCFR42§438.6.8CMShasissuedguidanceforsharedsavingsprogramsforbothMedicaidandforMedicareSharedSavingsPrograms.Seehttps://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.htmlandhttps://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram

24

ofthisQualityScorecardhasbeenpostedforpubliccomment.ThefinalQualityScorecardwillbemodified,basedonstakeholderinput,andwillalignwiththequalitymeasuresforAccountableCareOrganizations(ACOs),whichwereendorsedbyRISIM.EOHHSanticipatesasteadyprogressionfromprocesstooutcomemeasureswithintheScorecard.

QualifiedTCOC-basedcontractualarrangementsmustalsodemonstrateaprogressionofrisktoincludemeaningfuldownsidesharedriskorfullrisk.Bytheendoftheanticipatedfive-yearwaiverperiodinOctober2021,infrastructurefundingwillbephasedout.AEswillbesustainedgoingforwardbasedontheirsuccessfulperformanceandassociatedfinancialrewardsinaccordancewiththeircontractwithMCOs.2.SpecializedLTSSPilotAE:LTSSBundleIdeally,participatingAEswouldberesponsibleforthetotalcostofcare.However,fordualeligiblepopulationsMedicareisprimaryformanyservices,withdifferentarrangementsdependingontheprogramstructure.Assuch,thisinterimAPMarrangementwillprojectthetotalcostofcareforservicesincludedwithintheidentified“bundle”ofLongTermServicesandSupportsfortheattributedpopulation.Thiscalculationwillprovidethebasisforcomparingactualfinancialexperiencewiththeprojectedfinancialexperience.Tostart,thisprogrammayalsoincludeaperformancebonusforPilotLTSSAEperformanceacrossasetofagreedupondimensions.GiventhatEOHHSanticipatessignificantchallengesinbothcapturingkeydataelementsandmeasuringperformanceacrosspopulations,EOHHSwouldlikelybeginwithapayforreportingperiodforsomecomponents.

3.SpecializedMedicaidPre-EligiblesPilotAEs EOHHSseesanimportantopportunityincreatingatargetedprogramtoaddressMedicaidpre-eligibles.PreviousstudiesofMedicaidmigrationpatternsforlongtermcarerecipientshereinRhodeIslandhaveshownthatmuchoftheextendedstaynursinghomepopulationisalreadyinanursinghomewhenbecomingeligibleforMedicaid,likelyhavingenteredanursinghomeandthenspentdowntheirassetsuntiltheybecameMedicaideligible.Thissuggeststhatstrategiesto“rebalance,”awayfromexpensivenursinghomesettingsandtowardmorecosteffectivecommunitybasedcarewouldbenefitfromamulti-payerapproach,asthesehighriskindividualsmustbeidentifiedwellbeforetheyspenddownassetsandbecomeMedicaideligible–beforetheyenteranursinghome.

AsthisprogramisnotslatedtobeginduringthisDYapprovalperiod,EOHHSintendstoworkwithinterestedentitiesinthecomingmonthstodevelopareportinganddatasharingarrangementthateffectivelyenablescombinedMedicareandMedicaidpopulationreportingandtrackingforpopulationstransitioningfromMedicaretoMedicaid.

25

VIII. MedicaidInfrastructureIncentiveProgram(MIIP)Beginninginlate2015,EOHHSbeganpursuingMedicaidwaiverfinancingtoprovidesupportforAEsbycreatingapooloffundsprimarilyfocusedonassistinginthedesign,developmentandimplementationoftheinfrastructureneededtosupportAccountableEntities.CMShasapprovedupto$129.8MillioninHSTPprogramfunds9.Anestimated$76.8MshallbeallocatedtotheAEProgram,subjecttoavailablefundscapturedinaccordancewithCMSapprovedclaimingprotocols,asshownbelow.UnderthetermsofRhodeIsland’sagreementwiththefederalgovernment,thisisnotagrantprogram.AEsmustearnpaymentsbymeetingmetricsdefinedbyEOHHSanditsmanagedcarepartnersandapprovedbyCMStosecurefullfunding.

AnAEProgramAdvisoryCommitteeshallbeestablishedbyEOHHS.ThiscommitteeshallbechairedbyEOHHS,withacommunityCo-ChairandshallincluderepresentationfromparticipatingMCOs,AEs,andcommunitystakeholdersandshall:

• SupportthedevelopmentofAEinfrastructurepriorities,• HelptargetMedicaidInfrastructureIncentiveProgramfundstospecificprioritiesthat

maximizeimpact• ReviewspecificusesoffundsbyeachAEandMCO,suchthatindividualAEProjectplans

aredesignedandimplementedtomaximumeffect• MonitorongoingMCO/AEprogramperformance• Supporteffectiveprogramevaluationandintegratedlearnings

DetailedguidanceforthisprogramshallbesetforthbyEOHHS,withassistancefromtheAEProgramAdvisoryCommittee,inthefinalHSTPGuidelinesforHealthSystemTransformationProjectPlans.Draftguidanceshallbeposted,commentsreceivedwillbereviewed,anddocumentswillberevisedinconsiderationofpubliccommentsbeforefinalsubmissiontoCMSforapproval.

A. ProgramStructureTheMedicaidInfrastructureIncentiveProgram(MIIP)shallconsistofthreecoreprograms:(1)ComprehensiveAEProgram;(2)SpecializedLTSSAEPilotProgram;and(3)SpecializedPre-eligiblesAEPilotProgram.EOHHSshallallocateavailableHSTPfundstothesethreeprogramsasfollows,subjecttoavailablefundsandEOHHSidentificationofpriorityareasoffocusand

9ThecurrentRhodeIsland1115Waiverisa5-yeardemonstration,endingin2018.TheSTCsincludeDSHPfundingauthoritythrough2018,withacommitmentarticulatedinthecoverlettertoextendthisauthoritythru2020uponwaiverrenewalforatotalfundingopportunityof$129Million.

26

assessmentofreadiness.Thisallocationshallberevisitedannually.

AEProgramsShareofAvailableAEFunds

ProgramYear1 FullProgramComprehensiveAEProgram 60-70% 60%-70%SpecializedLTSSPilotAEProgram 30-40% 25%-35%SpecializedPre-eligiblesPilotAEProgram 5%-15%

ForeachMCOtheMIIPshallincludethreedimensions:

1. MaximumTotalIncentivePool(TIP)forMCOsThemaximumTIPforeachMCOshallbedeterminedbyEOHHSwithconsiderationtotheMCOshareofAEattributedlivesinaccordancewithEOHHSdefinedattributionguidelinesandassociatedreports.

2. MCOIncentiveProgramManagementPool(MCO-IMP)AssumingsatisfactoryMCOperformance,theMCOIncentiveProgramManagementPoolshallminimallybefivepercent(5%)oftheTotalIncentivePool.TothedegreethattheMCOhasmorethantheminimallyrequirednumberofcontractswithAEs,theMCO-IMPshallbeincreasedbyonepercentforeachAEcontracttoamaximumofeightpercent.Thesefundsareintendedforusetowardadvancingprogramsuccess,includingprogramadministrationandoversight,assistingwiththedevelopmentofthenecessaryinfrastructuretosupportanewbusinessmodel,andestablishingsharedresponsibilities,informationrequirementsandreportingbetweenEOHHS,theMCOandtheAccountableEntities.

3. AccountableEntityIncentivePool(AEIP)TheAccountableEntityIncentivePoolshallequaltheTotalIncentivePoolminustheMCOIncentiveProgramManagementPool(AEIP=TIP–MCO-IMP).Thispoolshallbedividedintothethreedistinctprogramsasspecifiedabove.IndevelopingcontractswithAEs,MCOsshallproposeAEInfrastructurePaymentCriteriaandMethodologyforEOHHSreviewandapprovalthatareconsistentwithEOHHSdefinedguidance.ThisshalldeterminethetotalannualamountandscheduleofincentivepaymentseachparticipatingAEmaybeeligibletoreceivefromtheAccountableEntityIncentivePool.

27

3a.AccountableEntitySpecificIncentivePoolsCertifiedAEsinqualifiedAlternativePaymentMethodology(APM)contractsconsistentwithEOHHSguidancemustbeeligiblefortheMedicaidInfrastructureIncentiveProgram.EachMCOmustcreateanAEIncentivePoolforeachCertifiedAEtoestablishthetotalincentivedollarsthatmaybeearnedbyeachAEduringtheperiod.ThePoolcalculationshallincludeabaseamountplusapmpmcomponentbasedonattributedlivesatthestartofeachcontractyearinaccordancewithEOHHSdefinedguidance.AnexampleofanAEIncentivePoolcalculationforasampleAEisshownbelow–pleasenotethenumbersshownhereareillustrativeonly.AE#1IncentivepoolYear1:IllustrativeExampleCalculationAE1has15,000attributedlives,10,000arewithMCO1,and5,000withMCO2PaymentsfromeachMCOarefordistinctattributedpopulationsandthereforenotduplicative.

3b.PerformanceBasedIncentivePaymentsAEsmustdevelopindividualHealthSystemTransformationprojectplansthatidentifyclearprojectobjectivesandspecifytheactivitiesandtimelinesforachievingtheproposedobjectives.ActualAEIPincentivepaymentamountstoAEswillbebasedondemonstratedAEperformance.IncentivepaymentsactuallyearnedbytheAEmaybelessthantheamounttheyarepotentiallyeligibletoearn.MCOsshallnotbeentitledtoanyportionoffundsfromtheAccountableEntityIncentivePoolthatarenotearnedbytheAE.

ReconciliationInadvanceoftheMCOspaymentstoAEs,theMCOshallreceivepaymentfromEOHHSintheamountandscheduleagreeduponwithEOHHS.AnyIncentiveProgramfundsthatarenotearnedbyEOHHSCertifiedAEsasplannedduringagivencontractyearshallbetrackedandretainedbytheMCOexclusivelyforfutureAccountableEntityIncentivePoolusesduringthefollowingcontractyear.AnyfundsnotearnedduringthefollowingcontractyearshallbereturnedtoEOHHSwithinthirtydaysofsuchrequestbyEOHHS.AnAE’sfailuretofullymeetaperformancemetricwithinthetimeframespecifiedwillresultinforfeitureoftheassociatedincentivepayment(i.e.,nopaymentforpartialfulfillment).AnAEthatfailstomeetaperformancemetricinatimelyfashioncanearntheincentivepaymentatalaterpointintime(nottoexceedoneyearaftertheoriginalperformancedeadline)byfullyachievingtheoriginalmetricincombinationwithtimelyperformanceonasubsequentrelatedmetric.

28

B. ProgramSpendingGuidanceIncentiveProgramfundsaredesignedtobeusedbyAEstoprepareprojectplansandtobuildthecapacityandtoolsrequiredforeffectivesystemtransformation.AllowableexpendituresmustalignwithEOHHSprogrampriorityareasandshallbedistributedbytheMCOstotheAEsindesignatedperformanceareas.

AllowableAreasofExpenditureAllowableusesoffundsincludethefollowingthreecoreareasandeightdomains.Costsmustbereasonableforservicesrendered.

Domains AllowableUsesofFunds AllowableExpenditureMix

Yr1 Yr2-3 Yr4

A.Readiness <50% <25% <10%

1. BreadthandCharacteristicsofParticipatingProviders

• Buildingproviderbase,populationspecificprovidercapacity,interdisciplinarypartnerships,developingadefinedaffiliationwithcommunitybasedorganizations(CBOs)

• Developingfullcontinuumofservices,IntegratedPH/BH,Socialdeterminants

2. CorporateStructureandGovernance

• Establishingadistinctcorporation,withinterdisciplinarypartnersJoinedinacommonenterprise

3. LeadershipandManagement

• Establishinganinitialmanagementstructure/staffingprofile• DevelopingabilitytomanagecareunderTotalCostofCare(TCOC)

arrangement,withincreasedriskandresponsibility

B.ITInfrastructure 30% 30% 30%

4. DataAnalyticCapacityandDeployment

• Buildingcoreinfrastructure:EHRcapacity,patientregistries,CurrentCare• Provider/caremanagers’accesstoinformation:Lookupcapability,medication

lists,sharedmessaging,referralmanagement,alerts• Patientportal• Analyticsforpopulationsegmentation,riskstratification,predictivemodeling• Integratinganalyticworkwithclinicalcare:Clinicaldecisionsupporttools,early

warningsystems,dashboard,alerts• Staffdevelopmentandtraining–individual/teamdrilldownsre:conformance

withacceptedstandardsofcare,deviationsfrombestpractice

AllowableAreasofExpenditure

EOHHSProgramPriorities

PerformanceAreas&

Milestones

29

C. SystemTransformation 20% 45% 70%

5. CommitmenttoPopulationHealthandSystemTransformation

• Developinganintegratedstrategicplanforpopulationhealththatispopulationbased,datadriven,evidencebased,clientcentered,recognizesSocialDeterminantsofHealth,teambased,integratesBH,IDsriskfactors

• Healthcareworkforceplanningandprogramming

6. IntegratedCareManagement

• SystematicprocesstoIDpatientsforcaremanagement• DefinedCoordinatedCareTeam,withspecializedexpertiseandstafffordistinct

subpopulations• Individualizedpersoncenteredcareplanforhighriskmembers

7. MemberEngagementandAccess

• Definedstrategiestomaximizeeffectivemembercontactandengagement• Useofnewtechnologiesformemberengagement,healthstatusmonitoring

andhealthpromotion

8. QualityManagement

• Definedqualityassessment&improvementplan,overseenbyqualitycommittee

EOHHSanticipatesthatspendingmaybeheavilyweightedtowardtheReadinessCoreArea(domains1-3)inyearone,asAEsbuildthecapacityandtoolsrequiredforeffectivesystemtransformation.However,overtimetheallowableareasofexpenditurewillberequiredtoshifttowardsystemtransformation(domains5-8).Apreliminaryallowablemixofexpendituresisshownabove.ProgramPrioritiesEachMCO’sAEIncentivePoolbudgetandactualspendingmustalignwiththeprioritiesofEOHHSasdevelopedwiththesupportoftheAdvisoryCommitteeandshownbelow.Note:Thisisadraftsetofpriorities–afinalsetofprioritiesshallbereviewedandconfirmedbytheAdvisoryCommittee,andspecifiedinthefinalAPMguidancedocument.Program Priorities

ComprehensiveAEs

• Planningandcoreinfrastructuredevelopment• Medicalenhancements:enhancedsystemsofcare,workforcedevelopment

o Forchildreno ForAdults

• Integrationandinnovationinbehavioralhealthcareo Forchildreno ForAdults

• IntegrationandinnovationinSUDtreatment• Integrationandinterventioninsocialdeterminants,includingcrosssystemimpacts

SpecializedPilotLTSSAEs

• Buildingpartnerships,includinggovernance,leadershipandfinancialarrangements,betweenLTSSproviders.

• Developingprogramsandcarecoordinationprocessestowardseffectiveandtimelycaretransitionsandreducedinstitutional/EDutilization

• Repurposingskillednursingcapacityforacutepsychiatrictransitionsand/oradultdaycapacity

30

• HomeandCommunitybasedBehavioralHealthcapacitydevelopmentforbehavioralhealthspecializedadultdaycare,homecare,andalternativelivingarrangements.

SpecializedMedicaidPre-EligiblesAEs

• Developingprocesses,toolsandprotocolsforidentificationofatriskMedicaidpre-eligiblepopulations

• Developingeffectiveandtimelyinterventionstosupportcommunitybasedcareforthesepopulations.EOHHSiscommittedtoworkingwiththeseentitiestodefineanddevelopopportunities(mechanismstopayfor)forthespecificservicesneededforidentifiedMedicaidpre-eligiblepopulationsthatmaynotcurrentlybeMedicarecoveredservices–e.g.,homebasedprimarycare,palliativecare,communityhealthworkers,etc.

PerformanceAreasAEsmustdevelopAESpecificHealthSystemTransformationProjectPlans.TheseplansshallspecifytheperformancethatwouldqualifyanAEtoearnincentivepayments.EarnedfundsshallbedistributedbytheMCOtotheAEinaccordancewiththedistributionbyperformanceareadefinedintheAEspecificHealthSystemTransformationPlan,consistentwiththerequirementsdefinedbelow:

PerformanceArea MinimumMilestones Year1 Year2 Year3 Year4

PlanningandDesign

• InitialWorkplan&budgetfordevelopinganAEProjectPlan,includingcompletedEOHHSBudgetTemplate

• DetailedAEGapAnalysis,withspecifiedimpactsbydomainandpopulation

70% 15% 0% 0%

DevelopmentalMilestones

• DetailedHealthSystemTransformationProjectPlan,includingproposedInfrastructureDevelopmentBudgetbyProject,Domainandpopulation,inaccordancewithstatespecifiedtemplate

• QuarterlyProgressReportinaccordancewithstatedefinedtemplate

• Quarterlyfinancialreport,inaccordancewithstatedefinedtemplate,includingdocumentedevidenceofexpenditures

• DevelopmentalmilestonesMCO/AEDefined(atleast3uniquedevelopmentalmilestonesperyear)

30% 85% 75% 50%

Valuebasedpurchasingmetrics

• DemonstratedAPMProgression• MarginalRiskRequirements• Minimumrequiredshareofmarginalriskfor

whichtheAEisliable,inaccordancewithEOHHSdefineAPMguidelines

0% 0% 20% 30%

SystemPerformanceMetrics

• PreventableAdmissions• Readmissions• AvoidableEDUse

0% 0% 5% 10%

31

• MCO/AESpecificPerformanceTargets(upto3)

FinalDeliverable 0% 0% 0% 10%

TheearlymilestonesareintendedtoallowAEstodevelopthefoundationaltoolsandhumanresourcesthatwillenableAEstobuildcorecompetenciesandcapacity.InaccordancewithEOHHS’agreementwithCMS,participatingAEsmustfullymeetmilestonesestablishedintheAEspecifichealthsystemtransformationplanpriortopayment.EOHHSrecognizesthefinancialconstraintsofmanyparticipatingAEs,andthattimelypaymentfortheachievementofearlymilestoneswillbecriticaltoprogramsuccess.TheseAE-specificHSTPprojectplansmayonlybemodifiedwithstateapproval.EOHHSmayrequirethataplanbemodifiedifitbecomesevidentthattheprevioustargeting/estimationisnolongerappropriateorthattargetsweregreatlyexceededorunderachieved.C.ImplementationandOversightAsdescribedabove,theMedicaidInfrastructureIncentiveProgram(MIIP)includesEOHHSprogrampriorityareas,allowableareasofexpenditure,andAEspecificperformanceareasthatqualifyanAEtoearnincentivepayments.WiththeassistanceoftheAdvisoryCommitteeEOHHSwilldevelop“EOHHSGuidelinesforHealthSystemTransformationProjectPlans”thatwillfurtherspecifyeachoftheseprogramelements.ThisguidancewilldefinespecificimplementationrequirementsthatmustbeadheredtobyAEsandMCOstoensurethatincentiveprogramsaredesignedandimplementedtomaximumeffect.Threekeyelementsoftheseimplementationrequirementstobefurtherstipulatedintheguidelinesareasfollows:1. SpecificationsRegardingAllowableHSTPProjectPlans

Specificationsshalldelineateadditionaldetailsregarding:• CoreGoals• AllowablePriorityareas• AllowableAreasofExpenditure• RequiredPerformanceAreas• Characteristicsofapprovableprojectplans:

o Approvableprojectplansmustdemonstratehowtheprojectwilladvancethecoregoalsandidentifyclearobjectivesandstepsforachievingthegoals.

o Approvableprojectplansmustsettimelinesanddeadlinesforthemeetingofmetricsassociatedwiththeprojectsandactivitiesundertakentoensuretimelyperformance.

2. MCOReviewCommitteeGuidelinesforEvaluationTheMCOshallconveneareviewcommitteetoevaluateeachproposal.EOHHSshallhavea

32

designeethatparticipatesontheMCOsubmissionevaluationcommitteetoensurethestate’sengagementintheprocesstoevaluatetheprojectplanandassociatedrecommendationsforapprovalordisapproval. TheMCOReviewCommittee,inaccordancewithEOHHSguidelines,shalldeterminewhether:• Projectassubmittediseligibleforaward

EligibleprojectswillincludeaprojectplanthatclearlyaddressEOHHSpriorityareasandclearlyincludesthetypesofactivitiestargetedforfunds.

• ProjectmeritsIncentiveFundingProjectsmustshowappropriatenessforsubmissionforthisprogrambyincludingthefollowing:o Clearstatementofunderstandingregardingtheintentofincentivedollarso Rationaleforthisincentiveopportunity,includingacleardescriptionofobjectivefor

theprojectandhowachievingthatobjectivewillpromotehealthsystemtransformationforthatAE

o Confirmationthatprojectdoesnotsupplantfundingfromanyothersourceandisnon-duplicativeofsubmissionthatmaybemadetoanotherMCO

o Highqualityproposalthatincludesagapanalysis,explainshowtheworkplanandbudgetaddressesthesegaps,anddescribestheAE’scurrentstrengthsandweaknessesinthisarea

o Clearinterimandfinalprojectmilestonesandprojectedimpacts,aswellascriteriaforrecognizingachievementofthesemilestonesandquantifyingtheseimpacts

• IncentiveFundingrequestisreasonableandappropriateThefundingrequestmustbereasonablefortheprojectidentified,withfundsclearlydedicatedtothisproject.Thelevelandapportionmentoftheincentivefundingrequestmustbecommensuratewithvalueandlevelofeffortrequired.

3. RequiredStructureforImplementationTheIncentiveFundingRequestmustbeawardedtotheAEviaaContractAmendmentbetweentheMCOandtheAE.TheContractAmendmentshall:• BesubjecttoEOHHSreviewandapproval• IncorporatethecentralelementsoftheapprovedAEsubmission,including:

- Stipulationofprogramobjective- Scopeofactivitytoachieve- Performanceschedule- Paymentterms–basisforearningincentivepayment(s)commensuratewiththe

valueandlevelofeffortrequired.• DefineareviewprocessandtimelinetoevaluateprogressanddeterminewhetherAE

performancewarrantsincentivepayments.TheMCOmustcertifythatanAEhasmetitsapprovedmetricsasaconditionforthereleaseofassociatedHealthSystemTransformationProjectfundstotheAE.

• MinimallyrequirethatAEsmustsubmitsemi-annualreportstotheMCOusingastandardreportingformtodocumentprogressinmeetingqualityandcostobjectives

33

thatwouldentitletheAEtoqualifytoreceiveHealthSystemTransformationProjectpayments,andthatsuchreportswillbeshareddirectlybytheMCOwithEOHHS.

• StipulatethattheAEmustearnpaymentsthroughdemonstratedperformance.TheAE’sfailuretofullymeetaperformancemetricunderitsAEHealthSystemTransformationProjectPlanwithinthetimeframespecifiedwillresultinforfeitureoftheassociatedincentivepayment(i.e.nopaymentforpartialfulfillment).

• ProvideaprocessbywhichanAEthatfailstomeetaperformancemetricinatimelyfashion(andtherebyforfeitstheassociatedHealthSystemTransformationProjectPayment)canreclaimthepaymentatalaterpointintime(nottoexceedoneyearaftertheoriginalperformancedeadline)byfullyachievingtheoriginalmetricincombinationwithtimelyperformanceonasubsequentrelatedmetric.

34

IX. ProgramMonitoring,Reporting,&EvaluationPlan RhodeIslandhasanestablishedtrackrecordofexpansionsandimprovementstoitsmanagedcareprogramsaswellasasystematicandactiveprogramofoversightofourcontractedMCOs.ThedevelopmentoftheAccountableEntitiesprogramprovidesanewandsignificantopportunitytofurthertransformtheperformanceofourdeliverysystemsandimprovehealthoutcomesforRhodeIsland’sMedicaidpopulation.RhodeIslandinitiateditsfirstmanagedcareprogramin1994withtheenrollmentofchildrenandfamiliesintoitsRIteCareprogram.IntheyearsfollowingtherehavebeenmanychangesinthestructureoftheprogramsothatitnowincludesthelargemajorityofMedicaidcoveredbeneficiaries,abroadrangeofMedicaidcoveredserviceswithveryfewservice“carveouts”,andanarrayofprograminitiativesintendedtoadvanceprogrameffectivenessandcostefficiencies.Ateachstepalongthewaywehaveadaptedandexpandedourprogramoversightactivitiestopromotehighqualityperformanceandensureprogramcompliance.RhodeIsland’sAccountableEntityprogramisdesignedtoworkwithinandinpartnershipwithourmanagedcareprogram.CertificationofAEsisperformeddirectlybyEOHHS,establishingtheireligibilitytoparticipateintheprogram.Annualcertificationensurescontinuedcompliancewithrequirementstoretaineligibility.EligibleAEswillthencontractwithmanagedcareorganizationswithintherequirementssetforthbyEOHHS.AstheprimarycontractorswithEOHHS,theMCOswillbedirectlyaccountablefortheperformanceoftheirsubcontractors.EOHHSisresponsibleforoverseeingcomplianceandperformanceoftheMCOsinaccordancewithEOHHScontractualrequirementsandfederalregulation,includingperformanceofsubcontractors.TheAEprogram,AEperformance,andMCO-AErelationswillbeintegratedintoexistingEOHHSmanagedcareoversightactivities.ForthisinitiativeEOHHSwillbuilduponandenhanceitsprogrammonitoringandoversightactivitiesinthefollowingfourkeyareas,eachofwhichisdescribedbelow:

1. MCOComplianceandPerformanceReportingRequirements2. In-PersonMeetingswithMCOs3. StateReportingRequirements4. EvaluationPlan

1.MCOComplianceandPerformanceReportingRequirementsUndercurrentcontractarrangements,MCOssubmitregularreportstoEOHHSacrossarangeofoperationalandperformanceareassuchasaccesstocare,appealsandgrievances,qualityofcaremetrics,consumerexperience,programoperationsandothers.EOHHSreservestherighttoreviewperformanceinanyareaofcontractualperformance,includingflowdownrequirementstoAccountableEntitysubcontractors.

35

Forthisinitiative,MCOreportingrequirementsthathavemoretypicallybeenprovidedbytheMCOsandreviewedbyEOHHSattheplan-levelwillbeextendedtoalsorequirereportingattheAElevel.AmenuofmetricsandmeasuresthatwillbeusedbytheMCOstoassesstheperformanceoftheAEsandthatwillbereportedtoEHOHHSwillbefurtherspecifiedinthefinalAPMguidancedocument. AreasofcurrentreportingthatareunderreviewasrequirementsforMCOstoreportondataaggregatedattheAccountableEntitylevelinclude:

MCORequiredReports Description

1. ProviderAccessSurveyReport

ReportcompletedbyeachHealthPlanbythefollowingprovidertypes:primarycare,specialtycare,andbehavioralhealthforroutineandurgentcare.ThisreportmeasureswhetherappointmentsmadearemeetingMedicaidaccessibilitystandards.

2. ProviderPanelReport AreportofwhichproviderpanelsbyeachHealthPlanareatcapacityand/orclosedtoenrollees.

3. AppealandGrievanceReport

AnaggregatereportofclinicalandadministrativedenialsandappealsbyeachHealthPlan,includingExternalReview.

4. InformalComplaintReport

Anaggregatereportoftheclinicalandadministrativecomplaintsspecifiedbycategoryandmajorprovidersub-groupsforeachHealthPlan

5. AccountableEntitySharedSavingsReport

ThisfinancialreportisincludedaspartofeachHealthPlan’srisksharereportandprovidesfinancialdataandinformationastohoweachAccountableEntityisperformingrelativetotheirtotalcostofcarebenchmark.

6. QualityScorecard ThisreportconsistsofthesetofNCQAHEDISandotherclinicalandqualitymeasuresthatareusedtodeterminethequalitymultiplierfortotalcostofcare.

7. MCOPerformanceIncentivePoolReport

DetailedbudgetedandactualMCOexpendituresinaccordancewithEOHHSdefinedtemplates

Inadditiontoenhancementofcurrentreports,theMedicaidMCOswillberequiredtosubmitreportsonaquarterlybasisthatdemonstratetheirperformanceinmovingtowardsvaluebasedpaymentmodels,including:

• AlternatePaymentMethodology(APM)DataReport• ValueBasedPaymentReport

PertainingmoredirectlytoAEprogramoperations,theMedicaidMCOswillberequiredtosubmitAccountableEntityspecificreports,includingthefollowing.

• AEAttributedLivesThisquarterlyreportwillprovideEOHHSwiththenumberofMedicaidMCOlivesattributedtoeachspecificAccountableEntityaswellasintotal.

• AEPopulationExtractFileThismonthlyreportwillprovideEOHHSwithamemberleveldetailedreportofallMedicaid

36

MCOmembersattributedtoeachAE.ThisdatawillbeusedbyEOHHSfordatavalidationpurposesaswellasforthepurposesofad-hocanalysis.

• AEParticipatingProviderRosterThismonthlyproviderreportwillprovideEOHHSwithanongoingrosteroftheAEprovidernetwork,inclusiveofprovidertype/specialtyandaffiliation(participating,affiliated,referraletc.)totheAccountableEntity.

2. In-PersonMeetingswithMCOsAspartofitsongoingmonitoringandoversightofitsMCOs,EOHHSconductsanin-personmeetingonamonthlybasiswitheachcontractedMCO.Thesemeetingsprovideanopportunityforamorefocusedreviewofspecifictopicsandareasofconcerns.Additionally,theyprovideavenueforareviewofmoredefinedareasofprogramperformancesuchasquality,finance,andoperations.DuringtheinitialpilotphasewithcomprehensiveAEsandastheprogrammovesforward,thesemeetingsprovideanimportantforumtoidentifyandaddressstatewideAEperformance,emergingissues,andtrendsthatmaybeimpactingtheAEprogram.Inadditiontothereportingnotedabove,thesemeetingssupportEOHHS’abilitytoreporttoCMS(inquarterlywaiverreports)issuesthatmayimpactAE’sabilitiestomeetmetricsoridentifyfactorsthatmaybenegativelyimpactingtheprogram.InsupportofdiscussiononAEsatthesemeetings,MCOswillberequiredtosubmitreportsonsuchareasas:• AdescriptionofactionstakenbytheMCOtomonitortheperformanceofcontractedAEs• ThestatusofeachAEundercontractwiththeMCO,includingAEperformance,trends,and

emergingissues• AdescriptionofanynegativeimpactsofAEperformanceonenrolleeaccess,qualityofcare

orbeneficiaryrights• Amitigation/correctiveactionplanifanysuchnegativeimpactsarefound/reported

MonthlymeetingswithMCOsprovideastructuredvenueforoversight.Atthesametime,EOHHScommunicationswithMCOstakeplacedailyonavarietyoftopics.AdditionalmeetingstoaddressparticularareasofconcernthatmayarisearearoutinepartofEOHHS’oversightactivities.RhodeIsland’ssmallsizegreatlyfacilitatestheseinpersoninteractionswithbothMCOsandAEs.3. StateReportingRequirementsThestatewillincorporateinformationabouttheHealthSystemTransformationwaiveramendmentintoitsexistingrequirementsforwaiverreports,includingquarterly,annual,andfinalwaiverprogramreports,andfinancial/expenditurereports.Inaddition,thestateshall

37

supplyseparatesectionsofsuchreportstomeetthereportingrequirementsintheSTCsthatarespecifictotheHealthSystemsTransformationwaiveramendment.ThestatewillprovidequarterlyexpenditurereportstoCMSusingFormCMS-64toreporttotalexpendituresforservicesprovidedthroughthisdemonstrationundersection1115authoritysubjecttobudgetneutrality.Thisprojectisapprovedforexpendituresapplicabletoallowablecostsincurredduringthedemonstrationperiod.CMSshallprovideFFPforallowabledemonstrationexpendituresonlyaslongastheydonotexceedthepre-definedlimitsontheexpendituresasspecifiedinSectionXVIoftheSTCs.

ThestatewillalsoseparatelyreporttheseexpendituresbyquarterforeachFFYontheFormCMS-37(narrativesection)forallexpendituresunderthedemonstration,includingHSTPProjectPayments,administrativecostsassociatedwiththedemonstration,andanyotherexpendituresspecificallyauthorizedunderthisdemonstration.Thereportwillinclude:

• AdescriptionofanyissueswithinanyoftheMedicaidAEsthatareimpactingtheAE’sabilitytomeetthemeasures/metrics.

• Adescriptionofanynegativeimpactstoenrolleeaccess,qualityofcareorbeneficiaryrightswithinanyoftheMedicaidAEs.

4. EvaluationPlanEOHHSwilldraftanEvaluationPlan,whichwillincludeadiscussionofthegoals,objectives,andevaluationquestionsspecifictotheentiredeliverysystemreformdemonstration.KeyareasofattentionintheevaluationwilltietothegoalsandobjectivessetforthinthisRoadmap,asspecifiedinSectionII.ThedraftEvaluationPlanshalllisttheoutcomemeasuresthatwillbeusedinevaluatingtheimpactofthedemonstrationduringtheperiodofapproval,particularlyamongthetargetpopulation.TheEvaluationPlanwillincludeadetaileddescriptionofhowtheeffectsofthedemonstrationwillbeisolatedfromotherinitiativesoccurringwithinthestate(i.e.,SIMgrantactivities).ThedraftEvaluationPlanwillincludedocumentationofadatastrategy,datasources,andsamplingmethodology.ThestatewillissueanRFP,basedontheCMS-approvedevaluationplan,foraqualifiedindependententitytoconducttheevaluation.TheEvaluationPlanwilldescribetheminimumqualificationsoftheevaluationcontractor,abudget,andaplantoassurenoconflictofinterest.ThestateplanstosubmitanInterimEvaluationReportoftheAccountableEntitiesprogramtoCMSby90calendardaysfollowingthecompletionofDY4.ThepurposeoftheInterimEvaluationReportistopresentpreliminaryevaluationfindingsanddescribeplansforcompletingtheevaluationplan.ThestatealsoplanstosubmitaFinalEvaluationReportafterthecompletionofthedemonstration.

38

AppendixA:DRAFTCertificationStandardsNote:TheseareDRAFTcertificationstandardsaspostedpubliclyonDecember27,2016.EOHHSreceivedmanyvaluablecommentsandfeedbackonthesestandardsthathavenotyetbeenincorporated.EOHHS’expectationisthattheAEshallbestructuredandorganizedtoassureitscommitmenttotheobjectivesandrequirementsofanEOHHScertifiedAccountableEntityanddemonstrateitsabilitytoprovidecareforeachpopulationitproposestoserve.Applicantsarerequiredtoidentifythepopulationstheyproposetoserve–children,adults,orboth.CertificationbyEOHHSwillbespecifictoeachpopulationandbasedontheparticularqualificationstomeetrequirementsforeachpopulation.SummaryofDomainsforCertification:1. BreadthandCharacteristicsofParticipatingProviders2. CorporateStructureandGovernance3. LeadershipandManagement4. CommitmenttoPopulationHealthandSystemTransformation5. ITInfrastructure–DataAnalyticCapacityandDeployment6. IntegratedCareManagement7. MemberEngagementandAccess8. QualityManagementWithineachofthedomainsconsiderableattentionisgiventotheintegrationofactivitiesfocusedonsocialdeterminants.AEsareexpectedtoworkdirectlywithpartnerorganizationstoaddresssocialdeterminantsneedswithinacareplan.1. BreadthandCharacteristicsofParticipatingProvidersAnAEneedstohaveacriticalmassofeitherPartnerProvidersorAffiliatedProvidersthataremulti-disciplinarywithcoreexpertise/directservicecapacityinprimarycare,behavioralhealth,socialsupports/determinantsforthepopulationstheAEproposestoserve.Anapplicationwillneedtoexplainwhoarethepartners,theroleofthepartners,andthecoreoftheAEdeliverysystem.TheAEmusthaveabaseattributableMedicaidpopulationof5,000members,basedonPCPassignmentofrecordwithintheMCOorassignmenttoanIHHasreportedbyBHDDH.ForanypopulationthatistobeattributedtotheAE,theapplicantmusthavethecapabilitytoaddressandcoordinatetheneedsofpopulationsatalllevelsandtheabilitytocoordinateanddirectasignificantportionofcareforthosepopulations.AEsshouldnotonlyhaveastrongfoundationinprimarycarebutalsobeabletoeffectivelycoordinatecarebeyondthescopeofPCPmedicalcare.

39

Amajorobjectiveofthisinitiativeisthatparticipantsbeabletodefinemethodsofcareforpeoplewithhighendneeds,includingco-occurringchronicconditions,andpersonswithco-occurringphysicalandbehavioralhealthneeds.AsuccessfulAEwillbeabletorecognizeandaddresshighriskandrisingriskindividualsandimprovecareatpointsoftransitionfromhigherlevelsofcaretolessintensivelevelsofcare.1.1. ProviderBase

1.1.1. CriticalMass,aseitherPartnerProvidersorAffiliatedProviderstoqualifyforattribution

1.1.1.1. Attribution:AcomprehensiveAEmusthaveabaseattributableMedicaidpopulationof5,000members.

1.1.2. PopulationspecificAEapplication:Children,adults,duals/seniors1.1.3. DescriptionoftypesofmemberprovidersandtheirrelationshiptotheEntity:

Partnervs.affiliatevsassociated/contractedproviders.Certificationthatallidentifiedprovidersarewillingtoparticipatein,andbeaccountableforhealthcaretransformationefforts,includinguseofatotalcostofcarebasedAlternativePaymentMethodology.

1.1.3.1. PartnerProvidersarethecoreorganizationalpartnersintheAE,withvotingrightsontheAE,whoparticipateinsharedsavings,movementtorisk,participateinmutual requirementsandprotocolsforcollaborativepractice(e.g.datasharing,caremanagement)topromoteandsupportintegratedcareand,asapplicable,arerecognized providersinattributionmethodologies.

1.1.3.2. AffiliateprovidersalthoughnotnecessarilyrepresentedasvotingmembersoftheAE,arepartofthedirectcapacitytheAEbringstotheorganizationofcare,havemeaningfuldirectparticipationinsharedsavingsarrangementsandprogressiontorisk,andparticipatein mutualrequirementsandprotocolsforcollaborativepractice(e.g.datasharing,caremanagement)topromoteandsupportintegratedcare,andasapplicable,arerecognizedprovidersinattributionmethodologies.

1.1.3.3. AssociateProvidershavereferralandworkingrelationshipswithAEPartnersorAffiliatesbutdonotparticipateinsharedsavingsorasabasisforattribution.

1.1.4. Multi-disciplinary,withdirectservicecapacityinprimarycare,BH,includinghighendbehavioralhealthservices,andinservicestoaddresssocialdeterminantsofhealth

1.1.5. Definedaffiliation,workingarrangementswithCBOs,suchasHealthEquityZoneparticipants,toaddressbroadersocialcontextsimpactinghealth,outcomes.FordifferentpopulationsTable2belowindicatescommunitybasedservicesthatcanhavecriticalimpactsinpromotingimprovedhealthoutcomes.

40

Table2:PopulationFocusedCommunityBasedServicesPopulation CommunityBasedServicesDuals/Individuals with Disabilities Requiring LTSS

- Housing - Nutrition - Employment supports - Self-care education - Assistance with ADLs and IADLs - Homemaker - Home health aide - PCA - Adult day health - Habilitation - Caregiver respite services - Assistive technology and home modifications

Adults-SMI/SPMI

- Housing - Nutrition - Employment supports - Self-care education - Navigators - Peer supports - Assistive technology and home modifications if

appropriate - Host home/Foster care - Group home - Adult day services - Financial support services - In-home supports if appropriate - Caregiver respite services

Children - Pediatric providers consistent with access standards - BH specialists in child and adolescent behavioral health - Coordination with relevant social service agencies and

providers including schools - Specialists as appropriate and necessary - DME providers as appropriate and necessary - Coordination of Medicaid and Medicare services for duals

only - Adaptive medical equipment - Parental support groups - Recreational activities - Early intervention - Family counseling/training

DevelopmentallyDisabled - Supported living services (individualized supports in a home setting based on needs and preferences.

o Can include up to 24 hours of care, supervision and training for up to five individuals with DD)

- Host home/Foster care - Group home - Adult day services - Financial services - In-home supports - Caregiver respite services - Assistive technology and home modifications - Adaptive medical equipment - Housing - Nutrition - Employment supports - Self-care education - Navigators - Peer support

41

1.2. AbilitytocoordinateforAllLevelsofNeedforanyAttributedpopulation1.2.1. DemonstratethattheAEeitherdirectlyprovidesoriscontractedwith

organizationscapableofmeetingallAErequirementstodeliverthefullcontinuumofAEservices.

1.2.1.1. PhysicalHealth:servicedelivery/coordinationcapacitybeyondthescopeofPCPmedicalcare.Forprimarycare,participantsachievePCMHrecognition(NCQALevel3)foratleast50%oftheAE’sattributedmembership(PCMHrecognitionasdefinedbyOHIC)inyearoneofcertification.

1.2.1.2. BehavioralHealth:meetpreventiveandroutinebehavioralhealthneeds.

1.2.1.3. Abilitytoaddresshighendbehavioralhealthneeds.LinkageswithBDDHrecognizedIHHproviders.

1.2.2. IntegratedPH/BH:EvidenceofdirectparticipationofidentifiedworkingrelationshipswithhighendBHproviders

1.2.3. SocialDeterminants:CommunityHealthTeam,CBOpartneraddressingtargetedsocialdeterminantarea,focusonhousing/housingsecurity

1.2.4. Developprotocolsthatguidetheinteractionbetweenprovidersacrossthecontinuumofcareandtointegratecaredelivery.

1.3. DefinedMethodstoCareforPeoplewithComplexNeeds

1.3.1. Abilitytoidentifyandaddressrisingrisk,highriskpopulations1.3.2. Improvecareatpointsoftransitionfromhighertolessintensivelevelsofcare1.3.3. Abilitytoworkeffectivelyatkeypointsoflifetransitionorimpact,suchas

dischargefromcorrections,engagementwithDCYFprotectivecustody,riskoflossofhousing,homelessness,substanceuse,domesticviolence/sexualviolence

1.3.4. AbilitytocareforpeoplewithCo-occurringchronicconditions,especiallyBH

1.4. AbletoEnsureTimelyAccesstoCareMinimally-AbletoDemonstrateCompliancewithallpertinentMCOAccessrequirements

1.4.1. Assuringtimely(within30minutes)after-hoursphoneaccess1.4.2. Useofopenaccessschedulinginprimarymedicalcareandbehavioralhealthcare-

rateofsamedayappointmentavailability30%+1.4.2.1. MinimumAccessStandards:

Appointment AccessStandardAfterHoursCareTelephone 24hours7daysaweekUrgentCareAppointment Within24hoursRoutineCareAppointment Within30calendardaysNewMemberAppointment 30calendardaysPhysicalExam 180calendardaysEPSDTappointment Within6weeks

42

Non-emergent,non-urgentmentalhealthorsubstanceusecondition

Withinten(10)businessdaysfordiagnosisortreatment

2. CorporateStructureandGovernanceAfundamentalEOHHSobjectiveistopromotethedevelopmentofanewtypeoforganizationinRhodeIslandMedicaid.Suchanorganizationmustmeetacoresetofcorporaterequirementssetforthintheserequirements.AEswillbeaseparateanddistinctcorporationrecognizedandauthorizedunderapplicableRhodeIslandStatelawandhaveagoverningboardthatisseparateanduniquetotheAEandnotthesameasagoverningboardofanyspecificAEparticipant.ThereshallbeanestablishedmeansforsharedgovernancethatprovidesallAEPartnerProviderswithanappropriate,meaningfulproportionatecontrolovertheAE’sdecision-makingprocesses.ThestructureoftheAEshouldensurethatpartnershavesharedandalignedincentivestodriveefficiencies,improvehealthoutcomes,worktogethertomanageandcoordinatecareforMedicaidbeneficiaries,andshareinsavingsandinpotentialrisk.AEsmusthaveamissionstatementthatalignswithEOHHSgoals–afocusonpopulationhealth,acommitmenttoanintegratedandaccountablesystemofcare,aprimaryconcernforthehealthoutcomesofattributedmembers,theprogressiveuseofoutcome-basedmetrics,andparticularconcernforthosewiththemostcomplexsetofmedical,behavioralhealth,andsocialneeds.

2.1. DistinctCorporation2.1.1. Separateanddistinctcorporation,recognizedandauthorizedunderapplicable

RhodeIslandStatelawandwithanapplicableTaxpayerIdentificationNumber.2.1.2. GoverningBoardmustmeetregularlyandbeseparateanduniquetotheAEand

notthesameasagoverningboardofanyspecificaccountableentityparticipant.2.1.3. StatementofPurpose–MissionStatementthatalignswithEOHHSgoals

2.1.3.1. Committedtoprogressiontoanintegratedandaccountablesystemofcarewithaprimaryconcernonthehealthoutcomesofattributedmembersandtheprogressiveuseofoutcome-basedmetricstoassessprogressandsuccess

2.1.4. By-LawsSetforthMembershipontheBoardofDirectorswithvotingrightsthatisinclusiveoftheminimumrequirementssetforthbyEOHHS

2.1.5. InclusionofBoardLevelGovernanceCommitteeswithadistinctfocusonMedicaid,suchasanIntegratedCareCommittee,aQualityOversightCommittee,andaFinanceCommittee

43

2.1.6. IncludequarterlyprogressdashboardstomonitorqualityandcosteffectivenesstosupporttheMCO’sandAE’sabilitytomonitorandimproveperformance.

2.1.7. AComplianceOfficerwithanunimpededlineofcommunicationwiththeBoardandwhoisnotthelegalcounselfortheBoard

2.1.8. CommunityAdvisoryCommittee2.1.8.1. CACconsistingofatleasttenpersonswhoareattributedMedicaid

beneficiarieswho arerepresentativeofthepopulationsservedbytheAE.

2.1.9. FiduciaryandAdministrativeResponsibilityResideswithBOD.2.1.9.1. TheAE’sadministrationmustreportexclusivelytothegoverning

BoardthroughtheAE’schiefexecutiveofficer2.1.10. Definedconflictofinterestprovisionsthat

2.1.10.1. Requireeachmemberofthegoverningbody,sub-committees,employeesandconsultantstodiscloserelevantfinancialinterests

2.1.10.2. Provideaproceduretodeterminewhetheraconflictofinterestexistsandsetforthaprocesstoaddressanyconflictsthatarise.

2.1.10.3. Addressremedialactionformembersofthegoverningbodythatfailtocomplywiththepolicy

2.2. CorporateMembers:Multi-DisciplinaryPartnersJoinedinaCommonEnterprise2.2.1. CorePremises

2.2.1.1. SharedgovernanceprovidesallAEPartnerProviderswithanappropriate,meaningfulproportionatecontrolovertheAE’sdecision-makingprocesses.

2.2.1.2. Multi-disciplinaryincompositionandorganizationallyintegratedinpractice.

2.2.1.3. Defined,transparentstructureensuringpartnershavesharedandalignedincentives

2.2.1.4. Leveragestrengthsofpartnerstowardanintegratedperson-centeredsystemofcare

2.2.2. BoardMembership–OrganizationalMembership2.2.2.1. Nolessthan66%ofvotingmembersoftheBoardshallbeprimary

careprovidersplusbehavioralhealthprovidersfromparticipatingPartnerorAffiliateproviderorganizations,providedthatatleastthreemembersoftheBODshallbeprimarycareprovidersandthreemembersshallbebehavioralhealthproviders.

2.2.2.2. Minimalboardrepresentationrequirements,foreachpopulationcertifiedtoserve2.2.2.2.1. Children:PediatricPCP,PediatricBH,Pediatric

representativememberofCAC,CBOproviderofageappropriatesocialsupports

44

2.2.2.2.2. Adults:InternalMedicinePCP,AdultBHprovider,AdultrepresentativememberofCAC,CBOproviderofageappropriatesocialsupports

2.2.2.2.3. Duals/Seniors:InternalMedicine/geriatricPCP,AdultBHprovider,LTSSprovider(includingLTC/NHandHCBSprovider),AdultrepresentativememberofCAC,CBOproviderofageappropriatesocialsupports

2.3. Compliance2.3.1. ProvisionsforassuringcompliancewithState,Federallawre:Medicaid,Medicare2.3.2. Debarredproviders,discrimination,protectionofprivacy,useofelectronicrecords2.3.3. Anti-trust2.3.4. ComplianceOfficerreportsjointlytotheGoverningBoard

2.4. Required-anExecutedContractwithaMedicaidManagedCareOrganization2.4.1. Requiredforattribution,sharedsavingsrequiredforDSHPincentivefunds

eligibility2.4.2. ComportwithEOHHSdefineddelegationrulesre:AE/MCOdistributionoffunctions

3. LeadershipandManagementAEsshouldhaveasingle,unifiedvisionandleadershipstructure,withthecommitmentofseniorleadersandbackedbytherequiredresourcestoimplementandsupportthevision.TheapplicationshoulddescribehowtheAEwilladdresskeyoperationalandmanagementareasandhowthevariouscomponentpartsoftheAEwillbeintegratedintoacoordinatedsystemofcare.TheAccountableEntityshouldhaveadefined,integratedstrategicplanforpopulationhealththatdescribeshowitwillorganizeitsresourcestoimpactcareandhealthoutcomesforattributedpopulations.Thegoalshouldbeapopulationhealthmodelthatworkstoimprovethehealthstatusoftheentireattributedpopulationwhilesystematicallysegmentingsubpopulationriskgroupswithcomplexneedsinordertoimplementfocusedstrategiestoimprovetheirhealthstatus.Aneffectivesystemwillrecognizeinterrelatedconditionsandfactorsthatinfluencethehealthofpopulations,identifysystematicvariationsintheirpatternsofoccurrence,andimplementactionstoimprovethehealthandwell-beingofthosepopulations.

3.1. LeadershipStructureTheremustbeasingle,unifiedvisionandleadershipstructure,withcommitmentofseniorleaders,backedbytherequiredresourcesto implementandsupportthevision.Thisincludes:

45

3.1.1. ChiefExecutiveresponsibletotheBODandresponsibleforAEoperations.Appointmentofremovalofthechiefexecutiveisunderthecontrolofthegoverningboard.

3.1.2. Managementstructure/staffingprofiledescribinghowthevariouscomponentpartsoftheAEwillbeintegratedintoacoordinatedsystemofcare.MayincludespecificmanagementservicesagreementswithMCOsorsubcontractsunderthedirectionoftheAE.Pertinentareasinclude:

3.1.2.1. IntegratedCareManagement3.1.2.2. ITInfrastructure/DataAnalytics3.1.2.3. QualityAssuranceandTracking3.1.2.4. Finance-Descriptionofinfrastructurefor

3.1.2.4.1. Unifiedfinancialleadershipandsystems3.1.2.4.2. Financialmodelingcapabilitiesandindicators3.1.2.4.3. Designingincentivesthatencouragecoordinated,

effective,efficientcare3.1.3. Developsabilitytomanagecareunderatotalcostofcare(TCOC)approach.

Includescommitmentandapproachtoincreasingriskandresponsibilityovertime.

4. CommitmenttoPopulationHealthandSystemTransformationDefined,integratedstrategicplanforpopulationhealththatsetsoutitstheoryofactionastohowtheentityproposestoorganizeresourcesandactionstoimpactcareandhealthoutcomesforattributedpopulations.CentraltotheAEisprogressiontoasystematicpopulationhealthmodelthatworkstoimprovethehealthstatusoftheentireattributedpopulationwhilesystematicallysegmentingsubpopulationriskgroupswithcomplexneedsinordertoimplementfocusedstrategiestoimprovetheirhealthstatus.Aneffectivesystemrecognizesinterrelatedconditionsandfactorsthatinfluencethehealthofpopulationsoverthelifecourse,identifiessystematicvariationsintheirpatternsofoccurrence,anddevelopsaroadmaptoaddresssocialdeterminantsofhealthbasedonbestpracticesnationally.Alongwithclinicalandclaimsdata,theentityidentifiespopulationneedsincollaborationwithstateandlocalagenciesusingpubliclyavailabledatatodevelopaplan.

4.1. KeyPopulationHealthElements4.1.1. PopulationBased4.1.2. Datadriven4.1.3. Evidencebased4.1.4. Clientcentered:Strengthbasedindividualandfamilysupport4.1.5. Recognizes/Addressesthedeterminantsofhealth.Createsprogrammatic

interventionsbysub-population.4.1.6. Teambased,includingCaremanagementandcarecoordination,effectively

managestransitionsofcare,CommunityHealthWorkersasintegralpartners4.1.7. IntegrationofBHandPH/primarycare

46

4.1.8. Identificationofmodifiable,non-modifiableriskfactorsforpoorbehavioralhealthoutcomes.

4.2. SocialDeterminantsofHealth

4.2.1. Recognizesandseeksmethodstoapproachkeysocialdeterminantsofhealth.Thesecanincludesocialfactorssuchashousing,familyandsocialsupport,educationandliteracy,foodsecurity,employment,transportation,criminaljusticeinvolvement,safetyanddomesticviolence,andneighborhoodstresslevels.

4.3. SystemTransformationandtheHealthcareWorkforce

InconsiderationoftheessentialrolethatAEswillplayinRI’shealthsystemtransformation,AEswillberequired,andfunded,topartnerwithEOHHS,URI,RICollege,CCRI,andothereducationandtrainingproviderstosupportRI’sworkforcetransformationefforts.Sucheffortsshallinclude,butnotbelimitedto,thefollowingactivities:

4.3.1. Healthcareworkforcetransformationplanning4.3.1.1. ParticipateontheEOHHSHealthcareWorkforceTransformation

Committeeand/orother relatedcommitteestoprovideongoingassessmentofhealthcareworkforcetransformationneedsandstrategies.

4.3.1.2. Participateinperiodicemployersurveysofhealthcareworkforcedevelopmentneedsandopportunities

4.3.2. Healthcareworkforcetransformationprogramming4.3.2.1. DeveloppartnershipswithURI,RIC,CCRIand/orothereducation

andtrainingproviderstoassistineducationalplanning,curriculumdevelopment,instruction,clinicaltraining,research,and/orothereducationalactivitiesrelatedtohealthcareworkforcetransformation.

4.3.2.2. DeveloppartnershipswithURI,RIC,CCRIand/orothereducationandtrainingproviderstoexpandclinicalrotationsand/orinternshipstopreparehealthprofessionalstudentswith newknowledgeandskills,fornewoccupationsandroles,innewsettingsandnewmodelsofcaretoachieveRI’shealthsystemtransformationgoals.

4.3.2.3. DeveloppartnershipswithURI,RIC,CCRIand/orothereducationandtrainingproviderstoexpandcontinuingeducationforcurrentemployeesofAEpartnerstoprovidethemwithnewknowledgeandskills,fornewoccupationsandroles,innewsettingsandnewmodelsofcare,toachieveRI’shealthsystemtransformationgoals.

4.3.2.4. Developpartnershipswithsecondaryschools,publicworkforcedevelopmentagencies,and/orcommunitybasedorganizationstodevelopcareerpathwaysthatprepareculturallyandlinguistically-

47

diversstudentsandadultsforentryleveljobsleadingtocareeradvancementinhealth-relatedemployment.

5. ITInfrastructure–DataAnalyticCapacityandDeploymentITinfrastructureanddataanalyticcapabilitiesarewidelyrecognizedascriticaltoeffectiveAEperformance.ThehighperformingAEwillmakeuseofcomprehensivehealthassessmentandevidence-baseddecisionsupportsystemsbasedoncompletepatientinformationandclinicaldataacrosslifedomains.ThisdatawillbeusedtoinformandfacilitateIntegratedCareManagementacrossdisciplines,includingstrategiestoaddresssocialdeterminantsofhealthcare.ItisnotnecessarythatanAEuselimitedresourcestoindependentlyinvestinanddevelop“bigdata”capabilities.TherearemanyeffortsunderwayinRhodeIslandtostandardizedatacollectionandtakeadvantageofemergingtechnologies,tobuildallpayerdatasystems,toenableaccesstoanup-to-datecomprehensiveclinicalcarerecordacrossproviders(e.g.CurrentCare),andtoforgesystemconnectionsthatgobeyondtraditionalmedicalclaimsandeligibilitysystems(e.g.SNAP,homelessness,censustractdataonsuchfactorsaspovertylevel,percentofadultswhoareunemployed,percentofpeopleoverage25withoutahighschooldegree).MCOshavelongestablishedadministrativeclaimsdataandeligibilityfiles.AsuccessfulAEwillbeabletodrawuponandintegratemultipleinformationsourcesthatusevalidatedandcredibleanalyticprofilingtoolstoconductregularriskstratification/predictivemodelingtosegmentthepopulationintoriskgroupsandtoidentifythosebeneficiarieswhowouldbenefitmostfromcarecoordinationandmanagement.Thegoalofanalyticaltoolsistodefineprocessestopromoteevidence-basedcare,reportonqualityandcostmeasures,andcoordinatecare.Analytictoolsshouldbedeployedtoreshapeworkflowsthatimpactcoststhroughafocusonoperationalmetricsandmeasurablebusinessprocesses.HITtoolscanprovideclinicaldecisionsupporttoproviderstohelpensuretheyfollowtheevidence-basedcarepathwaysandtoalertthecaremanagementteamtocriticalchangesinutilization.AEsmayevidencevariousformsofpartnershipwithMCOsandotherstoadvancethesecapabilities.5.1. CoreDataInfrastructureandProviderandPatientPortals

5.1.1. Abletoreceive,collect,integrate,utilizepersonspecificclinicalandhealthstatusinformation.

5.1.1.1. Abletoensuredataquality,completeness,consistencyoffields,definitions

5.1.1.2. EHRcapacity:Commonplatformsacrosspartnerproviders,abilitytoshareinformationwithaffiliateproviders.5.1.1.2.1. Achieve“State2MeaningfulUse”requirementsbased

onCMSEHRIncentiveprogram.UseEHRsystemsto

48

documentmedical,behavioral,andsocialneedsinonecommonmedicalrecordwhichcanbesharedacrossthenetworkwithinHIPAAguidelines.ComplieswithenhancedcertificationstandardsorEHRspromotedthroughCMSEHRincentivePaymentProgramthatrequireEHRstocaptureclinicaldatanecessaryforqualitymeasurementaspartofcaredeliveryandcalculateandreportelectronicclinicalqualityforallpatientstreatedbyindividualproviders.

5.1.1.3. Patientregistries–sharedpatientlists(e.g.PCP,BHprovider,Caremanagement)toensureprovidersareawareofpatientengagements.

5.1.1.4. Demonstratethatatleast60%ofAEpatientsareenrolledinCurrentCareand/ordocumentaplantoincreaseCurrentCareenrollment.

5.1.1.5. AEproviderparticipantsmustcontributedatafromtheirEHRstoCurrentCare(AEofficebasedproviderswillsendencounterdatainaClinicalCareDocumentFormat(CCD)via“Direct”securemessages).AEproviderparticipantsmusthavetheabilitytoreceivedatafromCurrentCareorCurrentCareenrolledpatientsinatleastoneofthefollowingways:Throughbi-directionalinterfaceswithCurrentCare,orwhereRIQIandAEproviderparticipants’EHRvendorcapacityexists,ensurestaffhaveappropriateaccesstoCurrentCareviewerorCurrentCaredatawithintheirEHR.

5.2. ProviderandCareManagers’Accesstoinformation

5.2.1. Lookupcapability–connectingclients,clientrecordsandproviders5.2.1.1. Abilitytoreviewmedicationslists5.2.1.2. PromoteCollaborativeservicedelivery5.2.1.3. Ensurecapabilitytocommunicateviasharedmessaging5.2.1.4. Referralmanagement-Abilitytocreate&routreferrals;receive

informationback5.2.1.5. ProviderAlerts&notifications:Criticalincidents,Hospital

admissions&discharges5.2.2. PatientPortalstoenhanceengagement,awareness,andself-management

opportunities.

5.3. UsingDataAnalyticsforPopulationSegmentation,Riskstratification,PredictiveModelingAbletodrawuponandintegratemultipleinformationsourcestoconductregularriskstratification/predictivemodelingtosegmentthepopulationintoriskgroups,identifythespecificpeoplethatwillbenefitthemostfromcarecoordinationandmanagement.Ideallysuchtoolswouldincorporatesocialriskfactors.

49

5.3.1. Riskstratification:Highestcomplexity,rising/imminentriskgroups5.3.2. Bypopulationgroups:Children,adults,duals/seniors5.3.3. Incorporatingsocialdeterminants(e.g.housing,familysupportsystems)intorisk

profiling,bypopulation5.3.4. Abletoidentifytheiruseofvalidated,effective,credibletoolsforanalyticprofiling

5.4. ReshapingworkflowsbyDeployingAnalyticTools–BusinessProcessSupportSystems

&Metrics DevelopmentofdefinedstrategicfocusontheAEprocessesandoutcomesthatimpactcosts.IntegratedCare-Translationofintegratedcareintobusinessprocessdesignandassessment

5.4.1. Definedsetofbusinessprocessmetricsre:Efficiency5.4.2. ActionstoEnhanceAbilitytoManageCare–operationalmetrics.Reshaping

workflowsfor:availabilityandaccess,highimpactinterventions,reducevarianceinquality/outcomes

5.4.3. Monitoringimplementationofthecaremodel

5.5. IntegratingAnalyticworkwithClinicalCareandCareManagementProcesses5.5.1. HITtoolstoprovideclinicaldecisionsupporttoproviderstohelpensurethey

followtheevidence-basedcarepathways5.5.2. Defineprocessestopromoteevidence-basedmedicine,reportonqualityandcost

measures,andcoordinatecare.5.5.3. Provisionofactionableinformationtoproviderswithinthesystem

5.5.3.1. Analysisofgaps,needs,risksbasedonevidencebasedpractice.Gapsincarereportsbasedondeviationsfromevidencebasedpractice.

5.5.3.2. Tohelpenhance,helpdirectcarecoordination/caremanagement.E.g.Medicationsmanagement–infoonthePharmclaims.Scriptfilled?

5.5.4. EarlywarningsystemEstablishedmethodstoalert,engagethecaremanagementteamtocriticalchangesinutilization.Alertedbeforebearingthefullburdenofcosts.

5.5.4.1. EmployaCareManagementDashboard(realtimedashboardofpatient-admissionsanddischargestoEDsandhospitals)

5.5.4.2. EmployCareManagementAlerts(ADTnotificationviadirectmessagingofEDandhospitaladmissionsanddischarges)

5.5.4.3. ContributeproviderfilesonownAEorganizationandproviderstostatewidecommonproviderdirectory

5.6. StaffDevelopment–Training5.6.1. Trainingin,andexpectationfor,usingdatasystemseffectively,usingdatato

managepatientscare.

50

5.6.2. Ongoingaggregatereportingwithindividual/teamdrill-downsre:Conformancewithacceptedstandardsofcare,deviationsfrombestpractice,identifiedbreakdownsinprocess

6. IntegratedCareManagementTheAEshallcreateTheintegrationapproachwillbedevelopedincollaborationwithprovidersacrossthecarecontinuumandincorporateevidencebasedstrategiesintopractice.AneffectiveAEmusthaveasystematicprocesstotargetthetop1%-5%mostcomplexpatientsineachrelevantsubpopulationforcaremanagementandsupport.TheAEwillhavetoolstosystematicallytrackandcoordinatecareacrossspecialtycare,facility-basedcareandcommunityorganizations,aswellastheabilitytorapidlyrecognizeandeffectivelyrespondtochangesinacondition.AnAEshouldhaveacarecoordinationteamwithspecializedexpertisepertinenttothecharacteristicsofeachtargetedpopulationandshouldbeabletodirectthemajorityofcarewithinawell-definedsetofproviders.Thegoalistocreateinterdependenceamonginstitutionsandpractitionersandtofacilitatecollaborationandinformationsharingwithafocusonimprovedclinicaloutcomesandefficiencies.Carecoordinationforhigh-riskmembersshouldincludeanindividualizedpersoncenteredcareplanbasedonacomprehensiveassessmentofcareneeds,includingincorporationofplanstomitigateimpactsofsocialdeterminantsofhealth.Personcenteredcareplansreflectthepatient’sprioritiesandgoals,ensuresthatthememberisengagedinandunderstandsthecarehe/shewillreceive,andincludesempowermentstrategiestoachievethosegoals.6.1. SystematicProcessestoIdentifyPatientsforCareManagement

ElectronicsystemstosupportEffectiveCasemanagement,TargetedCarecoordinatingfunction,top1%-5%ineachrelevantsubpopulation,including:

6.1.1. Systematicallyutilizesanalytics,risksegmentationtoidentify/targetindividualsformorehands-on,individualcaremanagement.Mayincludeindicatorssuchaspoly-pharmacy,behavioralhealthdiagnosis,limitstophysicalmobility,releasefromcorrections,neighborhoodstressindex,depression,hospitalization,clinicalindicators(e.g.diabetes),gapsincare.

6.1.2. Toolstosystematicallytrack&coordinatecareacrossspecialtycare,facility-basedcareandcommunityorganizations

6.1.3. ReferralTrackingandFollow-Up6.1.4. Abilitytorapidlyrecognizeandeffectivelyrespondtochangesinaconditionto

activatecarecoordinationandhelpavoiduseofunnecessaryservices,particularlyemergencydepartmentvisitsorhospitalizations

51

6.2. DefinedCareCoordinationTeamwithSpecializedExpertisePertinenttoCharacteristicsofTargetpopulation

6.2.1. CoordinatedCareTeam–withevidenceofability,toolstomanagecare6.2.1.1. Deliverevidencebasedcaremanagementtoindividualsathighrisk

forpooroutcomesbasedonidentifiedcoreprinciplesandrelatedprocessesspecifiedinthecare.Shouldbeabletodirect,organizemajorityofcare

6.2.1.2. Developandimplementatransitionsofcareapproachforindividualswhoaremovingbetweenhealthcaresettings,includingcaretransitionprotocolstoproactivelyaddresstheneedsofindividualsintransitionaccordingtoevidencebasedpracticeswheneverpossible.

6.2.1.3. Welldefinedsetofproviders–canvary,butinallcasesmustrepresentPCPs,BH,andexpertiseinsocialdeterminantsandLTSS,e.g.CommunityHealthWorker,SocialWorker

6.2.1.4. Canrepresentmultipleorganizations,butmusthavecleardelineationofroles

6.2.1.5. Greatestimpactandmemberbenefitifcare(handoffs)remainwithinthenetworkofparticipatingproviderswherepossible–topromotecoordination,accountabilityandefficiency

6.2.2. Specializedexpertiseandstaffforworkwithdistinctsub-populations6.2.2.1. IntegrationofBHandMedicalcare–children,adults,seniors6.2.2.2. coordinationofcareforpersonswithchronicdiseasesandthe

elderly,includingmedicalmanagement,Coordinatingtransitionsofcare(ED,hospital,home,SNF)

6.3. IndividualizedPersonCenteredCarePlan-CareCoordinationforHigh-RiskMembers

6.3.1. Comprehensiveassessmentofcareneedsandgaps:Symptomseverity,Functionalstatus,PotentiallyAvoidableHospitalReadmissionStrategiesandImprovementPlan

6.3.2. IndividualCarePlansCulturallyandlinguisticallyappropriatecaremanagement.Basedonassessment,developacareplanthattakesintoaccount:Gapsincare,Functionalstatus,Behavioralhealthandsocialserviceneeds,managingtransitions,Increasedpatientmedicationadherenceanduseofmedicationtherapy

6.3.3. IncorporatesmitigationstrategiesforsocialdeterminantsofhealthE.g.,Housingsecurity,Nutrition,Foodsecurity,Physical/activityandNutrition,Safety,safeenvironment;Involvementwithcriminaljustice,parole

6.3.4. Multi-disciplinarycareplanacrossproviders6.3.4.1. CarePlancoordinateseffortsofmedical,behavioralandsocial

supportproviders.6.3.4.2. Entityhasestablishedmethodstopromoteaccess,engagement,

accountability.

52

6.3.4.3. EngagementwithCBOs,providersofsocialsupportservicesaspartoftheimplementationofthecareplan

6.3.4.4. AEpayscloseattentiontoeffective,warmhandoffswheretheyoccur.

6.3.5. PersonCenteredCareplanisdrivenbythepatient’spriorities,motivations,andgoals,ensuresthatthememberisengagedinandunderstandsthecareshewillreceive.

6.3.5.1. Beginsbylookingattheperson.Motivationalinterviewing.Careplanbuiltaroundtheperson,notaroundservices.

6.3.5.2. TheCarePlanisreadilyavailabletothemember6.3.5.3. Strengthbased.Providesforcontinuity6.3.5.4. Processesforworkingcloselywithmembers,familymembersand

caregivers,rangeofproviderstoassureadherencetothecareplan6.3.5.5. Encouragepatientand/orfamilyhealtheducationandpromotion6.3.5.6. LeverageHome-basedservices,andtelephonicandweb-based

communications,groupcare,andtheuseofculturallyandlinguisticallyappropriatecare;

6.3.5.7. Programstopromotehealthylifestyles,developingskillsinself-care.Seesintermittentfailureaspartofthepathway.

6.3.6. Educatesandtrainsprovidersacrossthefullcontinuumofcareregardingthecareintegration strategyandproviderrequirementsforparticipation.

7. MemberEngagementAnAEmusthavedefinedstrategiestomaximizeeffectivemembercontactandengagement,includingtheabilitytoeffectivelyoutreachtoandconnectwithhard-to-reachhighneedtargetpopulations.Thebeststrategieswilluseevidence-basedandculturallyappropriateengagementmethodstoactivelydevelopatrustingrelationshipwithpatients.AsuccessfulAEwillmakeuseofnewtechnologiesformemberengagementandhealthstatusmonitoring.Socialmediaapplicationsandtelemedicinecanbeusedtopromoteadherencetotreatmentandforsupportandmonitoringofphysiologicalandfunctionalstatusofolderadults.7.1. DefinedStrategiestoMaximizeEffectiveMemberContactandEngagement

Abletoeffectivelyoutreachtoandconnectwithhard-to-reachhighneedtargetpopulations.Specifictoattributedpopulationsserved.

7.1.1. Communicationapproachthatrecognizeshighlycomplex,multi-conditionhighcostmembersRecognizesthattherootsofmanyproblemsarebasedinchildhoodtrauma;thatmanyofthehighestneedindividualshaveabasicmistrustofthehealthcaresystem.OftendoesnothaveaprimaryexistingaffiliationwithaPCP.

7.1.2. Identifiedstrategies,methodstoactivelydevelopatrustingrelationshipthroughtheuseofevidence-basedandpatient-centeredengagementmethods

53

7.1.3. Useculturallycompetentcommunicationmethodsandmaterialswithappropriatereadinglevelandcommunicationapproaches.

7.1.3.1. Usesmethodsadaptedtorecognizethatcompliancewithpatientnotificationrequirementsisnotthesameaseffectivecommunicationwithmembers

7.1.3.2. Toolsareunderstandable,andculturallyandlinguisticallyappropriate

7.2. Implementation,UseofNewtechnologiesforMemberEngagement,HealthStatus

Monitoring,andHealthPromotion7.2.1. Socialmediaapplicationstopromoteadherencetotreatment7.2.2. Demonstrateduseoftelemedicine7.2.3. DemonstrateduseofProductsthatsupportmonitoringandmanagementofan

olderadult’sphysiologicalstatusandmentalhealth(e.g.vitalsignmonitors,activity/sleepmonitors,mobilePERSwithGPS)

7.2.4. DemonstrateduseofProductsthatsupportmonitoringandmaintainingthefunctionalstatusofolderadultsintheirhomes(Falldetectiontechnologies,environmentalsensors,videomonitoring)

7.2.5. Useoftechnologiesthatenableolderadultstostaysociallyconnected(Socialcommunication/PCmobileappsforremotecaregivers,cognitivegaming&training,socialcontribution)

7.2.6. Technologies,productsthatsupportbothinformalandformalcaregiversprovidingtimely,effectiveassistance.

8. QualityManagement

8.1. DefinedQualityAssessmentandImprovementPlan,OverseenbytheQuality

Committee8.1.1. TheAEwillmaintainanongoingqualityprogramoverseenbyqualifiedhealthcare

professionalresponsiblefortheAE’squalityassuranceandimprovementprogram8.1.2. TheAEwillhaveanidentifiedboardcertifiedMedicalDirectorlicensedintheState

ofRhodeIslandwhoisanAEproviderandwhoisphysicallypresentattheAElocationonaregularbasisandhaveanindividualfromacommunitybasedserviceorganizationwhoisfamiliarwithhowtomeetneedsassociatedwithsocialdeterminantsofhealth.

8.1.3. AEwilldevelopaninfrastructureforitsPartners,Affiliatesandproviders/supplierstoaddresstheintegrationofmedical,behavioral,andsocialsupportsforAEmembers;andtointernallyreportonqualityandcostmetricsthatenablestheAEtomonitorperformance,emergingtrendsandqualityofcareandtousethese

54

resultstoimprovecareovertime.AEwillhavetheabilitytotrackandreportonkeyperformancemetrics.Performancemetricsshallincludeconsumerreportedqualitymeasures.

8.1.4. AEwillidentifyamethodforintegrationandreviewofclinicalpathways,caremanagementpathwaysbasedonevidencebasedpracticeandforestablishing,reporting,andensuringprovidercompliancewithhealthcarequalitycriteria,includingqualityperformancestandards

8.1.5. AEwillidentifya.TheAEwillbeabletoidentifyhowitwillrequireAEparticipantsandproviders/supplierstocomplywithandimplementeachprocess,includingtheremedialprocessesandpenalties(includingthepotentialforexpulsion)applicabletoAEparticipantsandAEproviders/suppliersforfailuretocomplywithandimplementtherequiredprocess;andexplainhowitwillemployitsinternalassessmentsofcostandqualityofcaretoimprovecontinuouslytheAE’scarepractices

8.1.6. TheAEshallundertaketopromoteevidence-basedmedicine.TheseprocessesmustcoverdiagnoseswithsignificantpotentialfortheAEtoachievequalityimprovementstakingintoaccountthecircumstancesofindividualbeneficiaries.

8.1.7. EOHHSshallestablishqualityperformancemeasurestoassessthequalityofcarefurnishedbytheAE.IftheAEdemonstratestotheMCOthatithassatisfiedthequalityperformancerequirementsandtheAEmeetsallotherapplicablerequirements,theAEiseligibleforsharedsavings.

55

AppendixB:StakeholderMeetingsandFeedback EOHHShaspresentedtothirteen(13)stakeholdermeetingsregardingtheHSTP/AEProgram.

• HSTP/AEPresentationtoICIProviderCouncil• HSTP/AEpresentationto1115TaskForce• AE/MCOmeetingsonAEinitiative(2sessions)• BroadStakeholdermeeting/presentationonComprehensiveAEs(2sessions)• StakeholdermeetingonSpecializedAEs• HSTP/AEmeetingtohomecare/childserviceproviders• NASWAgingCommitteemeeting• CoalitionforChildrenpresentation• GovernorBHcouncil(scheduled)• BHDDHHealthTransitionteam(scheduled)• DEAHomeandCommunityCareAdvisoryCommittee(scheduled)

Additionally,twenty-four(24)commentswerereceivedbyEOHHSfromthefollowinginterestedparties:

1. BlackstoneValleyCommunityHealthCenter2. Carelink3. CenterforTreatmentandRecovery4. CHCACO5. CoalitionforChildrenandFamilies6. CoastalMedical7. DisabilityLawCenter8. EconomicPolicyInstitute9. Integra10. KidsCount11. LeadingAge12. Lifespan13. NeighborhoodHealthPlanofRhodeIsland14. PartnershipforHomeCare15. ProspectHealthServicesofRI16. ProvidenceCommunityHealthCenter17. RICoalitionforChildren18. RICommunityActionAgencies19. RIHealthCareAssociation20. RIHealthCenterAssociation21. StateofRhodeIslandSIMTeam22. SubstanceUseandMentalHealthLeadershipCouncil23. TuftsHealthPublicPlans24. UnitedHealthcare

56

Manyofthesecommentsprovidedvaluableinputtothefinalroadmapasdocumentedhere.Somerequiredadditionaldiscussion,andwerefurtherrefinedthroughpublicinputsessionsinMarch2017,priortofinalizingtheroadmap.NotethatthedraftroadmapthatwaspostedinJanuary2017forcommentsincludedbothanin-depthdiscussionofRhodeIsland’svision,goalsandobjectivesofRhodeIsland’sAEprogram,aswellasappendicesthatoutlinedinitialdetailsofprogrammaticguidanceforAEs.Assuch,manyofthecommentsreceivedweremoredirectlyrelatedtofutureanticipatedguidance–eitherAPMguidance,IncentiveProgramGuidanceorAttributionguidance,andshallbeaddressedaspartofthatpublicinputprocess.Thefollowingisasummaryofthecommentsreceivedbythematicareas.StatePolicyAlignmentAnumberofcommentsspoketotheneedtoensurethatstatepolicyoutsideoftheAccountableEntityprogramwasalignedtoensuresuccess.Detailedpointsofalignmentincluded:

• Statutoryauthorityfordatasharing• BudgetarysupportfortheIntegratedCareInitiative,RhodeIsland’sdual-eligible

demonstrationprogram• FlexibilityinLongTermCareFacilityBedLicensing• IntegrationofPublicHealthInitiatives

OverallProgramStrategyCommentersalsospoketothegeneralprogramstrategyandvisionasoutlinedintheroadmap.Frequentcommentsfocusedonthefollowingtopics:

• Timelineandmilestoneexpectations–Manycommentersexpressedconcernatthespeedwithwhichthestatewasproposingtoimplementtheprogram.

• Flexibility–AnumberofcommentsspokewithvaryingdegreesofsupportforthegrantingofflexibilityfromthestatetoMCOsandfromMCOstoAEs.

• ConsumerChoiceandAccess–CommentershighlightedtheneedtoensuretheprotectionofconsumerchoiceintheMedicaidprogramandtoprotectaccesstoservicesgiventhepreferrednetworkstructurethatsomeAEsmayconsiderdeveloping.

ProgramOperationalDetailsCommentersprovidedsignificantfeedbackonoperationaldetailsthatEOHHSwilldevelopfurtherthroughupcomingguidancedocuments.Specificareasoffeedbackincluded:

• AECertification• AlternativePaymentMethodologies• Attribution

57

• DelegationofResponsibilities• IncentivePaymentProgram• QualityScorecard• ReportingandDataSharing• SocialServiceIntegration• SpecializedAEs(LTSS)

58

AppendixC:RoadmapRequiredComponents STCRequiredElementsofRoadmap WhereAddressed

A

(a)SpecifythatamenuofmetricsandmeasuresthatwillbeusedbytheMCOstoassesstheperformanceoftheAEsthroughtheactivitiesoftheAEsubcontractorsshallbedefinedintheAPMguidancedocument.

SectionIX.ProgramMonitoring,Reporting,&EvaluationPlan

• Page35,1stparagraph

B (b)IncludeguidelinesrequiringAEstodevelopindividualAEHealthSystemTransformationProjectPlans,whichshallincludetimelinesanddeadlinesforthemeetingofmetricsassociatedwiththeprojectsandactivitiesundertakentoensuretimelyperformance;

SectionVIII.MedicaidInfrastructureIncentiveProgram(MIIP)SectionC.Implementation&Oversight

• Page31,inbulletsunderparagraphtitled1.Specifications

C (c)ReporttoCMSanyissueswithintheAEsthatareimpactingtheAE’sabilitytomeetthemeasures/metrics,oranynegativeimpactstoenrolleeaccess,qualityofcareorbeneficiaryrights.Thestate,workingwiththeMCOsshallmonitorstatewideAEperformance,trends,andemergingissueswithinandamongAEsonamonthlybasis,andprovidereportstoCMSonaquarterlybasis.


• Page36,inparagraphtitled2.In-PersonMeetingswithMCOs

D (d)ProvideminimumstandardsfortheprocessbywhichEOHHSseekpublicinputinthedevelopmentoftheAECertificationStandards;

SectionVI.AECertificationRequirements• Page18,1stand2ndparagraphs

E (e)SpecifyaStatereviewprocessandcriteriatoevaluateeachAE’sindividualHealthSystemTransformationProjectPlananddevelopitsrecommendationforapprovalordisapproval;


• Page31-32,inparagraphtitled2.MCOReviewCommittee

F (f)Describe,andspecifytheroleandfunction,ofastandardized,AE-specificapplicationtobesubmittedtotheStateonanannualbasisforparticipationintheAEIncentiveProgram,aswellasanydatabooksorreportsthatAEsmayberequiredtosubmittoreportbaselineinformation

SectionVI.AECertificationRequirements• Page18,1stparagraph

SectionIX:ProgramMonitoring,Reporting,&EvaluationPlan

• Page35-36,inparagraphbeginningwith“Pertainingmoredirectlyto

59

orsubstantiateprogress; AEprogramoperations…”

G (g)SpecifythatAEsmustsubmitsemi-annualreportstotheMCOusingastandardizedreportingformtodocumentitsprogressinachievingqualityandcostobjectives,thatwouldentitletheAEtoqualifytoreceiveHealthSystemTransformationProjectPayments;


• Page32,inparagraphtitled3.RequiredStructureforImplementation,4thbullet

H (h)SpecifythateachMCOmustcontractwithCertifiedAEsinaccordancewithstatedefinedAPMguidanceandstatedefinedAEIncentiveProgramguidance.TheAPMguidancewillincludeaTotalCostofCare(TCOC)methodologyandqualitybenchmarks.ForspecializedAEswhereTCOCmethodologiesmaynotbeappropriate,otherAPMmodelswillbespecified.DescribetheprocessforthestatetoreviewandapproveeachMCO’sAPMmethodologiesandassociatedqualitygatestoensurecompliancewiththestandardsandforCMSreviewoftheAPMguidanceasstatedinSTC47(e).

SectionVII:AlternativePaymentMethodologies

• Page23,inparagraphtitledAEAttributablePopulations

I (i)SpecifytheroleandfunctionoftheAEIncentiveProgramguidancetospecifythemethodologyMCOsmustusetodeterminethetotalannualamountofHealthSystemTransformationProjectincentivepaymentseachparticipatingAEmaybeeligibletoreceiveduringimplementation.SuchdeterminationsdescribedwithintheAPMguidancedocumentshallbeassociatedwiththespecificactivitiesandmetricsselectedofeachAE,suchthattheamountofincentivepaymentiscommensuratewiththevalueandlevelofeffortrequired;theseelementsareincludedintheAEincentiveplansreferencedinSTC47(f).Eachyear,thestatewillsubmitanupdatedAPMguidancedocument,includingAPMProgramguidanceandtheAEIncentiveProgramGuidance.

SectionVIII.MedicaidInfrastructureIncentiveProgram(MIIP)SectionA.ProgramStructure

• Page26,inparagraphtitled3.AccountableEntityIncentivePool


• Page31-32,inparagraphtitled2.MCOReviewCommittee,3rdbullet

• Page32,inparagraphtitled3.RequiredStructureforImplementation,in2ndbullet,4thsub-bullet

J (j)SpecifyareviewprocessandtimelinetoevaluateAEprogressonitsHealthSystem

SectionVIII.MedicaidInfrastructureIncentiveProgram(MIIP)

60

TransformationProjectPlanmetricsinwhichtheMCOmustcertifythatanAEhasmetitsapprovedmetricsasaconditionforthereleaseofassociatedHealthSystemTransformationProjectfundstotheAE;

SectionC.Implementation&Oversight• Page32,inparagraphtitled3.

RequiredStructureforImplementation,in3rdbullet

K (k)SpecifythatAE’sfailuretofullymeetaperformancemetricunderitsAEHealthSystemTransformationProjectPlanwithinthetimeframespecifiedwillresultinforfeitureoftheassociatedincentivepayment(i.e.,nopaymentforpartialfulfillment);


• Page32-33,inparagraphtitled3.RequiredStructureforImplementation,5thbullet

L (l)DescribeaprocessbywhichanAEthatfailstomeetaperformancemetricinatimelyfashion(andtherebyforfeitstheassociatedHealthSystemTransformationProjectPayment)canreclaimthepaymentatalaterpointintime(nottoexceedoneyearaftertheoriginalperformancedeadline)byfullyachievingtheoriginalmetricincombinationwithtimelyperformanceonasubsequentrelatedmetric,


• Page32-33,inparagraphtitled3.RequiredStructureforImplementation,6thbullet

M (m)IncludeaprocessthatallowsforpotentialAEHealthSystemTransformationProjectPlanmodification(includingpossiblereclamation,orredistribution,pendingStateapproval)andanidentificationofcircumstancesunderwhichaplanmodificationmaybeconsidered,whichshallstipulatethatCMSmayrequirethataplanbemodifiedifitbecomesevidentthattheprevioustargeting/estimationisnolongerappropriateorthattargetsweregreatlyexceededorunderachieved;and

SectionVIII.MedicaidInfrastructureIncentiveProgram(MIIP)SectionB.ProgramSpendingGuidance

• Page31,2ndparagraph

N (n)IncludeaStateprocessofdevelopinganevaluationofHealthSystemTransformationProjectasacomponentofthedraftevaluationdesignasrequiredbySTC132.


• Page37,inparagraphtitled4.EvaluationPlan