An integrated appeal process which provides the strongest protections afforded by each program will be key to ensuring that new models are held accountable to provide beneficiaries access to the services they need.  Below are specific recommendations for advocates to make regarding appeals.

• Nothing in the rate structure should discourage the provision of home and community based services Different options can be used. In Medicaid managed care, Arizona pays plans a blended rate that incorporates nursing home and community based costs but gradually tilts to a greater percentage of community-based costs.  In Minnesota, the state pays plans for Medicaid beneficiaries who live in the community at rates based on community costs but requires ...
• Integrated models must ensure that the rates they pay network providers are high enough to create and maintain adequate and sustainable networks This will likely mean in most cases basing provider payments on Medicare rates since experience shows that current Medicaid rates, in many cases have led to critical provider shortages.  A paper by United Health Center for Reform reported that approximately 49% of primary care physicians would be willing to increase their Medicaid patient roster if Medicaid ...
• Rates should be adjusted for health status of the population using a variety of measures to facilitate this goal Rates should reflect functional limitations, not just diagnoses.  A paper from the Massachusetts Medicaid Policy Institute Risk Adjustment for Dual Eligibles: Breaking New Ground in Massachusetts, describes Massachusetts’ experience including functional status in risk adjusted rates.
• Capitation rates must be adequate to support needed care Whenever risk-based, capitated models are used, payment structures must encourage appropriate utilization of care and reward the provision of preventive care, intensive transition supports, and home and community-based services.  A  brief from the Kaiser Family Foundation, People with Disabilities and Medicaid Managed Care: Key Issues to Consider, states that evidence of significant unmet need among ...
• Financial structures must promote delivery of optimal care While integrating responsibility and payment for all Medicare and Medicaid services into one entity has the potential to improve care coordination and improve the health of dual eligibles, dangers exist. Poorly designed risk-sharing and capitated payment models could lead to delays and denials of medically necessary care or “cherry-picking” of healthy, less costly enrollees. If ...