Common use of STATEMENT OF INITIATIVE Clause in Contracts

STATEMENT OF INITIATIVE. ‌ The Centers for Medicare & Medicaid Services (CMS) and State of Illinois will establish a Federal-State partnership to implement the Medicare-Medicaid Alignment Initiative (Demonstration) to better serve individuals eligible for both Medicare and Medicaid (Medicare- Medicaid Enrollees). The Federal-State partnership will include a Three-way Contract with Demonstration Plans that will provide integrated benefits to Medicare-Medicaid Enrollees in the targeted geographic areas. The Demonstration will begin on October 1, 2013, subject to the conditions described in this Memorandum of Understanding (MOU). It will continue until December 31, 2016, unless terminated pursuant to section L or extended pursuant to section K of this MOU. The initiative is testing an innovative payment and service delivery model to alleviate the fragmentation and improve coordination of services for Medicare-Medicaid Enrollees, enhance quality of care, and reduce costs for both the State and the Federal government. (See Appendix 1 for definitions of terms and acronyms used in this MOU.) This Demonstration is one in a series of the State’s initiatives to transform the health care environment in Illinois to one that is more person‐centered with a focus on improved health outcomes, enhanced beneficiary access, and beneficiary safety. State law requires moving 50% of all Medicaid beneficiaries from fee-for-service (FFS) to risk-based care coordination by January 2015. This Demonstration helps support the State’s health reform efforts by testing integration with Medicare. The population that will be eligible to participate in this Demonstration includes those beneficiaries who are entitled to benefits under Medicare Part A, enrolled under Medicare Parts B and D, and receive full Medicaid benefits, and meet the requirements discussed in more detail in Section C.1 below. Under this initiative, Demonstration Plans will be required to provide for, either directly or through subcontracts, Medicare and Medicaid-Covered Services under a capitated model of financing. CMS, the State, and the Demonstration Plans will ensure that beneficiaries have access to an adequate network of medical and supportive services. CMS and the State shall jointly select and monitor the Demonstration Plans. CMS will implement this initiative under demonstration authority for Medicare and demonstration, State Plan, and waiver authority for Medicaid as described in Section III.A and detailed in Appendices 4 and 5. Key objectives of this Demonstration are to improve the beneficiary experience in accessing care, promote person-centered care planning, promote independence in the community, improve quality, rebalance long-term services and supports (LTSS) to strengthen and promote the community-based systems, eliminate cost shifting between Medicare and Medicaid, and achieve cost savings for the State and Federal government through improvements in care and coordination. Illinois’ care coordination project provides a strong foundation for this Demonstration and demonstrates a commitment from the State to improve the care of beneficiaries. Illinois has one of the highest rates of potentially avoidable hospital admissions among Medicare-Medicaid beneficiaries nationally1. Illinois also has one of the highest proportions of spending on institutional services compared to home and community-based services (HCBS).2 CMS and the State expect this model of integrated care and financing to, among other things, reduce avoidable hospital admissions, improve quality of care and reduce health disparities, meet both health and functional needs of Enrollees, and improve transitions between care settings. Meeting beneficiary needs, including the ability to self-direct care and live independently in the community, are central goals of this Demonstration. The Demonstration will evaluate the effect of an integrated service delivery and payment model on serving both community and institutional populations. In order to accomplish these objectives, comprehensive contract requirements will specify access, quality, network, financial solvency, and oversight standards. Contract management will focus on performance measurement and continuous quality improvement. Except as otherwise specified in this MOU or applicable Medicaid Waiver standards and conditions, Demonstration Plans will be required to comply with all applicable existing Medicare and Medicaid laws, rules, and regulations, as well as program specific and evaluation requirements, as will be further specified in a Three-way Contract to be executed among the Demonstration Plans, the State, and CMS. As part of this Demonstration, CMS and the State will test a new Medicare and Medicaid payment methodology designed to support Demonstration Plans in serving Medicare-Medicaid Enrollees. This financing approach will minimize cost-shifting, align incentives between Medicare and Medicaid, and support the best possible health and functional outcomes for Enrollees. CMS and the State will allow for certain flexibilities that will further the goal of providing a seamless experience for Medicare-Medicaid Enrollees, utilizing a simplified and unified set of rules, as detailed in the sections below. Flexibilities will be coupled with specific beneficiary 1 Center for Strategic Planning, Policy and Data Analysis Group Policy Insight Report: Dual Eligibles and Potentially Avoidable Hospitalizations. xxxx://xxx.xxx.xxx/reports/downloads/Segal_Policy_Insight_Report_Duals_PAH_June_2011.pdf. 2 Centers for Medicare & Medicaid Services: Patient Protection and Affordable Care Act Section 10202 State Balancing Incentive Payments Program Initial Announcement. xxxx://xxx.xxx.xxx/smdl/downloads/Final‐BIPP‐Application.pdf. safeguards that are included in this MOU and will be in the Three-way Contract. Demonstration Plans will have full accountability for managing the capitated payment to best meet the needs of Enrollees according to Care Plans developed by Enrollees, their caregivers, and interdisciplinary care teams using a person-centered planning process. CMS and the State expect Demonstration Plans to achieve savings through better-integrated and coordinated care. Subject to CMS and State oversight, Demonstration Plans will have significant flexibility to innovate around care delivery and to provide a range of community-based services as alternatives to or means to avoid high-cost traditional services if indicated by the Enrollee’s wishes, needs, and Care Plan. Preceding the signing of this MOU, the State has undergone necessary planning activities consistent with the CMS standards and conditions for participation, as detailed through supporting documentation provided in Appendix 2. This includes a robust beneficiary and stakeholder engagement process.

STATEMENT OF INITIATIVE. ‌ The To establish a Federal-State partnership between the Centers for Medicare & Medicaid Services (CMS) and State the Commonwealth of Illinois will establish a Federal-State partnership Massachusetts (Commonwealth/State/MassHealth) to implement the Medicare-Medicaid Alignment Initiative Demonstration to Integrate Care for Dual Eligible Individuals (Demonstration) to better serve individuals eligible for both Medicare and Medicaid (Medicare- “Medicare-Medicaid Enrollees” or “dual eligibles”). The Federal-State partnership will include a Threethree-way Contract contract with Demonstration Participating Plans and other qualified entities (“Participating Plans”) that will provide integrated benefits to Medicare-Medicaid Enrollees in the targeted geographic areasarea(s). The Demonstration will begin on October April 1, 2013, subject to the conditions described in this Memorandum of Understanding (MOU). It will 2013 and continue until December 31, 2016, unless terminated pursuant to section L or extended continued pursuant to section K of this Memorandum of Understanding (MOU). The initiative is testing an innovative payment and service delivery model intended to alleviate the fragmentation and improve coordination of services for Medicare-Medicaid Enrollees, enhance quality of care, care and reduce costs for both the State Commonwealth and the Federal government. (See Appendix 1 for definitions of terms and acronyms used in this MOU.) This Demonstration is one Individuals ages 21 through 64 at the time of enrollment who are enrolled in a series of the State’s initiatives to transform the Medicare Parts A and B and eligible for Medicare Part D and MassHealth Standard or CommonHealth and who have no other comprehensive private or public health care environment in Illinois to one that is more person‐centered with a focus on improved health outcomes, enhanced beneficiary access, and beneficiary safety. State law requires moving 50% of all Medicaid beneficiaries from fee-for-service (FFS) to risk-based care coordination by January 2015. This Demonstration helps support the State’s health reform efforts by testing integration with Medicare. The population that insurance will be eligible to participate for enrollment in this Demonstration includes those beneficiaries who are entitled to benefits under Medicare Part Ainitiative, enrolled under Medicare Parts B and D, and receive full Medicaid benefits, and meet the requirements as discussed in more detail in Section section C.1 below. Under this initiative, Demonstration Participating Plans will be required to provide for, either directly or through subcontracts, Medicare and Medicaid-Covered Services covered services, as well as supplemental items and services, under a capitated model of financing. CMS, the StateCommonwealth, and the Demonstration Participating Plans will ensure that beneficiaries have access to an adequate network of medical and supportive services. CMS and the State Commonwealth shall jointly select and monitor the Demonstration Participating Plans. CMS will implement this initiative under demonstration Demonstration authority for Medicare and demonstration, Demonstration or State Plan, and Plan authority or waiver authority for Medicaid as described in Section III.A section IIIA and detailed in Appendices 4 and 5. Key objectives of this Demonstration the initiative are to improve the beneficiary experience in accessing care, promote deliver person-centered care planningcare, promote independence in the community, improve quality, rebalance long-term services and supports (LTSS) to strengthen and promote the community-based systems, eliminate cost shifting between Medicare and Medicaid, Medicaid and achieve cost savings for the State Commonwealth and Federal government through improvements in care and coordination. Illinois’ care coordination project provides a strong foundation for this Demonstration and demonstrates a commitment from the State to improve the care of beneficiaries. Illinois has one of the highest rates of potentially avoidable hospital admissions among Medicare-Medicaid beneficiaries nationally1. Illinois also has one of the highest proportions of spending on institutional services compared to home and community-based services (HCBS).2 CMS and the State Commonwealth expect this model of integrated care and financing to, among other things, reduce avoidable hospital admissions, improve quality of care and reduce health disparities, meet both health and functional needs of Enrolleesneeds, and improve transitions between among care settings. Meeting beneficiary needs, including the ability to self-direct care care, be involved in one’s care, and live independently in the community, are central goals of this Demonstrationinitiative. CMS and the Commonwealth expect Integrated Care Organization (ICO) and provider implementation of the independent living and recovery philosophy, wellness principles, and cultural competence to contribute to achieving these goals. The Demonstration initiative will evaluate test the effect of an integrated service delivery care and payment model on serving both community and institutional populations. In order to accomplish these objectives, comprehensive contract requirements will specify access, quality, network, financial solvency, solvency and oversight standards. Contract management will focus on performance measurement and continuous quality improvement. Except as otherwise specified in this MOU or applicable Medicaid Waiver standards and conditionsthe Massachusetts Section 1115 Demonstration, Demonstration Participating Plans will be required to comply with all applicable existing Medicare and Medicaid laws, rules, and regulations, regulations as well as program specific and evaluation requirements, as will be further specified in a Threethree-way Contract contract to be executed among the Demonstration Participating Plans, the StateCommonwealth, and CMS. As part of this Demonstrationinitiative, CMS and the State Commonwealth will test a new Medicare and Medicaid payment methodology designed to support Demonstration Participating Plans in serving Medicare-Medicaid EnrolleesEnrollees in the Demonstration. This financing approach will minimize cost-shifting, align incentives between Medicare and Medicaid, and support the best possible health and functional outcomes for Enrollees. CMS and the State Commonwealth will allow for certain flexibilities that will further the goal of providing a seamless experience for Medicare-Medicaid Enrollees, utilizing a simplified and unified set of rules, as detailed in the sections below. Flexibilities will be coupled with specific beneficiary 1 Center for Strategic Planning, Policy safeguards and Data Analysis Group Policy Insight Report: Dual Eligibles and Potentially Avoidable Hospitalizations. xxxx://xxx.xxx.xxx/reports/downloads/Segal_Policy_Insight_Report_Duals_PAH_June_2011.pdf. 2 Centers for Medicare & Medicaid Services: Patient Protection and Affordable Care Act Section 10202 State Balancing Incentive Payments Program Initial Announcement. xxxx://xxx.xxx.xxx/smdl/downloads/Final‐BIPP‐Application.pdf. safeguards that are will be included in this MOU and will be in the Threethree-way Contractcontract. Demonstration Participating Plans will have full accountability for managing the integrated blended capitated payment to best meet the needs of Enrollees according to Individualized Care Plans developed by Enrollees, their caregivers, and interdisciplinary care teams using a person-centered planning process. CMS and the State Commonwealth expect Demonstration Participating Plans to achieve savings through better-better integrated and coordinated care. Subject to CMS and State Commonwealth oversight, Demonstration Participating Plans will have significant flexibility to innovate around care delivery and to provide a range of community-based services as alternatives to or means to avoid high-cost traditional services if indicated by the Enrollee’s Enrollees’ wishes, needs, needs and Individualized Care Plan. Preceding the signing of this MOU, the State Commonwealth has undergone necessary planning activities consistent with the CMS standards and conditions for participation, as detailed through supporting documentation provided in Appendix 2. This includes a robust beneficiary beneficiary- and stakeholder stakeholder- engagement process.

STATEMENT OF INITIATIVE. ‌ The Centers for Medicare & Medicaid Services (CMS) and the State of Illinois Texas Health and Human Services Commission (HHSC) will establish a Federalfederal-State state partnership to implement the Medicare-Medicaid Alignment Initiative Texas Dual Eligibles Integrated Care Demonstration (Demonstration) to better serve individuals eligible for both Medicare and Medicaid (Medicare- Medicare-Medicaid Enrolleesenrollees). The Federalfederal-State state partnership will include a Threethree-way Contract contract with Demonstration Plans managed care plans that will provide integrated benefits to Medicare-Medicaid Enrollees enrollees in the targeted geographic areas. The Demonstration will begin on October no sooner than March 1, 20132015 and continue until December 31, subject 2018, unless continued pursuant to the conditions described in sections K and L or terminated pursuant to section L of this Memorandum of Understanding (MOU). It will continue until December 31, 2016, unless terminated pursuant to section L or extended pursuant to section K of this MOU. The initiative is testing an innovative payment and service delivery model to alleviate the fragmentation and fragmentation, improve coordination of services services, and enhance quality of care for Medicare-Medicaid Enrollees, enhance quality of careenrollees, and reduce costs for both the State and the Federal government. (See Appendix 1 for definitions of terms and acronyms used in this MOU.) This Demonstration is one in a series of the State’s initiatives to transform the health care environment in Illinois to one that is more person‐centered with a focus on improved health outcomes, enhanced beneficiary access, and beneficiary safety. State law requires moving 50% of all Medicaid beneficiaries from fee-for-service (FFS) to risk-based care coordination by January 2015. This Demonstration helps support the State’s health reform efforts by testing integration with MedicareGovernment. The population that will be eligible to participate in this the Demonstration includes those beneficiaries is limited to full benefit Medicare-Medicaid enrollees who are entitled to benefits under Medicare Part A, enrolled under Medicare Parts B and D, and receive full Medicaid benefits, and meet the requirements discussed in more detail in age 21 or older. Section C.1 belowbelow provides more information on eligibility for the Demonstration. Under this initiative, Demonstration these managed care plans, called STAR+PLUS (State of Texas Access Reform Plus) Medicare-Medicaid Plans (MMPs) in Texas, will be required to provide for, either directly or through subcontracts, Medicare and Medicaid-Covered Services covered services, as well as additional items and services, under a capitated model of financing. CMS, the State, and the Demonstration Plans STAR+PLUS MMPs will ensure that beneficiaries have access to an adequate network of medical medical, behavioral health, and supportive services. CMS and the State shall jointly select and monitor the Demonstration PlansSTAR+PLUS MMPs. CMS will implement this initiative under demonstration authority for Medicare and demonstration, demonstration or State Plan, and Plan or waiver authority for Medicaid as described in Section section III.A and detailed in Appendices 4 and 5. Key objectives of this Demonstration the initiative are to improve the beneficiary experience in accessing careservices, promote deliver person-centered care planningcare, promote independence in the community, improve quality, rebalance long-term services and supports (LTSS) to strengthen and promote the community-based systemsquality of services, eliminate cost shifting between Medicare and Medicaid, and achieve cost savings for the State and Federal government Government through improvements in care and coordination. IllinoisThis initiative builds on the foundation of Texas’ STAR+PLUS Medicaid managed care coordination project provides a strong foundation program for individuals with disabilities or who are age 65 or older, which has allowed the state to be innovative in the service delivery model this population uses to access health care across the state. Many of the same performance checks and quality programs operating under the STAR+PLUS program will continue to apply to enrollees in this Demonstration in addition to Demonstration-specific quality withholds and demonstrates performance measures collected. Enrollees in this Demonstration will also benefit from a commitment from the State new initiative being developed for STAR+PLUS to improve the quality of care in nursing facilities and reduce avoidable hospitalizations, scheduled to start March 2015. The initiative aims to integrate the current, fragmented model of beneficiaries. Illinois has one of the highest rates of potentially avoidable hospital admissions among care for Medicare-Medicaid beneficiaries nationally1by creating a single point of accountability for the delivery, coordination, and management of Medicare and Medicaid services, including primary, preventive, acute, specialty, and behavioral health services, long-term services and supports (LTSS), and pharmacy products. Illinois also has one Currently, only 8% of STAR+PLUS members are enrolled in both a Medicare Advantage plan and a STAR+PLUS MCO that are operated by the highest proportions of spending on institutional same organization. Under this demonstration, dually eligible STAR+PLUS members will have the opportunity to have all their Medicare and Medicaid services compared to home and community-based services (HCBS).2 coordinated by the same plan. CMS and the State expect this model of integrated care and financing to, among other things, reduce avoidable hospital admissions, improve quality of care and reduce health disparities, meet both health and functional needs of Enrolleesenrollees, and improve transitions between care settings. Meeting beneficiary needs, including the ability to self-direct care services, be involved in one’s care, and live independently in the community, are central goals of this Demonstrationinitiative. CMS and the State expect that STAR+PLUS MMPs’ and providers’ implementation of the independent living and recovery philosophy, wellness principles, and cultural competence will contribute to achieving these goals. The Demonstration initiative will evaluate test the effect of an integrated service delivery care and payment model on serving both community and institutional populations. In order to accomplish these objectives, comprehensive contract requirements will specify access, quality, network, financial solvency, and oversight standards. Contract management will focus on performance measurement and continuous quality improvement. Except as otherwise specified in this MOU or applicable Medicaid Waiver standards and conditionsMOU, Demonstration Plans STAR+PLUS MMPs will be required to comply with all applicable existing Medicare and Medicaid laws, rules, and regulations, regulations as well as program program-specific and evaluation requirements, as will be further specified in a Threethree-way Contract contract to be executed among the Demonstration PlansSTAR+PLUS MMPs, the State, and CMS. As part of this Demonstrationinitiative, CMS and the State will test a new Medicare and Medicaid payment methodology designed to support Demonstration Plans STAR+PLUS MMPs in serving Medicare-Medicaid Enrolleesenrollees in the Demonstration. This financing approach will minimize cost-shifting, align incentives between Medicare and Medicaid, and support the best possible health and functional outcomes for Enrolleesenrollees. CMS and the State will allow for certain flexibilities that will further the goal of providing a seamless experience for Medicare-Medicaid Enrolleesenrollees, utilizing a simplified and unified set of rules, as detailed in the sections below. Flexibilities will be coupled with specific beneficiary 1 Center for Strategic Planning, Policy safeguards and Data Analysis Group Policy Insight Report: Dual Eligibles and Potentially Avoidable Hospitalizations. xxxx://xxx.xxx.xxx/reports/downloads/Segal_Policy_Insight_Report_Duals_PAH_June_2011.pdf. 2 Centers for Medicare & Medicaid Services: Patient Protection and Affordable Care Act Section 10202 State Balancing Incentive Payments Program Initial Announcement. xxxx://xxx.xxx.xxx/smdl/downloads/Final‐BIPP‐Application.pdf. safeguards that are will be included in this MOU and will be in the Threethree-way Contractcontract. Demonstration Plans STAR+PLUS MMPs will have full accountability for managing the capitated payment to best meet the needs of Enrollees enrollees according to Plans of Care Plans developed by Enrolleesenrollees, their caregivers, and interdisciplinary care teams their Service Coordination Teams using a person-centered planning process. CMS and the State expect Demonstration Plans STAR+PLUS MMPs to achieve savings through better-better integrated and coordinated care. Subject to CMS and State state oversight, Demonstration Plans STAR+PLUS MMPs will have significant flexibility to innovate around care delivery and to provide a range of community-based services as alternatives to or means to avoid high-cost traditional services if indicated by the Enrollee’s wishesenrollees’ preferences and goals, needs, and Care PlanPlan of Care. Preceding the signing of this MOU, the State has undergone necessary planning activities consistent with the CMS standards and conditions for participation, as detailed through supporting documentation provided in Appendix 2. This includes a robust beneficiary beneficiary- and stakeholder stakeholder- engagement process.

STATEMENT OF INITIATIVE. ‌ The Centers for Medicare & Medicaid Services (CMS) and State the Commonwealth of Illinois Virginia (Commonwealth/Department of Medical Assistance Services/DMAS) will establish a Federal-Federal- State partnership to implement the Medicare-Medicaid Alignment Initiative Commonwealth Coordinated Care program (also referred to as the Demonstration) to better serve individuals eligible for both Medicare and Medicaid (Medicare- “Medicare-Medicaid Enrollees” or “dual eligible individuals”). The Federal-State partnership will include a Threethree-way Contract contract with Demonstration Participating Plans that will provide integrated benefits to Medicare-Medicaid Enrollees in the targeted geographic areasarea(s). The Demonstration will begin on October February 1, 20132014 and will continue until December 31, subject 2017, unless terminated pursuant to the conditions described in section III. L or continued pursuant to section III. K of this Memorandum of Understanding (MOU). It will continue until December 31, 2016, unless terminated pursuant to section L or extended pursuant to section K of this MOU. The initiative is testing an innovative payment and service delivery model to alleviate the fragmentation and improve coordination of services for Medicare-Medicaid Enrollees, enhance quality of care, and reduce costs for both the State Commonwealth/DMAS and the Federal government. (See Appendix 1 for definitions of terms and acronyms used in this MOU.) This The Demonstration is one will operate in a series of specific regions within the State’s initiatives to transform Commonwealth. In those regions, the health care environment in Illinois to one that is more person‐centered with a focus on improved health outcomes, enhanced beneficiary access, and beneficiary safety. State law requires moving 50% of all Medicaid beneficiaries from fee-for-service (FFS) to risk-based care coordination by January 2015. This Demonstration helps support the State’s health reform efforts by testing integration with Medicare. The population that will be eligible to participate in this the Demonstration includes those beneficiaries will be limited to individuals ages 21 years and older at the time of enrollment who are entitled to benefits under Medicare Part A, enrolled under Medicare Parts B and D, and receive full Medicaid benefitsbenefits (including individuals enrolled in the Elderly or Disabled with Consumer Direction (EDCD) Waiver and those residing in nursing facilities), and meet the requirements discussed addressed in more detail in Section section C.1 below. Under this initiative, Demonstration Participating Plans will be required to provide for, either directly or through subcontracts, Medicare and Medicaid-Covered Services covered services, as well as additional items and services, under a capitated model of financing. CMS, the StateDMAS, and the Demonstration Participating Plans will ensure that beneficiaries have access to an adequate network of medical and supportive services. CMS and the State DMAS shall jointly select and monitor the Demonstration Participating Plans. CMS will implement this initiative under demonstration authority for Medicare and demonstrationdemonstration authority, State PlanPlan authority, and waiver authority for Medicaid as described in Section section III.A and detailed in Appendices 4 and 5. Key objectives Built on principles of independent living, wellness promotion, and cultural competence, this Demonstration are initiative aims to improve the entire beneficiary care experience. By engaging beneficiaries in their care and allowing them to self-direct services as appropriate, the Demonstration will address beneficiaries’ health and functional needs in order to better equip individuals to live independently in their communities. Improving the beneficiary experience in accessing care, promote personcan then lead to system-centered care planning, promote independence in the community, improve wide benefits such as better quality, rebalance long-term services improved transitions between care settings, fewer health disparities, reduced costs for both payers, and supports (LTSS) to strengthen and promote the community-based systems, eliminate elimination of cost shifting between Medicare and Medicaid, and achieve cost savings for the State and Federal government through improvements in care and coordination. Illinois’ care coordination project provides a strong foundation for this Demonstration and demonstrates a commitment from the State to improve the care of beneficiaries. Illinois has one of the highest rates of potentially avoidable hospital admissions among Medicare-Medicaid beneficiaries nationally1. Illinois also has one of the highest proportions of spending on institutional services compared to home and community-based services (HCBS).2 CMS and the State expect this model of integrated care and financing to, among other things, reduce avoidable hospital admissions, improve quality of care and reduce health disparities, meet both health and functional needs of Enrollees, and improve transitions between care settings. Meeting beneficiary needs, including the ability to self-direct care and live independently in the community, are central goals of this Demonstration. The Demonstration will evaluate the effect of an integrated service delivery care and payment model on serving both community and institutional populations. In order to accomplish these objectives, comprehensive contract requirements will specify access, quality, network, financial solvency, and oversight standards. Contract management will focus on performance measurement and continuous quality improvement. Except as otherwise specified in this MOU or and/or applicable Medicaid Waiver waiver standards and conditionsconditions or State Plan Amendments, Demonstration Participating Plans will be required to comply with all applicable existing Medicare and Medicaid laws, rules, and regulations, regulations as well as program specific and evaluation requirements, as will be further specified in a Threethree-way Contract contract to be executed among the Demonstration Participating Plans, the StateDMAS, and CMS. As part of this Demonstrationinitiative, CMS and the State DMAS will test implement a new Medicare and Medicaid payment methodology designed to support Demonstration Participating Plans in serving Medicare-Medicaid EnrolleesEnrollees in the Demonstration. This financing approach will minimize cost-shifting, align incentives between Medicare and Medicaid, and support the best possible health and functional outcomes for Enrollees. CMS and the State DMAS will allow for certain flexibilities that will further the goal of providing a seamless experience for Medicare-Medicaid Enrollees, utilizing a simplified and unified set of rules, as detailed in the sections below. Flexibilities will be coupled with specific beneficiary 1 Center for Strategic Planning, Policy and Data Analysis Group Policy Insight Report: Dual Eligibles and Potentially Avoidable Hospitalizations. xxxx://xxx.xxx.xxx/reports/downloads/Segal_Policy_Insight_Report_Duals_PAH_June_2011.pdf. 2 Centers for Medicare & Medicaid Services: Patient Protection and Affordable Care Act Section 10202 State Balancing Incentive Payments Program Initial Announcement. xxxx://xxx.xxx.xxx/smdl/downloads/Final‐BIPP‐Application.pdf. safeguards that are included in this MOU and will also be in the Threethree-way Contractcontract. Demonstration Participating Plans will have full accountability for managing the capitated payment to best meet the needs of Enrollees according to Plans of Care Plans developed by Enrollees, their caregivers, and interdisciplinary care teams Interdisciplinary Care Teams using a person-centered planning process. CMS and the State DMAS expect Demonstration Participating Plans to achieve savings through better-better integrated and coordinated care. Subject to CMS and State DMAS oversight, Demonstration Participating Plans will have significant flexibility to innovate around care delivery and to provide a range of community-based services as alternatives to or means to avoid high-cost traditional services if indicated by the Enrollee’s Enrollees’ wishes, needs, and Care PlanPlans of Care. Preceding the signing of this MOU, the State DMAS has undergone necessary planning activities consistent with the CMS standards and conditions for participation, as detailed through supporting documentation provided in Appendix 2. This includes a robust beneficiary beneficiary- and stakeholder stakeholder- engagement process.

STATEMENT OF INITIATIVE. ‌ The Centers for Medicare & Medicaid Services (CMS) and State the South Carolina Department of Illinois Health and Human Services (“State”) will establish a Federal-State partnership to implement the Medicare-Medicaid Alignment Initiative Healthy Connections Prime program (“Demonstration”) to better serve individuals eligible for both Medicare and Medicaid (Medicare- “Medicare-Medicaid Enrollees”). The Federal-State partnership will include a Three-way Way Contract with Demonstration Plans Coordinated and Integrated Care Organizations (CICOs) that will provide integrated benefits to Medicare-Medicaid Enrollees in the targeted geographic areasstatewide. The Demonstration will begin on October no sooner than July 1, 20132014 and continue until December 31, subject 2017 unless terminated pursuant to the conditions described in Section III.L or continued pursuant to Section III.K of this Memorandum of Understanding (MOU). It will continue until December 31, 2016, unless terminated pursuant to section L or extended pursuant to section K of this MOU. The initiative is testing an innovative payment and service delivery model to alleviate the fragmentation and improve coordination of services for Medicare-Medicare- Medicaid Enrollees, enhance quality of care, and reduce costs for both the State state and the Federal federal government. (See Appendix 1 for definitions of terms and acronyms used in this MOU. Defined terms will be capitalized throughout the MOU.) This Demonstration is one in a series of the State’s initiatives to transform the health care environment in Illinois to one that is more person‐centered with a focus on improved health outcomes, enhanced beneficiary access, and beneficiary safety. State law requires moving 50% of all Medicaid beneficiaries from fee-for-service (FFS) to risk-based care coordination by January 2015. This Demonstration helps support the State’s health reform efforts by testing integration with Medicare. The population individuals that will be eligible to participate in this the Demonstration includes those beneficiaries are persons 65 and over living in the community at the time of enrollment, receiving full Medicaid benefits, and who are entitled to benefits under Medicare Part A, A and enrolled under Medicare Parts B and D, and receive full Medicaid benefits, and meet D. Section III.C.1 below provides more information on eligibility for the requirements discussed in more detail in Section C.1 belowDemonstration. Under this initiative, Demonstration Plans CICOs will be required to provide for, either directly or through subcontracts, Medicare and Medicaid-Covered Services covered services, as well as additional items and services, under a capitated model of financing. CMS, the State, and the Demonstration Plans CICOs will ensure that beneficiaries have access to an adequate network of medical and supportive services. CMS and the State shall jointly select and monitor the Demonstration PlansCICOs. CMS and the State will implement this initiative under demonstration authority for Medicare and demonstration, South Carolina State Plan for Medical Assistance (State Plan) authority, and waiver authority for Medicaid Medicaid, as described in Section III.A and detailed in Appendices 4 and 5. Key objectives Built on principles of independent living, wellness promotion, and cultural competence, this Demonstration are initiative aims to improve the entire beneficiary care experience. By engaging beneficiaries in their care and allowing them to self-direct services as appropriate, the Demonstration will address beneficiaries’ health and functional needs in order to better equip individuals to live independently in their communities. Improving the beneficiary experience in accessing care, promote person-centered care planning, promote independence in the community, improve can lead to system- wide benefits such as better quality, rebalance long-term services improved transitions between care settings, fewer health disparities, reduced costs for both payers, and supports (LTSS) to strengthen and promote the community-based systems, eliminate elimination of cost shifting between Medicare and Medicaid, . Integral to South Carolina’s model is a phased transition of roles and achieve cost savings for the State and Federal government through improvements in care and coordination. Illinois’ care coordination project provides a strong foundation for this Demonstration and demonstrates a commitment from the State to improve the care responsibilities of beneficiaries. Illinois has one of the highest rates of potentially avoidable hospital admissions among Medicare-Medicaid beneficiaries nationally1. Illinois also has one of the highest proportions of spending on institutional services compared to home and community-community based services service (HCBS).2 CMS and HCBS) to the State expect this model of integrated care and financing to, among other things, reduce avoidable hospital admissions, improve quality of care and reduce health disparities, meet both health and functional needs of Enrollees, and improve transitions between care settingsCICOs. Meeting beneficiary needs, including the ability to self-direct care and live independently This phased approach is described in the community, are central goals of this Demonstrationdetail in Appendix 7. The Demonstration will evaluate the effect of an integrated service delivery care and payment model on serving both community and institutional populations. In order to accomplish these objectives, comprehensive contract requirements will specify access, quality, network, financial solvency, and oversight standards. Contract management will focus on performance measurement and continuous quality improvement. Except as otherwise specified in this MOU or and/or applicable Medicaid Waiver waiver standards and conditionsconditions or State Plan Amendments, Demonstration Plans CICOs will be required to comply with all applicable existing Medicare and Medicaid laws, rules, and regulations, regulations as well as program specific and evaluation requirements, as will be further specified in a Three-way Way Contract to be executed among the Demonstration PlansCICOs, the State, and CMS. As part of this Demonstration, CMS and the State will test implement a new Medicare and Medicaid payment methodology designed to support Demonstration Plans CICOs in serving Medicare-Medicaid EnrolleesEnrollees in the Demonstration. This financing approach will minimize cost-shifting, align incentives between Medicare and Medicaid, and support the best possible health and functional outcomes for Enrollees. CMS and the State will allow for certain flexibilities that will further the goal of providing a seamless experience for Medicare-Medicaid Enrollees, utilizing a simplified and unified set of rules, as detailed in the sections below. Flexibilities will be coupled with specific beneficiary 1 Center for Strategic Planning, Policy and Data Analysis Group Policy Insight Report: Dual Eligibles and Potentially Avoidable Hospitalizations. xxxx://xxx.xxx.xxx/reports/downloads/Segal_Policy_Insight_Report_Duals_PAH_June_2011.pdf. 2 Centers for Medicare & Medicaid Services: Patient Protection and Affordable Care Act Section 10202 State Balancing Incentive Payments Program Initial Announcement. xxxx://xxx.xxx.xxx/smdl/downloads/Final‐BIPP‐Application.pdf. safeguards that are included in this MOU and will also be in the Three-way Way Contract. Demonstration Plans CICOs will have full accountability for managing the capitated payment to best meet the needs of Enrollees according to Individualized Care Plans developed by Enrollees, their caregivers, and interdisciplinary care teams Multidisciplinary Teams using a person-centered planning process. CMS and the State expect Demonstration Plans CICOs to achieve savings through better-integrated and coordinated care. Subject to CMS and State oversight, Demonstration Plans CICOs will have significant flexibility to innovate around care delivery and to provide a range of community-based services as alternatives to or means to avoid high-cost traditional services if indicated by the Enrollee’s Enrollees’ wishes, needs, and Individualized Care Plan. Preceding the signing of this MOU, the State South Carolina has undergone necessary planning activities consistent with the CMS standards and conditions for participation, as detailed through supporting documentation provided in Appendix 2. This includes a robust beneficiary beneficiary- and stakeholder stakeholder-engagement process.