Duals Demonstration Ombudsman Program Technical Assistance

Know your rights imageACL’s Duals Demonstration Ombudsman Technical Assistance Program meets the technical assistance needs of Centers for Medicare and Medicaid Services (CMS) state grantees that are designing and implementing an ombudsman program as a part of CMS’s Support for Demonstration Ombudsman Programs Serving Beneficiaries of Financial Alignment Models for Medicare-Medicaid Enrollees. In addition to CMS grantees, ACL works with aging and disability organizations, advocacy groups, and other key stakeholders to help dually-eligible beneficiaries to receive person-centered care and support.

We assist state grantees by helping them:

  • Plan and launch a program;

  • Meet data collection and reporting requirements;

  • Collaborate with other grantees to share ideas and experiences; and

  • Develop training materials.

CMS’s Financial Alignment Initiative addresses issues of care coordination caused by financial misalignment between Medicare and Medicaid. In response to these concerns, CMS is testing two models to improve state coordination of financing of Medicare and Medicaid. The goal is to integrate primary care, acute care, behavioral health care, and long-term services and supports for beneficiaries that are eligible for both Medicare and Medicaid.

Resources and Useful Links

State Demonstration Program Descriptions

Below are links to summaries, which outline the Demonstration Ombudsman Program in states that currently receive a CMS Ombudsman Program grant.

California

Program Summary

  • The California Department of Health Care Services (DHCS) implemented a capitated model duals demonstration under the Financial Alignment Initiative, called Cal MediConnect.

  • Cal MediConnect will begin operations in April 2014 in five counties: Los Angeles, Riverside, San Bernardino, San Diego, and San Mateo counties.

  • DHCS applied for and received funding from CMS to operate a demonstration ombudsman program for Cal Mediconnect beneficiaries.

  • Amount of funding for year 1 is $708,366.

  • DHCS collaborated with the Department for Managed Health Care (DMHC) to develop a Cal MediConnect Ombudsman Program modeled after the existing DMHC administered Consumer Assistance Program (CAP).

    • Roles of Department of Managed Health Care

      • In collaboration with DHCS, develop the Request For Proposal

      • Soliciting RFP for bid, reviewing submissions, and awarding contract for Ombudsman Service Providers (OSP)

      • Act as the principal agent administering the Cal MediConnect  OSP component of the program

      • Managing selected OSPs

    • Role of Department of Health Care Services

      • Obtaining stakeholder input

      • Collaborating with DMHC in development of RFP

      • Developing an outreach strategy

      • Developing the training curriculum and training OSPs

      • Providing ongoing support to OSPs

  • DMHC released a Request For Proposal (RFP) to contract with independent, qualified Ombudsman Service Providers (OSP) who will provide ombudsman services to individuals enrolled in Cal MediConnect plans. OSP providers must have:

    • Demonstrated experience in providing direct consumer assistance services relative to health coverage and health insurance in the designated region

    • Expertise in Medi-Cal, Medicare and Long Term Services and Supports and competency in serving seniors and persons with disabilities

    • Proven ability to coordinate its services with other entities

    • Ability to provide culturally and linguistically competent services

Phase I Activities

  • Obtain stakeholder input.

  • Generate, solicit, and initiate Cal MediConnect Ombudsman Program RFP.

  • Create OSP training materials and administer training.

  • Develop reporting elements and system.

  • Design an outreach plan.

  • Refine strategy and work plan.

  • Share resources across states.

Phase II Activities

  • Implement the outreach plan.

  • Deliver ombudsman services.

  • Provide project oversight and management.

  • Collect data and track casework.

  • Submit reports.

Colorado

Program Summary

  • The Colorado Department of Human Services (CDHS) will contract with the state’s current Long Term Care Ombudsman contractor, The Legal Center, to establish the Ombudsman Program for dual eligible individuals enrolled in the State Demonstration to Integrate Care for Medicare and Medicaid Enrollees (the Demonstration).

  • The Legal Center will hire additional staff to provide individual assistance to beneficiaries, their family members, and/or representatives, and triage certain cases to Colorado Legal Services, which handles Medicare appeals.

  • The Ombudsman Program will be available to Medicare-Medicaid enrollees statewide.

  • Amount of funding for year 1 is $210,760. 

  • Colorado will use an existing committee, the Colorado Beneficiary Rights and Protections Alliance (the Alliance), to serve an advisory role to the Ombudsman Program and assist in the planning and implementation activities.  The Alliance is comprised of members such as the Department of Health Care Policy and Financing (HCPF), CDHS, The Legal Center, the Medicaid Managed Care Ombudsman, the State Health Insurance Assistance Program (SHIP), and the Colorado Center on Law and Policy.

Phase I Activities

  • Hire a Program Manager who will oversee all aspects of the Ombudsman Program.
  • Gather best practice information from other states.

  • Leverage technical assistance to refine program strategies.

  • Work with CMS and ACL to finalize the program implementation plan.

  • Adjust and enhance the program work plan.

  • Develop a full Ombudsman services training work plan.

  • Conduct training for Ombudsman staff.

  • Develop a reporting system.

  • The Alliance will be involved in contract development between the CDHS and The Legal Center, codification of the organizational structure of the program, acquiring required staff for the program, ensuring coordination with CMS regulations and guidance, and establishing a tracking system for all service delivery.

Phase II Activities

  • Execute contract between CDHS and the Legal Center.

  • Begin to provide individual assistance to beneficiaries, their family members, and/or representatives, which include providing information and education, and direct assistance and advocacy on behalf of beneficiaries who have issues or complaints.

  • Collect required data.

  • Continue to monitor, improve, and evaluate training.

  • Provide analysis of complaint trends and make recommendations to CMS, the State Unit on Aging, the Plan, and other stakeholders of systemic findings.

  • Complete satisfaction survey for 10 percent of beneficiaries served.

  • Strengthen partnerships with the SHIP, the Area Agencies on Aging, and Colorado Cross Disability Coalition to ensure statewide outreach to individuals enrolled in the Demonstration.

Illinois

Program Summary

  • Illinois Department of Healthcare and Family Services (HFS) implemented a capitated model duals demonstration under the Financial Alignment Initiative, called the Illinois Medicare-Medicaid Alignment Initiative (MMAI).

  • MMAI began operations in March 2014.

  • The Illinois Department on Aging (IDoA) applied for and received funding to operate the demonstration ombudsman program for MMAI beneficiaries.

  • Amount of funding for year 1 is $267,556.

  • Illinois HFS is collaborating with IDoA to provide ombudsman services through its Long Term Care Ombudsman Program (LTCOP).

  • The LTCOP will administer the duals demonstration ombudsman program, and leverage its local and regional ombudsman programs to provide individual assistance to MMAI beneficiaries.

  • The state will hire two employees to implement and administer the MMAI ombudsman program.  The state will also execute grants to the agencies responsible for providing regional ombudsman program services to the MMAI beneficiaries.

Phase I Activities

  • Hire state employees to administer the program.

  • Revise LTCOP standards to include, home and community based ombudsman program policies and procedures, the intake and referral process, and reporting requirements.

  • Execute contracts with local provider agencies.

  • Hold quarterly stakeholder meetings, beginning 60 days after grant award.

  • Coordinate with Aging and Disability Resource Centers (ADRC) and State Health Insurance Programs (SHIP) to provide pre-enrollment counseling services.

  • Develop educational, marketing and training materials for regional ombudsman providers and beneficiaries.

  • Create a data collection and tracking system to monitor issues and trends encountered by MMAI beneficiaries.

Phase II Activities

  • Implement the outreach and education plan.

  • Deliver ombudsman services.

  • Provide quarterly trainings to the Long Term Care Ombudsman on MMAI, managed care, Integrated Care Program, and Medicaid waiver programs.

  • Conduct stakeholder engagement meetings. Monitor and provide technical assistance to local ombudsman providers.

  • Submit reports.

Massachusetts

Program Summary

  • Under the Financial Alignment Initiative, Massachusetts designed and implemented a capitated Demonstration model called “One Care: MassHealth plus Medicare.”

  • One Care began serving beneficiaries on October 1, 2013.

  • One Care is operating in nine counties:

    • Essex

    • Franklin

    • Hampden

    • Hampshire

    • Middlesex

    • Norfolk

    • Plymouth-except the towns of East Wareham, Lakeville, Marion, Mattapoisett, Wareham, and West Wareham

    • Suffolk

    • Worcester

  • The Commonwealth of Massachusetts, MassHealth, applied for and received funding from CMS to expand the operations of their Demonstration Ombudsman Program, called the “One Care Ombudsman (OCO).”

  • Amount of funding for year 1 is $159,084.

  • Beginning in March 2014, MassHealth contracted with the Disability Policy Consortium (DPC) to provide ombudsman services, including a helpline (triage ombudsman) and a Boston-area office with two additional ombudsmen to perform investigations and other ombudsman services for One Care enrollees.

  • Under this grant, the OCO will increase its capacity to support Spanish-speaking beneficiaries and beneficiaries living outside the metro Boston area. This funding will support OCO’s hiring of a bilingual ombudsman to assist Spanish-speaking beneficiaries in all One Care covered counties. The OCO will also add a regional ombudsman and office based in the central/western part of the state to provide local support for beneficiaries in Franklin, Hampden, Hampshire, and Worcester counties.

  • Additionally, the OCO will develop accessible, multi-media educational materials on Medicare/Medicaid beneficiary rights that are designed to empower individuals with knowledge and strategies to advocate for their rights in One Care.

Phase I Activities

  • OCO will hire and train a full-time bilingual ombudsman:

    • Advertise availability of bilingual ombudsman services.

    • Launch bilingual ombudsman services.

  • Hire and train full-time regional ombudsman:

    • Advertise availability of regional ombudsman to central/western Massachusetts stakeholders.

    • Launch regional ombudsman service.

  • Collaborate with subcontractor Consumer Quality Initiatives (CQI) to develop a data reporting strategy to integrate the regional ombudsman with the existing OCO data management system.

  • MassHealth and the OCO will hold ongoing weekly phone conferences to discuss OCO’s implementation progress.

  • Share resources with other states.

Phase II Activities

  • Support OCO’s communication with One Care plans to ensure the plans are responsive to OCO staff’s requests.

  • Partner with CQI to secure, organize, track, and analyze all OCO data to identify emerging trends.

  • Publish OCO analysis and findings through the Early Indicators Project (EIP) on the One Care website.

  • Produce culturally, linguistically, cognitively, and physically accessible multimedia tools that empower beneficiaries to exercise their rights to quality services under the Demonstration:

    • Engage stakeholders to determine content and format of multi-media tools beneficiary empowerment tools.

    • OCO Director will distribute the multimedia empowerment tools via community-based organizations and networks of caregivers, advocates, and community health workers.

    • Post the materials on the OCO and One Care websites for viewing/listening, download, and/or request for hard copy.

  • Continue ongoing weekly phone conferences between MassHealth and the OCO to discuss OCO’s implementation progress.

Ohio

Program Summary

  • Under the Financial Alignment Initiative, Ohio is designing and implementing a Medicare-Medicaid Integrated Care Delivery System (ICDS) called “MyCare Ohio.”

  • Under MyCare Ohio, individuals will have a combined benefit package that includes all the benefits available through traditional Medicare and Medicaid, including long term services and supports and behavioral health services, and any other additional services that any of the five MyCare Ohio managed care plans may elect to include.

  • MyCare Ohio will begin in the spring of 2014, with dual eligible individuals beginning to enroll in a MyCare Ohio managed care plan on May 1, 2014.

  • MyCare Ohio will be implemented in seven multi-county regions:

    • Central: Delaware, Franklin, Madison, Pickaway, Union

    • East Central: Portage, Stark, Summit, Wayne

    • Northeast: Cuyahoga, Geauga, Lake, Lorain, Medina

    • Northeast Central: Columbiana, Mahoning, Trumbull

    • Northwest: Fulton, Lucas, Ottawa, Wood

    • West Central: Clark, Greene, Montgomery

    • Southwest: Butler, Clermont, Clinton, Hamilton, Warren

  • The Ohio Department of Aging applied for and received funding from CMS to operate an ombudsman program, called “MyCare Ohio Ombudsman,” for beneficiaries participating in the demonstration.

  • Amount of funding for year 1 is $272,354.

  • The Ohio Department of Aging is collaborating with the Ohio Department of Medicaid to provide ombudsman services through its state Long Term Care Ombudsman Program.

  • The Ohio Department of Aging will also hire additional MyCare Ohio Ombudsman to assist beneficiaries in the community, conduct outreach, and serve on the MyCare Ohio managed care plans’ advisory councils.

  • The Ohio Department of Aging will also hire a MyCare Ohio Ombudsman Coordinator to provide technical assistance to the regional ombudsman and to analyze the data to identify systemic issues.

  • The Ohio Department of Aging will work closely with Ohio’s Protection and Advocacy Agency, Disability Rights Ohio, throughout the demonstration.

Phase I Activities

  • Hire MyCare Ohio Ombudsman Coordinator and regional ombudsman staff.

  • Create written protocols for the MyCare Ohio Ombudsman Program.  

  • Establish regular meeting schedule with MyCare Ohio managed care plans.

  • Create a series of trainings for regional ombudsman in collaboration with other consumer advocacy organizations.

  • Implement training for staff and volunteer ombudsman representatives.

  • Develop a reporting system leveraging Ohio’s existing data reporting system, ODIS.

  • Engage in teleconference calls with Ohio advocacy groups.

  • Create ombudsman promotional materials and increase consumer awareness of the ombudsman program.

  • Present at community education events.

  • Build relationship with the Ohio State Medical Association, Ohio Association of County Behavioral Health Authorities, and further relationship with the Ohio Department of Mental Health and Addiction Services.

  • Develop protocols with the Aging and Disability Resource Networks, hospitals, and other critical pathways for referrals to ombudsman services.

Phase II Activities

  • Deliver ombudsman services and investigate MyCare Ohio complaints.

  • Analyze data and make recommendations to CMS, the Department of Medicaid, and any other entities on how to improve the Final Alignment Initiative for individuals with Medicare and Medicaid.

Virginia

Program Summary

  • The Department of Medical Assistance Services (DMAS) implemented a capitated model duals demonstration under the Financial Alignment Initiative, called the Commonwealth Coordinated Care (CCC).
  • CCC began operations in the Tidewater, Richmond, and central Virginia regions in March 2014.
  • Virginia Department for Aging and Rehabilitative Services (DARS) applied for and received funding to operate the Demonstration Ombudsman program for CCC beneficiaries.
  • Amount of funding for year 1 is $245,079.
  • DMAS is collaborating with DARS to implement a “hybrid” approach to provide ombudsman services through its Long Term Care Ombudsman Program (LTCOP).
  • The LTCOP will administer the duals demonstration ombudsman program by leveraging its local and regional ombudsman programs provided through its Area Agencies on Aging (AAA) network, and expand services through a Request For Proposal (RFP) to build a new component of ombudsman services to address the needs of CCC beneficiaries of any age, who live in the community.

VA Hybrid Model

Level/Role

Entity/Location

Service/Strategy

Target Population

State

State Level Manager for CCC Advocate Program housed in DARS

Statewide Oversight / Training / Coordination / Systems Advocacy

CCC Enrollees—All dually eligible individuals in the 5 demonstration regions

Regional

Local Long-Term Care Ombudsmen housed in AAAs

Leverage existing infrastructure to expand the current LTC Ombudsmen capacity by hiring additional ombudsmen, trained to work with managed care plans and to advocate on behalf of enrollees living in facilities, to help them to understand and exercise their rights and to ensure enrollees’ needs are met and systemic problems addressed

Dually eligible individuals enrolled in CCC living in LTC Facilities, Nursing Homes & assisted living facilities

Regional

Contract with entities such as Center for Independent Living, AAAs, Community Service Board, Legal Services or individual professionals with skills and knowledge in behavioral health, disability services, language and cultural diversity (RFP process to ensure conflict free resolution)

Contract through RFP process to create a new network of trained professionals to work with managed care plans and advocate on behalf of enrollees living in the community, to help them to understand and exercise their rights and to ensure enrollees’ needs are met and systemic problems addressed

Dually eligible individuals enrolled in CCC living in the community including "Community Well” and enrollees on Elder or Disabled with Consumer Direction waiver.

Phase I Activities

  • Establish and convene stakeholder advisory group to discuss mission and goals, and solicit input on proposed schedule and methods for optimizing communication.

  • Recruit, interview and hire state-level Coordinated Care Advocate Program Manager.

  • Develop policies and procedures for the Coordinated Care Advocacy Program.

  • Develop job descriptions and requirements for RFP, write and disseminate RFP and contract with Coordinated Care Advocates.

  • Secure and equip field offices for Coordinated Care Advocates.

  • Develop tools and protocol for capturing critical data to measure outcomes, produce reports, and inform appropriate systems advocacy.

  • Develop and modify MOUs with key partners and stakeholders for ombudsman services for CCC.

  • Support AAAs in modifying area plans to enhance capacity of current ombudsman for CCC.

  • Review pertinent statutes to address necessary changes in legislative authority to perform prescribed functions of the Ombudsman component of CCC.

  • Modify existing LTCOP data management and reporting system to create and ensure capability to collect and report data elements and capture trends and outcomes.

Phase II Activities

  • Develop and implement training.

  • Work with CCC Communications Committee and Ombudsman stakeholder advisory group to enhance public awareness of and access to ombudsman/advocate services for CCC.

  • Deliver advocacy and problem-resolution supports to CCC enrollees.

  • Monitor program data and develop required and requested reports.

  • Develop recommendations for the Plans, DMAS, and CMS regarding delivery of care and services to the dual eligible population.

Technical Assistance Exchange

The Duals Demonstration Ombudsman Technical Assistance Program operates a Technical Assistance Exchange to make information and resources available to Demonstration Ombudsman Program Grantees and their contractors. In addition to providing information and support, the Exchange fosters a community to exchange ideas, knowledge, and best practices. To access the Exchange, complete the Access Request Form.

Webinar

November 21, 2013
Support for Demonstration Ombudsman Programs Serving Beneficiaries of Financial Alignment Models for Medicare-Medicaid Enrollees


Last modified on 04/30/2017