Name of Organization

[Name of Organization]

2014 (Updated July 1, 2014)

1 Consumer Advisory Committee Handbook (Sample)

Contents

This is a sample tool. Please see Community Catalyst’s Meaningful Consumer Engagement toolkit, “Step-by-Step: Getting Started,” for additional tools and resources to support Consumer Advisory Committee development and other stakeholder engagement strategies.

2 [insert letterhead and date]

Welcome! As the leader of [insert organization here], I would like to thank you for agreeing to participate in our [insert name] Consumer Advisory Committee. The mission of our [insert organization here] is to [insert mission]. You are helping us to achieve this mission by sharing your thoughts and ideas on how we can better serve our members.

We understand this may be the first time you have been involved in a Consumer Advisory Committee. This packet will provide you with some helpful information on [organization], [initiative name], and our Consumer Advisory Committee. We hope this information is helpful now and throughout your involvement.

Our next meeting of the [insert name] Consumer Advisory Committee is scheduled for [insert date] at [insert location]. You will receive additional information before this meeting to help you prepare and arrange for any transportation assistance you may need. In the meantime, please review the contents of this packet. Also, please complete the Accommodations Request Form (found on page X of this packet) and mail it back to us using the self- addressed stamped envelope. This will help us to understand how we can better help you to participate. If you have any questions or concerns about your involvement, please don’t hesitate to contact [insert name] at [insert phone and TTY] or [insert email].

Thank you again for your interest in our work and helping us improve our services! We can’t wait to see you.

Sincerely,

[CEO/ Executive Director]

3 Accommodations Request Form

Person Making Request: ______Name: ______Mailing Address: ______Phone: ______E-mail: ______Relationship to person requiring accommodation:______

Person Requiring Accommodation (if different than above): ______Name: ______Mailing Address: ______Phone: ______E-mail: ______

The following accommodations are needed to participate:  American Sign Language Interpreter  Language Interpreter/Translation (Primary language:______)

 Note Taker

 Assistive Listening Device

 Captioning

 Large Print

 Braille

 Electronic Version (Note if Email or CD Preferred) ______

 Wheelchair Access

 Guidance Getting Into the Building

 Dietary Needs (Please Describe) ______

4  I Will Bring an Assistant With Me ___ Yes ___ No

 Other (Please Describe)

______

What Is [add Name of Initiative]?

[Organization Name, e.g. health plan or provider group] is part of a program (sometimes known as a demonstration or pilot project) to try a new way to provide care. [Initiative, e.g. One Care] is a joint project between [state] (Medicaid) and the federal government (Medicare). [Initiative, e.g. One Care] is a 3 year project and is available to some people who have both Medicare and Medicaid. This includes older adults and people with disabilities [revise based on eligibility]. The goals of [Initiative, e.g. One Care] are to:

 Improve your health and well-being

 Improve the quality of care you receive

 Provide care based on your goals and in a way that meets your needs

 Improve coordination among your providers, including your medical care, behavioral health care and long-term services and support providers

 Provide cost-effective care

Under this program, [organization] was selected by [state agency] and the Centers for Medicare and Medicaid Services (CMS) to provide both Medicaid and Medicare benefits to the people that enroll in [organization].

5 [Insert brief description of the program, such as the health plan’s values, program elements, benefits covered, role of care coordinator and care team, etc. Provide link to official member booklet or other member materials]

We [at organization] are looking for you to share your experiences with us. We want to learn from you how we can improve our member education and care coordination efforts [modify as appropriate]. [Organization’s] members can join our Consumer Advisory Committee to share their experiences!

6 Consumer Advisory Committee Charter

This is just one sample. Please consult Mechanics of Consumer Advisory Committee Meetings for more ideas about how to structure your committee.

Purpose The Consumer Advisory Committee will advise [name initiative]. For example, our Consumer Advisory Committee members may provide us with new ways to think about: . Providing member education . Providing member outreach . Addressing members’ needs

. Addressing service challenges

. Working with community partners

Meeting Frequency and Location The Consumer Advisory Committee meets [quarterly]. All meetings are held in a fully accessible, ADA-compliant facility that is close to the [train/bus]. Members are asked to attend all meetings. We understand that this is not always possible. Please contact [contact person and information] if you cannot attend a meeting. Please also speak to [contact person] if you have ideas on how we can make it easier for you to attend and participate in meetings. Members who have more than 2 unexcused absences may be replaced by new members to allow the group to move forward.

Membership Terms and Positions Members commit to a one or two-year [or three-year] term. We have a mix of new and experienced members so we can help each other learn. We seek members of different ages, disabilities, cultures, and geographic areas so we learn from these differences as well. Members can assume a leadership role as they gain more experience. If you want to learn about becoming a [Chairperson, Vice Chairperson, or Secretary], please ask [contact person and contact information] for more information.

Meeting Accommodations Members can get many kinds of help to support their involvement. Members should fill out the Accommodations Request Form to tell us about their needs. Large print, Braille, electronic format, American Sign Language interpreters, language interpreters, Communication Access Real-time Translation (CART), transportation, and personal assistance are examples of the support available. Members also may request personal meetings with staff to talk about the

7 meetings and ask questions ahead of time. We provide [stipends/ gift cards/ meals] for those who come to meetings to thank them for their involvement.

Roles and Responsibilities Members will allocate approximately [2-4 hours] per month to do any of the following: . Prepare for and attend Consumer Advisory Committee meetings . Review materials shared, ask questions, and provide feedback . Provide input based on personal experiences . Attend community events to better understand the needs of members and local communities

. Work with staff to find creative ways to understand the needs of other members

. Focus on solutions that benefit a wide range of members

Staff Roles and Responsibilities Staff will provide Consumer Advisory Committee members with the following: . Information on [organization], [initiative], and Consumer Advisory Committee roles and responsibilities . Notice of meetings at least one month prior to the meeting . Agendas and meeting materials at least two weeks prior to the meeting by mail or email (method chosen by member) . Assistance to support member involvement, such as accessible materials and transportation . One-on-one opportunities to meet with staff, share ideas, and ask questions . Access to peers for education and mentoring

Decision Making and Conflict Resolution The [Initiative] Consumer Advisory Committee advises [organization] by providing recommendations to improve [organization]’s practices and member benefits. Members will seek consensus before making recommendations. Consumer Advisory Committee Ground Rules will be used to ensure fair conversations.

Code of Conduct Consumer Advisory Committee members are asked to respect the following Code of Conduct: . Maintain the confidentiality of personal information shared in the meeting; . Treat each other with dignity and respect;

. Avoid being aggressive when you disagree with a decision or a statement;

. Work collaboratively with others to further [organization’s] mission [or goals];

. Do not make statements or assumptions based on race, ethnicity, gender, sexual orientation, gender identity, age, disability, or any other personal characteristic; and

8 . Disclose potential conflicts of interest, real or perceived, before participating in discussions or votes.

This sample Committee Charter is an adaptation of one created by the Collaborative Leaders Network. For more information: http://collaborativeleadersnetwork.org/about-us/

Non-Disclosure and Confidentiality Agreement

Please return a signed copy of this Non-Disclosure and Confidentiality Agreement to [insert name] prior to your Consumer Advisory Committee attendance.

This Non-Disclosure and Confidentiality Agreement, hereinafter called "Agreement," is by and between ______, hereinafter called "Advisor," and [insert organization] and is subject to the terms and conditions contained herein.

This Agreement is obtained to permit the protection of Consumer Advisory Committee discussions and materials deemed confidential and vital to the success of [insert organization]. The Advisor understands that this information is sensitive and confidential and that disclosure to others could be damaging and detrimental to [insert organization] or its members served.

The original information and materials developed by [insert organization], including, but not limited to, its methods, programs, and business operations as well as its Members’ information shall remain the confidential and/or proprietary property of [insert organization] and will not be revealed to any third party, except as required by law.

It is recognized that certain information, methods, programs, operations and procedures are unique to [insert organization] and critical to the growth and success of [insert organization]. The Advisor recognizes the sensitivity, proprietary and confidential nature of this information. The Advisor agrees that this material and personal member information will be held in strictest confidence and shall not at any time, or in any manner, be utilized by others to the detriment of [insert organization] or its members. [Insert organization] retains exclusive rights to publish the results of Consumer Advisory Committee meetings and materials.

This Agreement is for a period of one twelve month period. At the end of this period, should the Advisor and [insert organization] mutually agree to continue a relationship, it will be in accordance with a new Non-Disclosure and Confidentiality Agreement.

Agreed this ______day of ______, 20__ __.

Printed Name Signature

9 This is a sample Non-Disclosure and Confidentiality Agreement adapted from a template (http://www.servicesca.org/non_disclosure.htm) created by Services Cooperative Association. Please seek legal review and approval prior to using this form.

Consumer Advisory Committee Ground Rules

Our Consumer Advisory Committee has “Ground Rules” to support fair conversations. Please review and follow these important Ground Rules.

Come prepared to participate and share your story

Learn from others in your community and share their experiences

Speak one person at a time

Provider others with a chance to speak

Use simple language and no acronyms

Assume everyone is here to help

Support others to learn

Ask questions to understand

Respect personal views and opinions

Respect member and business confidentiality

10 Do you have ideas on how to make our meetings better? Let us know!

(Add contact information here)

11 Advocating for You and Others: General Tips

Consumer Advisory Committee members who join the group will come with different types of experiences. Some members will feel comfortable sharing their ideas and others may feel less comfortable. Here are some tips on how you can advocate for you and others so that all voices can be heard:

 Know your stuff by spending time preparing for meetings  Be assertive when speaking up, but not passive or aggressive  Be persistent and committed to communicating  Help to identify challenges and assist to resolve them  Try to be objective and see the big picture  Ask questions if you don’t understand something

Additional tips to consider when advocating for others…

 Don’t feel bad for others, just try to walk in their shoes  Be prepared to learn  Assist others to understand and then assist them to make their own points  Create time and space for others to say what they need to say  Be sensitive to people's feelings- both members and staff  Create a group of members who can help each other  Maintain confidentiality

Tips retrieved and adapted from the Association for Children with a Disability. For more helpful tips, please visit: http://www.acd.org.au/support/tips_advocate.htm

12 Conflict is Normal! …But, What Do I Do About It?

Conflict will happen when passionate people come together to make a difference. We ask Consumer Advisory Committee members to call on these simple ideas to help us work through any difficult times.

Create a safe place to talk Help to set and follow ground rules that create a safe place for everyone to be heard, respected, and supported. Do not personally attack others. Do not speak over others.

Vent fairly Describe what impact the issue has on you without blaming others or making assumptions about how others feel.

Listen actively Ask open-ended and non-judgmental questions. Take time to summarize what other people are saying so they know you hear them.

Identify what you have in common Work with others to identify the areas where you agree and be creative (together) to develop solutions.

Keep your eyes on the prize! The goal is not to win, but rather to come to an agreement and improve the services and care members receive.

This resource was informed by “Working with group conflict.” GroupWorks, The University of Maine Cooperative Extension. http://www.umext.maine.edu/onlinepubs/PDFpubs/6106.pdf

13 Biography and Contact List Form

Please see [page X] for a Consumer Advisory Committee contact list and information about members. Your fellow committee members want to learn about you, too! Complete this form and [organization] staff will add your information to the booklet. Please check “no, thank you” if you do not want your name added. Please send this document back in the provided self-addressed stamped envelope or bring it with you to our next meeting. Please contact [staff] at [phone, TTY, email] if you need help filling out this form.

First Name: ______Last Name: ______

Phone: ______Email: ______

3 Things You Think Are Important to Know About You:

Hobbies, (Previous) Employment, or Areas of Interest:

What you believe you can bring to the Consumer Advisory Committee. For instance: Who do you think you can represent?

What personal experiences would you like the group to learn from?

____ Please add me to the Committee biographies and contact list. ____ No, thank you.

Printed Name Signature Date

14 Additional Tools and Resources

Medicaid Overviews . Medicaid at-a-Glance (Kaiser Family Foundation) http://kaiserfamilyfoundation.files.wordpress.com/2013/03/7235-061.pdf . Medicaid Moving Forward (Kaiser Family Foundation) http://kaiserfamilyfoundation.files.wordpress.com/2014/06/7235-07- medicaid-moving-forward2.pdf

Medicare Overviews . Medicare at-a-Glance (Kaiser Family Foundation) http://kff.org/medicare/fact-sheet/medicare-at-a-glance-fact-sheet/ . The Medicare Program: A Brief Overview (AARP) http://www.aarp.org/content/dam/aarp/research/public_policy_institute/he alth/medicare-program-brief-overview-fs-AARP-ppi-health.pdf . Medicare 101: A Must-Read Guide to the Basics http://www.aarp.org/health/medicare-insurance/info-10-2013/medicare- for-dummies-patricia-barry.html . Medicare Program: General Information (Centers for Medicare and Medicaid Services) https://www.cms.gov/Medicare/Medicare-General- Information/MedicareGenInfo/index.html?redirect=/MedicareGenInfo/

States’ Demonstrations to Integrate Medicare and Medicaid Services . State Demonstration Proposals to Integrate Care and Align Financing and/or Administration for Dual Eligible Beneficiaries (Kaiser Family Foundation) http://kff.org/medicaid/fact-sheet/state-demonstration-proposals-to- integrate-care-and-align-financing-for-dual-eligible-beneficiaries/ . Financial Alignment Initiative (Centers for Medicare and Medicaid Services) http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and- Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsin CareCoordination.html Additional Tools and Resources (Continued)

15 Dual Eligible Integrated Care: Resources for Consumers . Dual Eligible Populations (Community Catalyst) http://www.communitycatalyst.org/initiatives-and-issues/issues/dually- eligible-populations . Top Ten Consumer Advocacy Priorities for Dual Demonstration Projects (Community Catalyst) http://www.communitycatalyst.org/doc- store/publications/Top_Ten_Duals_Projects_Guide_Advocates.pdf . Dual Eligible Integrated Care Demonstrations: Resources for Advocates (National Senior Citizens Law Center) http://dualsdemoadvocacy.org/#

Working with Group Conflict and Effective Facilitation of Groups . Working with Group Conflict: Getting Things Done (The University of Maine Cooperative Extension) http://www.umext.maine.edu/onlinepubs/PDFpubs/6106.pdf . From Conflict to Consensus: Three Critical Tasks for Leaders (Interaction Associates) http://interactionassociates.com/sites/default/files/whitepapers/From %20Conflict%20to%20Consensus_2013.pdf . Facilitating Trust: What Team Leaders Need to Know (Interaction Associates) http://interactionassociates.com/sites/default/files/whitepapers/Facilitating _Trust_Cone.pdf . Free Training Manual (Conflict Resolution Network) http://www.crnhq.org/

16 Glossary of Terms

Accountable Care Organizations: Groups of doctors, hospitals and other health care providers who join together to provide coordinated care for a group of patients, and who agree to be held responsible for the quality and total cost of those patients’ care. Acute Care: Medical care provided at doctors’ offices, acute care hospitals, and outpatient care facilities. Services such as prescription drugs and dental care are also considered to be acute care. Aged, Blind, or Disabled (ABD) Medicaid Beneficiaries: People who are eligible for and receive Medicaid benefits because of age, blindness, or disability in addition to the amount of their income and assets. The dual eligible population is a subset of those beneficiaries. Appeal: A request for a review of a health plan’s decision on care or coverage. Behavioral Health Care: Treatment of mental health and/or substance abuse needs. Beneficiary: A person who is eligible for and receives Medicare and/or Medicaid benefits. Capitated Payment: A single payment, made on a per-person (“per-capita”) basis that covers all care for beneficiaries within a listed set of benefits they are entitled to. Medicare and Medicaid make capitated payments to the demonstration health plan, which then pay health care providers for services they provide to people enrolled in a managed care plan. Care Coordination: The work of a single person or team to make sure beneficiaries get the necessary Medicare and Medicaid health care they need, as well as social, educational and other support services they are entitled to, regardless of which program pays for the care. Care Coordinator: A clinician or other specially trained person employed or contracted by the health care provider or the integrated care organization (see ICO), whose job it is to coordinate all services for enrollees. He or she participates in the initial assessment; arranges appropriate referrals to all services and care, and supports safe transitions in care for enrollees moving between home, hospital or any other care facility. The Care Coordinator serves on one or more Interdisciplinary Care Teams (ICT).

Centers for Medicare and Medicaid Services (CMS): A federal government organization that runs and oversees the Medicare and Medicaid programs. It is part of the U.S. Department of Health & Human Services.

Center for Medicare and Medicaid Innovation (CMMI): Established by the Affordable Care Act, CMMI works with health providers and plans to test new ideas for payment and service delivery to reduce total costs under Medicare and Medicaid while keeping the same quality or improving the quality of care. Choice Form: The form a beneficiary fills out to choose or change a health plan. Clinical Care Management: A set of skilled services provided by a Clinical Care Manager that might include intensive monitoring, follow-up, and care coordination, clinical management of high-risk enrollees.

17 Clinical Care Manager: A licensed registered nurse or other individual licensed to provide Clinical Care Management. CMS: Centers for Medicare and Medicaid Services; SEE LISTING ABOVE Consumer Assessment of Healthcare Providers and Systems (CAHPS): A survey tool developed and maintained by the Agency for Healthcare Research and Quality to help assess consumers’ experiences with health care.

Contract: A legal agreement that CMS and the State make with an Integrated Care Organization (ICO), stating the terms and conditions that control how the ICO may participate in this Demonstration.

Contract Management Team: A group of CMS and State Agency representatives responsible for overseeing the contract, and that all rules and terms are followed.

Covered Individuals: Individuals enrolled in the demonstration (enrollees).

Covered Services: The set of services to be offered by the demonstration plan.

Cueing and Monitoring: Providing a hint or instruction to assist an individual in performing activities they are physically capable of performing, but are unable to begin doing independently without a little help.

Cultural Competence: Having sensitivity to and understanding of the values, beliefs and needs that are associated with a patient’s age, gender identity, sexual orientation, and/or racial, ethnic, or religious backgrounds. Also includes understanding which is required to ensure appropriate, culturally sensitive health care to persons with congenital (from birth) or acquired disabilities. Deductible: The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other coverage begins to cover the rest of the cost. Demonstration Health Plan: The health plans selected to participate in the duals demonstration. Health plans sometimes are called “integrated care organizations” (ICO), “managed care organizations” (MCO) or “health maintenance organizations” (HMO). Dual Eligible Beneficiaries: People who are jointly enrolled in Medicare and Medicaid and are eligible to receive benefits from both programs. All dual eligible beneficiaries qualify for full Medicare benefits, which cover their acute and post-acute care. Dual eligible beneficiaries vary, however, in the amount of Medicaid benefits for which they qualify. At a minimum, all dual-eligible beneficiaries qualify to have the Medicaid program pay their premiums for Part B of Medicare (and for Part A, if applicable). Enrollee: A person enrolled in the integrated care demonstration or a health plan. Enrollment: The processes by which an individual who is eligible for the Demonstration is enrolled in a Participating Plan. Such processes include completion of an enrollment form or application in order to become a member of an ICO. (Passive enrollment is defined below.)

18 Enrollee Communications: Materials designed to communicate to enrollees plan benefits, policies, processes and/or enrollee rights. This includes pre-enrollment, post-enrollment, and membership materials. Fair Hearing: An official meeting with a judge about an appeal or grievance. Fee-for-service (FFS): A payment system in which a health care program or plan pays providers a fee for each specific covered service or procedure that is provided or performed for its enrollees. Full Duals: Dual-eligible beneficiaries who qualify for full benefits from Medicaid as well as from Medicare. Thus, Medicaid pays for their premiums for Part B of Medicare (and for Part A, if applicable) and covers various health care services that Medicare does not cover, such as most types of long-term services and supports (as well as dental care and other services in some states). Grievance: A way to write or tell the health plan about your unhappiness with your provider or medical care service. Healthcare Effectiveness Data and Information Set (HEDIS): A tool developed and maintained by the National Committee for Quality Assurance that is used by health plans to measure performance on many areas of care and service in order to maintain and/or improve quality. Health Home: This is not an actual home or building. A Health Home is a specific type of “medical home” (SEE BELOW) that serves Medicaid beneficiaries who have a particular set of chronic conditions. Health homes are intended to address those beneficiaries’ needs for behavioral and physical health care, as well as for institutional or community-based long-term care. The Affordable Care Act created an optional program in which states can receive a 90 percent federal matching rate for up to two years for providing this type of service. Health Outcomes Survey (HOS): Beneficiary survey used by the Centers for Medicare and Medicaid Services to gather reliable health status data in Medicare managed care for use in quality improvement activities, plan accountability, public reporting, and improving health. Health Plan: A group of doctors, specialists, clinics, pharmacies, hospitals, and long-term care services and supports that provide health care services. Health plans are also called “managed care plans.” People enrolled in the health plan are called “members” and have a primary care provider who helps guide all of their health care. Home and Community Based Services (HCBS): Services and supports provided to individuals in their own home or other community residential setting that promote their independence, inclusion, and personal goals.

Individualized Care Plan (ICP): The plan of care developed by an enrollee and an enrollee’s Interdisciplinary Care Team.

Integrated Care: Brings all Medicare and Medicaid covered benefits into one well-managed place so beneficiaries receive the right care at the right time and place. Integrated care uses a person-centered approach that takes into account individuals’ needs and preferences to

19 ensure they have seamless access to the full range of care, including medical care, behavioral health services, long-term services and supports and care coordination of all of these.

Integrated Care Organization (ICO): A health plan or provider-based organization contracted to provide integrated care to enrollees. Integrated Financing: The combining of Federal and state Medicare and Medicaid funds at the health plan level to pay for all covered services for people who are eligible for both Medicare and Medicaid and enrolled in an integrated care plan. Interdisciplinary Care Team (ICT): A team of primary care provider, Care Coordinator, and other individuals (if the enrollee wishes) that work with the enrollee to develop, implement, and maintain the Individualized Care Plan. Long-term services and supports (LTSS): A category that includes a variety of supportive services provided to people who have limits on their ability to perform daily activities, such as bathing or dressing. LTSS can be provided in nursing homes or other institutions, in people’s homes, or in community-based settings (such as adult day care centers). Medicaid is the primary government payer for most of these types of services. Managed FFS: A model in which providers are paid on a fee-for-service basis for a group of beneficiaries who are enrolled in care management programs designed to improve the quality of, and promote the appropriate use of, health care services. Managed LTSS: Long-term services and supports provided to Medicaid beneficiaries through managed care programs. The number of state Medicaid programs offering managed LTSS is growing rapidly. Medicaid: The health care program established under authority of Title XIX of the Social Security Act that covers medical assistance for low-income people who meet specific income and asset eligibility criteria. This federal program is carried out in cooperation with each state, which has its own Medicaid department or agency. Medicaid Waiver: Generally, a waiver of existing Medicaid law intended to let states try out new and different ways of serving their Medicaid beneficiaries. Medical Home: A model for delivering health care—increasingly being used by state Medicaid programs—in which a team of health care professionals, led by a primary care provider, coordinates the care given to an individual or family. (SEE ALSO “Health Home” ABOVE) Medically Necessary Services: Medically Necessary Services must be provided in a way that provides all protections to the enrollee provided by Medicare and Medicaid. Under Medicare rules, services must be reasonable and necessary for the diagnosis or treatment of illness or injury. In accordance with Medicaid law and regulations, this term means reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness, or injury.

Medicare: The federal health program to provide health care for people aged 65 and older, people younger than 65 with certain disabilities, and people with certain listed diseases.

20 Medicare Advantage: Medicare’s managed care program, known formally as “Medicare Part C.” (SEE BELOW). Most Medicare Advantage plans receive a capitated payment from Medicare in exchange for providing beneficiaries with all of the services covered by Parts A and B of Medicare (SEE BELOW). Roughly 20 percent of dual-eligible beneficiaries are enrolled in Medicare Advantage plans.

Medicare-Medicaid Coordination Office (MMCO): Formally named the Federal Coordinated Health Care Office, was established by the Affordable Care Act. It is part of the U.S. Department of Health & Human Services. Medicare Part A covers inpatient hospital services and certain other services, including skilled nursing facilities, and in-home care, provided by home health agencies. Medicare Part B covers physician services, outpatient services, some home health care, durable medical equipment, and laboratory services and supplies. Medicare Part C provides Medicare beneficiaries with the option of receiving Part A and Part B services through a private health plan. Such programs are called “Medicare Advantage” plans. Medicare Part D provides coverage for most prescription drugs. Medicare Waiver: Generally, a waiver of existing law authorized under Section 1115A of the Social Security Act. It lets states try out new and different ways of serving their Medicare beneficiaries. Member: A person enrolled in a managed care health plan, also called an “Enrollee.” Memorandum of Understanding (MOU): A document that guide how CMS and the State will work together to implement and operate the Demonstration. It also outlines the activities CMS and the State plan to conduct in preparation for implementation of the Demonstration. After all terms of the MOU are met, and qualified plans are selected, a three-way contract controlling the terms and conditions of the Demonstration can be signed by those plans, CMS and the state. Non-dual: A term used to describe Medicare beneficiaries who are not enrolled in Medicaid or Medicaid beneficiaries who are not enrolled in Medicare. Participating Plan: A health plan or other qualified entity serving as an Integrated Care Organization, selected by the State and CMS for participation in this Demonstration.

Passive Enrollment: An eligible individual is enrolled by the State (or its vendor) into a Participating Plan. Before this can happen, there needs to be a minimum 60-day advance notification period that includes the opportunity to choose a different one of the offered plans, or opt out of the Demonstration completely. Person-Centered Process: A planning process that recognizes the person receiving services as the primary expert in his or her own goals and needs. Post-acute Care: Recuperation and rehabilitation services provided to patients recovering after a stay in a hospital for acute care. Post-acute care is provided by skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities, among others.

21 Preferred Drug List: A list of medications covered by a health plan offering prescription drugs. Primary Care Provider: Your main health care provider. This may be a doctor, nurse practitioner, nurse midwife, or physician’s assistant. They help connect you to all the services you need, including care from specialists. Privacy Rules: Requirements established in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and implementing regulations, as well as relevant State privacy laws. Program of All-Inclusive Care for the Elderly (PACE): A health care program that receives capitated payments in exchange for offering specialized services to Medicare and Medicaid beneficiaries who are age 55 or older and who need the degree of care usually provided in nursing facilities. PACE provides beneficiaries with community-based long-term services and supports that are intended to help them remain in their home, rather than in an institution. These include physical improvements to make the home more accessible. In addition, PACE programs have their own facilities—which provide services such as adult day care and visits by physicians—and offer transportation between a beneficiary’s home and those facilities. Provider Directory: A list of doctors, clinics, pharmacies, and hospitals that are in a health plan’s network. Enrollees must use the providers in their health plan’s network. Readiness Review: Prior to entering into a three-way agreement with the State and CMS, each Integrated Care Organization selected to participate in the Demonstration has to have a full readiness review. The readiness review will evaluate each ICO’s ability to meet the Demonstration requirements, including, but not limited to: the ability to quickly and accurately process claims and enrollment information; accept and start providing service to new members; and provide adequate access to all Medicare- and Medicaid-covered medically necessary services. CMS and the State will use the results of the Readiness Review to help decide whether each ICO is ready to participate in the Demonstration.

Recovery Model: A framework for behavioral health that uses “recovery oriented” services. "Recovery oriented" systems shift the focus from illness and its symptoms to achieving wellness; custodial care to community integration; and seek meaningful outcomes such as health, home, purpose and community. Core practices within recovery-oriented systems include peer support, individual choice and person-driven approaches. Risk-Based Managed Care: A system in which a health care program contracts with health plans, most of which are privately run, to provide a set of covered benefits for a fixed amount of money per beneficiary. Those amounts may be adjusted to reflect the health risks of beneficiaries. Skilled Nursing Facilities (SNF): SNFs refer to nursing homes and rehabilitation facilities and provide nursing, rehabilitative, and medical care. Solvency: Standards for requirements placed on health plans participating in the demonstration on their cash flow, net worth, cash reserves, working capital requirements, insolvency protection and reserves established by the State and agreed to by CMS.

22 Special-Needs Plan (SNP): A type of Medicare Advantage plan that is designed to provide targeted services to Medicare beneficiaries who are in institutions, are dual-eligible beneficiaries, or have a severe or disabling chronic condition.

This sample Glossary of Terms builds on the work of the Congressional Budget Office; the CalDuals Initiative in partnership with the World Institute on Disability; and the Commonwealth of Massachusetts’ One Care. While this member handbook template glossary provides a helpful resource for training Consumer Advisory Committee members, a final Glossary of Terms should always be tailored to state-specific initiatives and to the needs of the individuals engaged.