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CMS to partner with Massachusetts to test patient-centered care for dual eligible enrollees

Posted on August 23, 2012 | No Comments

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Today, the U.S. Department of Health and Human Services (HHS) announced that Massachusetts will become the first State to partner with the Centers for Medicare & Medicaid Services (CMS) to test a new model for providing coordinated, patient-centered care to dual eligible individuals enrolled in both Medicare and Medicaid. Massachusetts and CMS will contract with Integrated Care Organizations (ICOs) to oversee the delivery of Medicare, Medicaid and expanded services for Medicare-Medicaid enrollees in Massachusetts.  The program is expected to launch on April 1, 2013.

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According to a working paper recently released by UnitedHealth Center, better coordination of care for individuals dually eligible for Medicare and Medicaid could result in savings of nearly $190 billion by 2022. According to the report, dual eligible spending is estimated to reach $330 billion in 2013. Of this total, about $150 billion will be dedicated to long-term care expenditures. The Centers for Medicare & Medicaid Services (CMS) is currently attempting to address dual eligible spending through a Financial Alignment Demonstration model. In one version of the model, a managed care plan receives blended payment streams of Medicare and Medicaid. The UnitedHealth Center report estimates that the model will cover about 20% of duals and proposes that states can institute more aggressive managed care models to more comprehensively address the health care needs of this population.
Dual-eligible beneficiaries are low-income seniors and individuals with disabilities enrolled in both Medicare and Medicaid. In 2010, there were about 9.9 million dual-eligible beneficiaries. Both programs have requirements to protect the rights of beneficiaries. The Government Accountability Office (GAO) released a report which (1) compared selected consumer protection requirements within Medicare FFS and Medicare Advantage, and Medicaid FFS and managed care, and (2) described related compliance and enforcement actions taken by CMS and selected states against managed care plans. Medicare and Medicaid consumer protection requirements vary across programs, payment systems and states. Within Medicare, enrollment in managed care through the Medicare Advantage (MA) program must always be voluntary, whereas state Medicaid programs can require enrollment in managed care in certain situations. In addition, Medicare and state Medicaid programs require managed care plans to meet certain provider network requirements. Subject to federal parameters, states also establish network requirements for their Medicaid programs. Finally, Medicare and Medicaid have different appeals processes that do not align with each other. The Medicare appeals process has up to five levels of review for decisions to deny, reduce, or terminate services, with certain differences between FFS and MA. In Medicaid, states can structure appeals processes within federal parameters. States must establish a Medicaid appeals process that provides access to a state fair hearing and Medicaid managed care plans must provide beneficiaries with the right to appeal to the plan, though states can determine the sequence of these appeals.
The Centers for Medicare and Medicaid Services (CMS) has proposed two models to align financing for beneficiaries eligible for both Medicare and Medicaid benefits, or dual eligibles. One is a capitated model and one a managed fee-for-service model. In the spring of 2012, 26 states submitted proposals to CMS seeking to test one or both of these models. CMS is presently reviewing the states' proposals to determine which will be implemented. According to a report released by the Kaiser Family Foundation's Commission on Medicaid and the Uninsured (KCMU), 21 of the 26 states that have submitted demonstration project proposals include a plan to insure all dual eligibles in their proposal. CMS has said that it will include as many as 2 million (out of the 9.1 million people eligible for both Medicare and Medicaid nationally) dual eligible beneficiairies in the demonstration project. The remaining 5 states have issued restrictions based on age, diagnosis, and/or service in their proposals. 23 of the 26 states plan to use a passive enrollment system to cover dual eligibles. In other words, the duals would be covered unless they actively chose to opt out of the program.
The Robert Wood Johnson Foundation published a report by grantee Mark A. Hall, J.D., entitled "Employers’ Use of Health Insurance Exchanges: Lessons from Massachusetts." Hall, a professor of law and public health in the Division of Public Health Sciences at Wake Forest University Medical School, is completing a qualitative investigation of employers’ use of the Massachusetts Connector in order to inform states and the federal government about best strategies for the design and operation of the Affordable Care Act's (ACA's) small-group health insurance exchanges and market regulations.
9 percent or 1.2 million of the population eligible to enroll in both Medicare and Medicaid are enrolled in the 322 Medicare dual-eligible special needs plans (D-SNP), a type of Medicare Advantage plan. The Democratic members of the House Ways and Means and Energy and Commerce committees asked the Government Accountability Office (GAO) to examine these dual eligible SNPs. GAO (1) analyzed the characteristics of dual-eligible beneficiaries in D-SNPs and other MA plans, (2) reviewed differences in specialized services between D-SNPs and other MA plans, and (3) reviewed how D-SNPs work with state Medicaid agencies to enhance benefit integration and care coordination. GAO analyzed CMS enrollment, plan benefit package, projected revenue, and beneficiary health status data; reviewed 15 D-SNP models of care and 2012 contracts with states; and interviewed representatives from 15 D-SNPs and Medicaid agency officials in 5 states. The GAO report found...
Jane Hyatt Thorpe and Katherine Jett Hayes recently released an article funded by the Association for Communication Affiliated Plans (ACAP), "A New State Plan Option to Integrate Care and Financing for Persons Dually Eligible for Medicare and Medicaid," which reviews barriers to clinical and financial integration in services for dual eligibles prior to passage of the ACA, identifies models used by states to integrate care through contract and waiver authorities available to CMS prior to passage of the ACA, describes two new demonstrations proposed by CMS through the Medicare-Medicaid Coordination Office and Innovation Center, and introduces a state plan option as a new model for consideration by federal and state policymakers. This new model draws on experience from existing programs and waivers to provide a permanent state plan option for a fully integrated, capitated care model that could be made available to states prior to the completion of the demonstration process begun by the Medicare-Medicaid Coordination Office and Innovation Center.
The current lack of coordination between Medicare and Medicaid creates barriers for dual eligibles to access care. Additionally, although they comprise only 15% of all Medicaid beneficiaries, dual eligibles account for nearly 40% of Medicaid expenditures. America's Health Insurance Plans (AHIP), a national trade association which represents much of the health insurance industry, recently released a proposal to address the serious fiscal and access challenges associated with dual eligibility. AHIP provides a menu of models for Medicare/Medicaid integration, which groups six models into three alternative approaches suited to States with varying readiness for integration. To learn more about dual eligibles, click here.
"Refocusing Responsibility For Dual Eligibles: Why Medicare Should Take The Lead," a new paper authored by researchers at the Urban Institute and funded by the Robert Wood Johnson Foundation, explores why Medicare, as opposed to the States or Medicaid, should take responsibility for dual eligibles. The authors rationalize that acute care, where savings and quality improvement are most readily achievable, best falls under Medicare's umbrella. According to the paper, enhancing State responsibility for overall spending, on the other hand, would increase the risk of cost-shifting to Medicare, which could potentially undermine the quality of care for vulnerable beneficiaries.
The Centers for Medicare & Medicaid Services (CMS) announced seven awards partnering with 145 nursing facilities to implement the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. The CMS initiative will test models to improve health care delivery quality and reduce the number of preventable rehospitalizations among nursing facility residents. The initiative will fund organizations to provide additional support to members of nursing facility communities. Many nursing facility residents are enrolled in both Medicaid and Medicare, and are thus known as dual eligibles. Dual eligibles are the most chronically ill patients served by the two programs. Research found that approximately 45 percent of hospitalizations among duals receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided. Total costs for these potentially avoidable hospitalizations for Medicare-Medicaid enrollees for 2011 were estimated to be between $7 and 8 billion. CMS will partner with seven organizations to improve care for long-stay nursing facility residents. These organizations will collaborate with nursing facilities and State Medicaid programs to provide better quality of care in nursing facilities. For more information on the initiative, click here.
The Affordable Care Act (ACA) included a number of provisions designed to improve the delivery of health and long-term care support services for individuals who are eligible for and enrolled in both the Medicare and Medicaid programs, commonly referred to as “dual eligible.” An earlier Health Reform GPS Implementation Brief outlined these changes. Among the provisions identified in the Brief was new demonstration authority provided to the Department of Health and Human Services (HHS) to permit states to waive certain provisions of Medicare law to better coordinate care for dual eligibles, new grant funding available to as many as 15 states to plan and implement integrated programs of care for dual eligibles, and the release of a July 11 State Medicaid Director (SMD) Letter providing preliminary guidance to states on demonstration models designed to improve care coordination for dual eligibles, including both capitated and fee-for-service models. This Brief provides an update on the financial alignment model outlined in the SMD letter, with a focus on subsequent guidance to states and health plans seeking to participate in capitated demonstrations. This demonstration is being followed closely at the federal level, and both...