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New KCMU report finds most states will aim to cover dual eligibles in demonstration projects

Posted on October 30, 2012 | No Comments

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Key Developments
Implementation Briefs

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.

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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.
The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health of Health and Human Services (HHS) has announced a new round of initiatives to help improve quality and cost of care for individuals who are eligible for both Medicare and Medicaid. CMS has issued three fact sheets, along with preliminary guidance in the form of a State Medicaid Director Letter (SMDL), further outlining these initiatives. They involve upcoming demonstrations on new financial models for improved care coordination, efforts to improve nursing home care quality, and information on a new technical assistance resource center that will help states better serve high-cost, high-need beneficiaries.
The U.S. Department of Health and Human Services (HHS) has issued a Request for Comment (RFC) on opportunities for aligning benefits and incentives to improve overall care for individuals eligible for both Medicare and Medicaid.
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...
According to the Centers for Medicare and Medicaid Services (CMS), in 2008 there were an estimated 9.2 million individuals who were eligible for and enrolled in both the Medicare and Medicaid programs (commonly referred to as “dual eligibles”). Two-thirds of dual eligibles qualify because they are over age 65, while the other third qualify because of a disability. Dual-eligible beneficiaries typically have multiple chronic conditions that require a higher level of care and result in increased spending relative to other Medicare and Medicaid beneficiaries; however, their care is not usually coordinated. Policymakers have expressed concern that the lack of coordination between the two programs results in higher costs and poorer health outcomes than would be achieved if Medicare and Medicaid services were better integrated.
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.
The Measure Applications Partnership (MAP), a public-private group of stakeholders working with the National Quality Forum (NQF) submitted the report, "Strategic Approach to Performance Measurement for Dual Eligible Beneficiaries," to the Department of Health and Human Services (HHS) to detail potential health care quality measures for dual eligibles under the Affordable Care Act (ACA). Dual eligible members account for a disproportionate share of Medicare and Medicaid spending. While dual eligibles make up only 15% of Medicaid enrollees, they account for 39% of all Medicaid expenditures. Similarly, dual eligibles account for 16% of Medicare enrollees and 27% of program expenditures. The MAP report proposes a broad outline for measuring health care quality for dual eligibles and for identifying difficulties in obtaining comprehensive treatment data. The five measures of quality that HHS could use to improve care and control spending for dual eligibles include 1) quality of life, 2) care coordination, 3) screening and assessment, 4) mental health and substance abuse, and 5) structural measures.
The AARP has released a new study analyzing care management practices in integrated care models serving dual eligibles.