CMS gives states 3 options to test care models for dual eligibles

The Centers for Medicare and Medicaid Services is looking for states to take shared accountability in new methods to integrate care between beneficiaries eligible for both Medicare and Medicaid.

Approaches include the capitated financial alignment model, a joint contract between CMS, states and health plans to provide Medicare and Medicaid services for enrollees for a set capitated dollar amount.

Another is the managed fee-for-service model. This is a partnership between CMS and the participating state which allows states to share in Medicare savings for innovative services covered on a fee-for-service basis.

A state-specific model tests ideas brought by states to better serve dually eligible individuals.

WHY THIS MATTERS

Less than 10 percent of dually-eligible beneficiaries have integrated care services across Medicare and Medicaid, according to CMS Administrator Seema Verma.

CMS and states spend over $300 billion per year on the care of the 12 million dually-eligible individuals, but health outcomes remain below acceptable standards.

Many beneficiaries have complex healthcare issues such as multiple chronic conditions and socioeconomic risk factors.

In a letter to state Medicaid directors, CMS said it wants to address those complex needs, align incentives, encourage marketplace innovation through the private sector, lower costs, and reduce administrative burdens.

TREND

Today's letter complements a state Medicaid director letter CMS released in December 2018 that highlighted 10 opportunities to improve care for dually- eligible individuals, including using Medicare data for better care coordination and program integrity initiatives, and reducing administrative burden.

ON THE RECORD

"Less than 10 percent of dually-eligible individuals are enrolled in any form of care that integrates Medicare and Medicaid services, and instead have to navigate disconnected delivery and payment systems," Verma said. "This lack of coordination can lead to fragmented care for individuals, misaligned incentives for payers and providers, and administrative inefficiencies and programmatic burdens for all."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com