A longstanding barrier to care coordination for Medicare-Medicaid enrollees has been the financial misalignment between the two government programs. In addition, care is often fragmented for patients, who have to navigate multiple sets of rules, benefits, cards and providers for Medicare A/B, Part D, and Medicaid.
To help improve care coordination for these patients, Massachusetts will become the first state to partner with the Centers for Medicare & Medicaid Services in the Financial Alignment Demonstration to test a new model for individuals enrolled in both Medicare and Medicaid – also known as dual eligibles.
Announced Aug. 23, the demonstration will provide enrollees of the two government programs with a better coordinated, more person-centered care experience.
Targeting dual eligibles is a priority for CMS because total annual spending for their care exceeds $300 billion across both programs.
Under the Demonstration, Massachusetts and CMS will contract with Integrated Care Organizations that will coordinate the delivery of and be accountable for all covered Medicare, Medicaid, and expanded services for participating Medicare-Medicaid enrollees in Massachusetts ages 21 to 64. Through the demonstration, about 110,000 Medicare-Medicaid enrollees in Massachusetts will have an opportunity to receive better, more coordinated care.
Through the demonstration, Massachusetts will offer expanded and enhanced healthcare services, such as additional dental care, vision, and durable medical equipment benefits to dual eligibles participating in the program. In addition, Medicare-Medicaid enrollees will also have access to new services meant to promote community supports as alternatives to long-term institutional services, as well as new behavioral health services for individuals with serious mental illness and substance abuse disorders.
The program is designed for Medicare-Medicaid enrollees participating in the demonstration to have a more comprehensive and coordinated care experience. Dual eligibles will have the ability to shape and direct the care they receive by developing an individualized care plan under the demonstration.
Teams consisting of a primary care provider, care coordinator, independent long-term services and supports (LTSS) coordinator, and other care providers, will deliver care to dual eligible patients.
The new demonstration includes important protections for beneficiaries that will ensure high-quality care is delivered. CMS and Massachusetts have established a number of quality measures relating to the beneficiary and caregiver overall experience of care, care coordination, and fostering and supporting community living, among many others. In addition, all ICOs will include Medicare-Medicaid enrollee participation in their governance structure.
Under the demonstration, CMS will test two payment methods for their effectiveness – the capitated model and the managed fee-for-service model. In the capitated model, a state and CMS contract with a health plan or other qualified entity that receives a prospective, blended payment to provide enrolled Medicare-Medicaid enrollees with coordinated care.
In the managed fee-for-service model, a state and CMS enter into an agreement by which the state would be eligible to benefit from savings resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid.
Beneficiaries will be able to voluntarily enroll in the demonstration beginning in April 2013. In July and October of 2013, eligible beneficiaries who have not enrolled will be enrolled in a demonstration plan and be provided with the choice to opt out of the demonstration or select an alternate demonstration plan.
To participate in the Financial Alignment Demonstration, each state had to submit a proposal outlining its proposed approach for the demonstration. A total of 26 states have submitted proposals. Up to 2 million dual eligibles nationwide could be service collectively with these programs. CMS will choose 15 states to receive design contracts under the State Demonstrations to Integrate Care for Dual Eligible Individuals.
CMS will evaluate the demonstrations’ ability to improve quality and reduce costs. Meaningful engagement with stakeholders and ensuring beneficiary protections will be a crucial part of developing and testing these models, CMS says.