By Elena Eyber, J.D.
CMS invited states to partner with CMS to test three innovative approaches to better serve individuals dually eligible for Medicare and Medicaid.
CMS described three new opportunities to test state-driven approaches to integrating care for dually eligible individuals. The first opportunity is integrating care through the capitated financial alignment model. The second opportunity is integrating care through the managed fee-for-service model. The third opportunity includes new state-specific models (CMS Letter, SMDL #19-002, April 24, 2019).
Dually eligible individuals are enrolled in Medicare because of age or disability and qualify for Medicaid based on income. Such individuals experience high rates of chronic and mental illnesses, and account for a disproportionately large share of Medicare and Medicaid expenditures. Improving care for this population provides opportunities for state and federal governments to achieve greater value from Medicare and Medicaid investment.
The Capitated Financial Alignment Model. Through a joint contract with CMS, states and health plans, this model option creates a way to provide the full array of Medicare and Medicaid services for enrollees for a set capitated dollar amount.
Managed Fee-for-Service Model. This model is a partnership between CMS and the participating state and allows states to share in Medicare savings from innovations where services are covered on a fee-for-service (FFS) basis or combinations of capitated managed care and FFS.
State-Specific Models. CMS is open to partnering with states on testing new state-developed models to better serve dually eligible individuals and invites states to come to CMS with ideas, concept papers, and/or proposals.
This CMS Letter complements CMS Letter released December 19, 2018 highlighting ten opportunities to improve care for dually eligible individuals, including using Medicare data to inform care coordination and program integrity initiatives, and reducing administrative burden for dually eligible individuals and the providers who serve them.
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