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Analysis

CMS Pushes Integrated Care Models for Dual Eligibles

By John Commins  
   April 24, 2019

States are encouraged to adopt integrated care models for serving dual eligibles, with options that include capitated payments, managed fee-for-service, and state-specific models.  

States are being invited to partner with the federal government in integrated care models designed to improve outcomes for the nation's 12 million dual eligible enrollees in Medicare and Medicaid.

"Less than 10% 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," Centers for Medicare & Medicaid Services Administrator Seema Verma said in a media release.

"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. We must do better, and CMS is taking action, Verma said.

In a letter this week to state Medicaid directors, Verma encouraged them to work with the federal government to address the complex needs of dual eligibles, who often have multiple chronic and mental health and socioeconomic risk factors that can lead to poor outcomes.

"Historically, dually eligible individuals have accounted for 20% of Medicare enrollees, yet 34% of Medicare spending. The same individuals have accounted for 15% of Medicaid enrollees and 33% of Medicaid spending. Across both programs, that equates to over $300 billion in state and federal spending each year," Verma said.

"Improving care for this population provides opportunities for state and federal governments to achieve greater value from our Medicare and Medicaid investment," she said. "This is especially critical as Medicaid spending is already among the two largest items in most state budgets and as more of the baby boom generation ages into Medicare eligibility each day."

Verma told the state Medicaid directors that CMS was considering several care options for dual eligibles, including:

  • 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 basis.
     
  • State-Specific Models. CMS is open to partnering with states on testing new state-developed models to better serve dually eligible individuals and invite states to come to us with ideas, concept papers, and/or proposals.

This week'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 to inform care coordination and program integrity initiatives, and reducing administrative burden for dually eligible individuals and the providers who serve them.

“Less than 10% 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.”

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

Photo credit: Michael Wick / Shutterstock


KEY TAKEAWAYS

CMS Administrator Seema Verma is encouraging state Medicaid directors to work with the federal government to address the complex needs of dual eligibles.

Dual eligibles account for 20% of Medicare enrollees and 34% of Medicare spending. They also account for 15% of Medicaid enrollees and 33% of Medicaid spending.


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