The Centers for Medicare & Medicaid Services (CMS) announced plans Wednesday to expand coverage options for Americans who qualify for both Medicare and Medicaid, giving states the freedom to develop their own programs for dual-eligible beneficiaries.
While the directive doesn’t outline specific opportunities for home-based care providers, the move is still encouraging for the industry, at least one executive in the space believes.
“It represents continued CMS recognition of the value of coordination of care and looking to lower-cost providers and lower-cost settings, caring for people in the home and not in institutions,” Addus HomeCare Corporation (Nasdaq: ADUS) Executive Vice President and Chief Development Officer Darby Anderson told Home Health Care News. “Home care providers should feel encouraged by CMS’s recognition of this and promotion of these kinds of opportunities.”
In a letter to state governors, CMS Administrator Seema Verma explained the need to better integrate care for more than 11 million Americans currently enrolled in both Medicare and Medicaid, inviting states to participate in existing test programs for dual-eligible coverage or develop unique programs of their own.
“Our goal is to bring shared accountability for creating a more seamless experience for beneficiaries and providers across the two programs, while ensuring that the Medicaid programs’ incentives are aligned and pointed toward lower cost and better outcomes,” Verma wrote.
Dually eligible beneficiaries have higher rates of chronic illness, along with more chronic conditions and social risk factors than their singularly eligible counterparts. But because the rules governing federal Medicare and state Medicaid differ — and the programs communicate infrequently — dually eligible beneficiaries rarely have a single resource to use to maximize their benefits.
In fact, only 10% of dual-eligibles are currently enrolled in integrated care programs, Verma’s letter states.
“These challenges have contributed to sub-optimal health outcomes, despite our shared investment of over $300 billion a year to serve this population,” she wrote. “In many states, dually eligible individuals account for over a third of state spending on Medicaid.”
The options
The CMS directive encourages states to test one of three integrated models to improve care and maximize savings for dual-eligibles.
The first option is the capitated financial alignment model, in which Medicare and Medicaid team up with health plans known as Medicare-Medicaid Plans (MMPs) to provide a one-stop contract for dual-eligibles.
Nine states currently use this model on a pilot basis, which has been extended through 2023 and opened to any other state interested in participating. So far, the programs have achieved an estimated savings of 4.4% and 90% of users rating their experience as a seven or higher on the 0-to-10 satisfaction scale.
The second option is the managed fee-for-service model. It would encourage shared savings between Medicaid and Medicare.
In Washington, the model has generated 11% savings to Medicare Parts A and B, along with improvements in quality and enrollee satisfaction. However, a similar program in Colorado was not successful.
The final option allows states to create their own models for dually eligible beneficiaries. Still, the ultimate goal is to coordinate care, while reducing Medicare and Medicaid costs and improving outcomes.
“I encourage you to talk to your health policy staff and state Medicaid leadership about these opportunities to better serve those older adults and people with disabilities,” Verma wrote in the letter. “The Trump administration stands ready to partner with you and your staff on this important challenge.”
Addus, whose population is largely made up of dual-eligibles, is equally bullish on all three opportunities, Anderson said.
“We’d be willing to participate with anybody that is taking the responsibility and financial risk of coordinating both Medicaid and Medicare services,” he said. “In short, we’re kind of agnostic to the actual model because we feel like we can be supportive and beneficial to either type of program.”
Because Addus has a large percentage of Medicaid and senior clients, a substantial portion of its population is dually eligible.
“We would like to grow our dually eligible populations specifically through the expansion of dual-eligible projects such as [those] CMS is recommending.”
Additional reporting by Alex Spanko
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