CMS Accepts State's Proposal To Coordinate Care for Dual Eligibles

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BOSTON--Federal and state officials Aug. 23 announced that Massachusetts will become the first state to implement a new coordinated care model covering adults who are eligible for both Medicare and Medicaid.

The pilot program for about 111,000 “dual eligibles” in Massachusetts will test a capitated financial model, under which integrated care organizations (ICOs) will receive a prospective payment to provide Medicare-Medicaid enrollees with coordinated care. The state said the demonstration will focus on disabled adults.

Last year, the Centers for Medicare & Medicaid Services announced that it would seek demonstration projects to test two models, capitated arrangements and managed fee-for-service, under the provisions of the Patient Protection and Affordable Care Act (see previous article).


The demonstration program will enable Massachusetts to offer expanded and enhanced services for adults ages 21-64, such as additional dental care, vision, and durable medical equipment benefits.  


“By entering this agreement with the Obama Administration, we continue to be a leader in providing integrated, high quality care for our residents with complex needs,” Gov. Deval Patrick (D) said in a statement.

“This program also will decrease costs by providing better coordination of care,” added JudyAnn Bigby, Massachusetts secretary of health and human services.

CMS says that total annual spending for dual eligibles currently exceeds $300 billion and that beneficiaries are required to navigate multiple sets of rules, benefits, cards, and providers.

ICOs to Influence Utilization Patterns.

“The current lack of integration fosters cost-shifting and underinvestment,” the state wrote in its proposal for the demonstration project. “The lack of alignment between Medicare and [Medicaid] coverage rules creates incentives for providers to shift costs by transferring patients from one service or setting to another,” increasing both state and federal spending over time, it said.

“Savings should grow over time as ICOs influence utilization patterns by helping enrollees stay well, manage chronic conditions, gain better access to coordinated behavioral health services, and remain in community settings longer,” the proposal stated.

The demonstration program will enable the state to offer expanded and enhanced services for adults ages 21-64, such as additional dental care, vision, and durable medical equipment benefits. They also will have access to alternatives to long-term institutional services, as well as new behavioral health services.

Care will be delivered through teams that include a primary care provider, care coordinator, and independent long-term services coordinators.

Massachusetts already has put the program out for bids and selected integrated care organizations are expected to begin accepting enrollments in January 2013 for coverage starting in April 2013.

In July and October 2013, eligible beneficiaries who have not enrolled will be placed in a demonstration plan, but they will be able to opt out or to switch to an alternate plan. The Massachusetts Medicaid program will manage enrollments and disenrollments from the plans.

By Rick Valliere  

The Massachusetts proposal is at More information is at