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Medical Coding News Archives

Integrated Care Demonstration for ‘Dual Eligibles’

July 18, 2011:

Regina Magnani, Clinical/Technical Editor

Those who receive both Medicare and Medicaid benefits (dual eligibles) are the focus of states’ new care models designed to improve the way they get health care.

The Affordable Care Act of 2010 created the Medicare-Medicaid Coordination Office with the goal of serving people who receive benefits from both Medicaid and Medicare. In partnership with states, the office is working on developing new ways to provide care to this population.

In December 2010, the Centers for Medicare & Medicaid Services invited states to submit proposals to integrate care for dual eligible individuals. All states were eligible to submit a proposal explaining how the state would design person-centered models that coordinate primary, acute, behavioral, and long-term supports and services for Medicare-Medicaid enrollees. A technical review panel selected 15 states to receive up to $1 million to support the design of their proposed program. The 15 states are California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington, and Wisconsin.

The 12-month design period began April or May 2011, depending on the state’s contract. The design contract will be a detailed demonstration model describing how each state would structure and implement its proposed integrated program. States are required to work closely with their stakeholder community during the design phase to ensure broad and ongoing input on their implementation proposal. All final proposals will undergo federal review. CMS will work with states to implement the plans that hold the most promise.

State proposals are varied. For example, Vermont plans to become a managed care entity to manage both Medicare and Medicaid services for the dual eligibles. As part of Vermont’s broader statewide delivery system reform and community-based infrastructure development for integrating care, the state would expand its current practices and more comprehensively link case management services offered for dual eligibles to improve the coordination of primary, acute, and long-term care.

Michigan, on the other hand, proposes to integrate Medicare and Medicaid funds to deliver all covered services for dually eligible beneficiaries. The state proposes to contract with one or more entities to administer the program under an acuity-based capitation arrangement. Risk would initially be shared between the state and the contracted entities, with full risk eventually transferred to the contractors. The core of the delivery model would be a strong care coordination program with each enrollee having a health home focused on person-centered care.

Oregon proposes a similar model, blending Medicare and Medicaid funds to contract with regional plans to provide coordinated acute and behavioral health services for dual eligible individuals. This delivery model would also require person-centered plans for those with the most acute needs and would phase in health homes for all beneficiaries as soon as possible. The program for dual eligibles would be part of a broader effort to provide integrated care for all Medicaid and Children’s Health Insurance Program (CHIP) enrollees.

The full proposals for Vermont, Michigan, Oregon, and the other 12 states awarded design contracts are available at: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-MedicaidCoordination.html. Click on “State Design Contract Summaries” in the box on the left.


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