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Meaningful Health Care Informatics Blog

Jul 10 2011   9:37PM GMT

CMS is testing new reimbursement models for patients with dual membership

Posted by: RedaChouffani
Dual eligibles, Health care reform, HHS, Medicaid, Medicare, Reform

As we continue to be reminded of the state of our deficit and the need to raise the debt ceiling, the Center for Medicare & Medicaid Services (CMS) is continuing to push through and test different initiatives that will help cut costs in the health care arena. Many state leaders are already feeling the pressure, pleading against the looming Medicaid cuts included in the recent debt ceiling talks. This leaves no options for HHS except to test different models that focus on coordinated care, promoting and rewarding for healthier lifestyles, reducing the overall cost of care at a systemic level.

Currently, CMS is working to increase the number of enrollees in the Medicare-Medicaid system to coordinate care. The intent is to take advantage of collaborating on patient care to achieve an increase in quality and reduction in cost at both the state and federal levels.

The different initiatives that are being proposed for testing are specific to patients under the Medicare-Medicaid program, i.e. the dual eligibles. The idea is to test different models under which CMS will better align the financing of the two programs, integrating primary, acute, behavioral health and long term care services.

The models listed are:

  • Capitated Model: A State, CMS, and a health plan enter into a three-way contract, and the plan receives a prospective blended payment to provide comprehensive, coordinated care.
  • Managed Fee-for-Service Model: A State and CMS enter into an agreement by which the State would be eligible to benefit from savings resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid.

The CMS Center for Medicare and Medicaid Innovation will test these models to determine whether they save money while preserving or enhancing the quality of care for Medicare-Medicaid enrollees.  Interested States can send a letter of intent and work with CMS to determine whether they meet established standards and conditions.  The Innovation Center will approve qualifying States that collectively serve up to 1 to 2 million dual eligibles.

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