Back­ing out

Many in dual-el­i­gi­ble pilot drop out, de­lay plans

Modern Healthcare - - LATE NEWS - Rich Daly

Re­al­ity is squeez­ing down what had been a mas­sive pilot pro­ject tar­get­ing the dis­pro­por­tion­ately ex­pen­sive care for Amer­i­cans en­rolled in both Medi­care and Med­i­caid. More than half of the states that ap­plied to par­tic­i­pate in the con­tro­ver­sial CMS demon­stra­tion have ei­ther dropped out or de­layed their pro­grams, ac­cord­ing to the CMS and health pol­icy ex­perts.

Among the 26 states that ap­plied to en­roll 3 mil­lion ben­e­fi­cia­ries in the CMS Fi­nan­cial Align­ment Ini­tia­tive, six have dropped out or opted for dif­fer­ent “cus­tom­ized” plans and nine have de­layed their start dates. The am­bi­tious pro­gram was au­tho­rized by the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

Dual-el­i­gi­bles make up 15% of Med­i­caid en­rollees and con­sume 39% of its ex­pen­di­tures, said Me­lanie Bella, di­rec­tor of the Medi­careMed­i­caid Co­or­di­na­tion Of­fice at the CMS. Like­wise, dual-el­i­gi­bles ac­count for 18% of Medi­care ben­e­fi­cia­ries and 31% of its bud­get.

Ad­vo­cates for ben­e­fi­cia­ries and providers have crit­i­cized the state projects for their size, scope and ag­gres­sive time­frames, which had some start­ing as soon as early 2013 and the rest by Jan­uary 2014.

But none may launch this year and few by early next year. “The time­lines were al­ways too am­bi­tious; it’s tak­ing even longer to get stuff set up than they thought it would,” said Kevin Prindiville, deputy di­rec­tor of the National Se­nior Cit­i­zens Law Cen­ter.

Three states—Arizona, New Mex­ico and Ten­nessee—of­fi­cially an­nounced they are drop­ping out of the pro­gram, said Caro­line Pear­son, vice pres­i­dent at Avalere Health. Mean­while, Ore­gon, Min­nesota and Wis­con­sin are look­ing to change their pro­pos­als into ones that might fit other CMS projects, a CMS of­fi­cial said.

Nine other states have ac­knowl­edged pub­licly or to health pol­icy ex­perts that they will de­lay their pro­grams, in­clud­ing three of the six that have re­ceived CMS ap­proval to start: Cal­i­for­nia, Mas­sachusetts and Wash­ing­ton. Mean­while, Hawaii, Iowa, Michi­gan, Mis­souri, New York and Ver­mont have not re­ceived ap­proval but also plan to de­lay their start dates, ac­cord­ing to sources track­ing the demon­stra­tion.

A com­mon rea­son cited for the delays is the rate-set­ting process for in­sur­ance plans that would be re­spon­si­ble for man­ag­ing dual-el­i­gi­bles’ health to im­prove care while re­duc­ing spend­ing. “It’s taken a long time to fig­ure out what the rates are go­ing to be, and that’s an on­go­ing is­sue,” Prindiville said.

In­sur­ers dis­agreed. Joe Moser, in­terim ex­ec­u­tive di­rec­tor of Med­i­caid Health Plans for Amer­ica, said in a writ­ten state­ment that the delays chiefly stemmed from ne­go­ti­a­tions be­tween states and the CMS. “Work­ing out the pa­per­work, set­ting the rules, com­mu­ni­cat­ing the rules to health plans, and then mak­ing sure the health plans are ready to pro­vide cov­er­age has taken longer than some had hoped or ex­pected but is not sur­pris­ing to us given the scope of the un­der­tak­ing here,” Moser said.

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