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All 13 Duals-Demo States Submit Nonbinding Extension Requests

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By James Gutman, Managing Editor
October 29, 2015Volume 21Issue 21

The CMS Medicare-Medicaid Coordination Office has received letters from all 13 states participating in the three-year integration demonstration for dual eligibles of intent to stay in the demo under terms of the two-year extension the agency offered this summer (MAN 7/30/15, p. 1), MMCO Director Tim Engelhardt told MAN Oct. 20. But the letters are nonbinding, as Engelhardt pointed out, and there are at least three states in which participation in the extension still is uncertain and may depend partly on action by the state legislatures.

One of those states is Texas, which asked for a host of changes as part of its extension-request letter and for which, Engelhardt said in his Oct. 20 comments at the America’s Health Insurance Plans’ Dual Eligibles Summit in Washington, D.C., there are “some things we need to do.” He didn’t elaborate on what those things are.

Other states were not specifically identified by Engelhardt in his brief remarks at the conference, but include California. Under state law, California must give notice by the beginning of 2016 that it will pull out of the demo effective Jan. 1, 2017, unless state officials can show the demo has met its projections for cost savings (MAN 6/27/13, p. 1). The state’s budget office said this January that the demo has not been doing so, but it is later data due out next month that will determine the decision, Martha Smith, chief officer in the dual-eligible program of Health Net, Inc., told MAN. Health Net has the largest single-state duals program in the demo with about 25,000 California members

Also, Virginia intends to start a large-scale Medicaid managed long term services and supports (MLTSS) initiative in July 2016 that would include duals who either opted out or were not eligible for the ongoing CMS-backed duals demo there. In a memo to stakeholders Sept. 15, after it had sent the extension acceptance letter to the MMCO, Virginia’s Department of Medical Assistance Services referred in two places to its CMS-backed duals demo ending in December 2017 and said the demo “ceases to enroll new participants starting June 30, 2017.” One participant in the state’s demo, Centene Corp., said in its third-quarter earnings conference call Oct. 27 that Virginia is not expecting to extend the demo.

Low Enrollment Keeps Hampering N.Y. Demo

Moreover, New York’s long-term-care-focused duals demo continues to have major problems attracting enrollees and is seeking to make changes in care management systems as part of its extension. AIS’s DUAL database this month reported the demo has enrolled only 9,942 duals since January out of about 170,000 eligibles. MMCO and plans have had “special challenges” in that state’s demo, acknowledged Engelhardt, partly including the need for “utterly massive” investments, especially in infrastructure. He praised participants for making those investments. Another big hurdle in New York has been the large volume of opt-outs, and he said the demo there needs “more provider engagement and buy-in.” Engelhardt noted that the level of market penetration in New York’s demo is “not even remotely close” to what it is in other demo states.

Despite all of the obstacles in these and other states, there also are signs of progress in the CMS duals demo, based on the presentations by Engelhardt and several plan executives at the AHIP conference.

The overall demo now has about 400,000 enrollees, and “we have created a product line that’s integrated,” said Engelhardt, for instance, although he acknowledged that the Medicare and Medicaid components aren’t “fully integrated yet.” And while “it’s going to be a little while” until CMS’s external review can evaluate whether the demo is meeting its goals, the “initial signs are very positive,” he added.

Similarly, although Virginia Premier Health Plan, Inc. still considers finding its dual members for care integration purposes “a challenge,” its membership in the demo now has “stabilized” at about 5,000, said Richard Gordon, director, Medicare duals network development for the plan. He told a duals implementation session at the AHIP conference that the plan has added 4,000 providers to its network for the duals demo and now is seeing “light at the end of the tunnel.”

Health Net’s data are starting to show that the demo model is successful, said the insurer’s Smith. Although the California opt-out rate continues to be “higher than expected” at between 55% and 60% overall and 70% in Los Angeles County, she added, Health Net has found ways to reduce the rate by such means as new financial-incentive programs for providers and caregivers.

And Lisa Rubino, senior vice president, strategic products at Molina Healthcare, Inc., which participates in the demo in six states where it now has a combined membership of 60,000 duals, said she found it “very encouraging” that spending on home- and community-based services now exceeds “institutional spend” for the first time.

© 2015 by Atlantic Information Services, Inc. All Rights Reserved.

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