CMS, Texas Partner to Coordinate Care for Dual Eligibles

On May 23, the Centers for Medicare & Medicaid Services (CMS) announced it's partnering with Texas to test a new model for providing Medicare-Medicaid enrollees with more coordinated care. The demonstration builds on Texas’ STAR+PLUS Medicaid HMO program in six counties: Bexar, Dallas, El Paso, Harris, Hidalgo, and Tarrant. In total, 168,000 individuals will be eligible to enroll in the demonstration. 

Under the demonstration, Medicare-Medicaid Plans (MMPs) will cover Medicare benefits in addition to the existing set of Medicaid benefits they currently offer under STAR+PLUS, allowing for an integrated set of benefits for enrollees.

Texas physicians who care for dual-eligible patients say they see the need for better coordination but remain concerned about how well the demonstration project will work.

"I'm all for saving money in a program that's very fragmented. It's crazy to have to go to Medicaid for some things and Medicare for others. And from the patient side, it would be simpler if it works out the way it shows on paper," San Antonio pulmonologist John Holcomb, MD, told Texas Medicine in an article in the May 2014 issue of the magazine. "But the devil is always in the details, and we just don't have much faith that managed care companies are really going to do what needs to be done to coordinate care for these patients."

To ensure each MMP can serve Medicare-Medicaid enrollees, all participating plans must first meet core Medicare and Medicaid requirements, state procurements standards, and state insurance rules. Each plan must also pass a comprehensive readiness review operated by CMS and the state. 

Enrollment is set to begin March 1, 2015, with one month of opt-in-only enrollment. Passive enrollment will be phased in over six months starting April 1, 2015.

Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and health providers (Medicare parts A, B, D, and Medicaid). CMS says many dual-eligible patients suffer from multiple or severe chronic conditions and could benefit from better care coordination and management of health care and long-term services. 

In July 2011, CMS announced the opportunity for states to partner with CMS through one of two models:

  1. 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 to improve quality and reduce costs for Medicare and Medicaid.
  2. Capitated model: A state and CMS contract with health plans or other qualified entities that receive a prospective, blended payment to provide enrolled Medicare-Medicaid enrollees with coordinated care.

Texas' demonstration falls under the capitated model.

Texas currently operates the STAR+PLUS program, which provides managed care services to Medicaid members with disabilities or those aged 65 and older, including those dually eligible for Medicaid and Medicare. Eligible Medicaid members receive long-term support and services through participating health plans.

Under Texas' demonstration, MMPs will cover Medicare benefits in addition to the Medicaid benefits currently covered through STAR+PLUS. CMS says the change will allow MMPs to offer Medicare-Medicaid enrollees an integrated set of benefits to more comprehensively address their individual service needs. 

Visit the Texas Health and Human Services website for additional information about the STAR+PLUS program in Texas and the demonstration. 

Action, June 2, 2014