CMS and Texas Partner to Coordinate Care for Medicare-Medicaid Enrollees
On May 23, 2014, the Centers for Medicare & Medicaid Services (CMS) announced that CMS is partnering with the state of Texas to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience.
The demonstration builds upon Texas’ STAR+PLUS program in six counties. 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.
Improving the care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees – sometimes referred to as “dual eligibles” – is a priority for CMS.
Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers (Medicare Parts A and B, Part D, and Medicaid). Many Medicare-Medicaid enrollees suffer from multiple or severe chronic conditions and could benefit from better care coordination and management of health care and long-term supports and services.
The Financial Alignment Initiative – Partnerships to Provide Better Care
Through the demonstrations approved under the Financial Alignment Initiative, CMS seeks to provide Medicare-Medicaid enrollees with a better care experience by offering a person-centered, integrated care initiative that provides a more easily navigable and seamless path to all covered Medicare and Medicaid services.
In July 2011, CMS announced the opportunity for states to partner with CMS through one of two models:
- Managed Fee-for-Service Model in which 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;
- Capitated Model in which 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.
The STAR+PLUS Program
Texas currently operates the STAR+PLUS program, which is designed to provide enhanced care coordination services to Medicaid members with disabilities or those that are age 65 and over, including those dually eligible for Medicaid and Medicare. Under the program, eligible Medicaid members receive long-term supports and services through participating health plans.
The Texas Demonstration
Under Texas’ demonstration, MMPs will cover Medicare benefits in addition to the Medicaid benefits currently covered through STAR+PLUS. This change will allow the MMPs to offer Medicare-Medicaid enrollees an integrated set of benefits to more comprehensively address their individual service needs.
The Texas demonstration will take place in six counties: Bexar, Dallas, El Paso, Harris, Hidalgo, and Tarrant. In total, 168,000 individuals will be eligible to enroll in the demonstration.
To ensure each MMP is prepared to serve Medicare-Medicaid enrollees, all participating plans must first meet core Medicare and Medicaid requirements, state procurements standards, and state insurance rules (as applicable). Each plan must also pass a comprehensive readiness review operated by both CMS and the state.
Enrollment is scheduled to begin on March 1, 2015 with one month of opt-in only enrollment; then passive enrollment will be phased in over six months starting on April 1, 2015.
Putting the Beneficiary First
Under the demonstration, care coordination services will be available to all enrollees. Plans will offer a service coordination team to ensure the integration of the enrollee’s medical, behavioral health, long-term services and supports, and social needs. The team will be person-centered and built on the enrollee’s specific preferences and goals.
The new demonstration includes beneficiary protections to ensure that enrollees receive high-quality care. CMS and Texas have established quality measures relating to the beneficiary’s overall experience, care coordination, and fostering and supporting community living, among many others.
The demonstration also includes continuity of care requirements to ensure that enrollees can continue to see their current providers during transitions into the plans. Texas’ Ombudsman program will support individual advocacy and provide the State and CMS with feedback on plan performance for the demonstration, with a focus on compliance with principles of community integration, independent living, and person-centered care.
CMS is funding and managing an external evaluation of each state’s demonstration. The evaluation for the Texas demonstration will measure quality, including overall beneficiary experience of care, care coordination, care transitions, and support of community living. CMS will develop a unique, Texas-specific evaluation using a comparison group to analyze the impact of the demonstration.
A Transparent Process Supporting Public Input
The Texas demonstration is the product of an ongoing planning and development process through which the public helped shape the demonstration’s design. To develop this demonstration, Texas:
- Worked with a diverse group of stakeholders, including providers, health plans, nursing facilities, hospitals, state agencies, advocacy groups, associations, and beneficiaries.
- Held public information sessions around the state with external stakeholders to inform demonstration development and policy.
- Posted its draft proposal for public comment and incorporated the feedback into its demonstration proposal before officially submitting it to CMS. The proposal was then posted by CMS for public comment.
Additional information about the STAR+PLUS program in Texas and the demonstration is available at: https://www.hhsc.state.tx.us/.
Additional information about the Financial Alignment Initiative is available at: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.html.
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