Forum Session - Coordinating Care for Beneficiaries Eligible for Both Medicare and Medicaid: An Update on the “Duals Demos”

The Massachusetts demonstration, for example, is the only model focused solely on duals under the age of 65, many of whom have behavioral health and substance abuse problems.11 Texas’s demonstration will serve adult duals with disabilities who qualify for Supplemental Security Income or Medicaid waiver home- and community-based services.12 Duals in Virginia13 can opt out of the demonstration for b. [...] Each agreement with states choosing the capitated model includes the terms under which anticipated aggregate program savings are deducted up front from both CMS and state payments to health plans.15 In anticipation of greater savings over time, the deduction increases over the three-year life of the demonstration, starting at 1 percent and ending between 2 and 5.5 percent. [...] Illinois plans, for example, will incur deductions of 1, 3, and 5 percent over the three years of the demonstration.16 In addition, all of the states participating in the capitated model withhold a portion of plan payments that are returned if quality metrics are met. [...] Consumer advocacy groups are actively involved in monitoring the implementation of the duals demonstrations, with several providing a steady stream of educational materials for advocates and families.21 In response to early concerns about beneficiary rights, CMS has made funds available to states with approved MOUs to plan and provide ombudsman services for beneficiaries in the demonstration. [...] KEY QUESTIONS • What have been the main implementation challenges faced by CMS and the Medicare-Medicaid Coordination Office in getting the duals demos started? What is the outlook for the future? • What challenges have the states faced? How do these vary by the type of model (capitation or managed fee-for-service) chosen? What other factors at the state level have made it easier or harder for s.