[Updated] Industry Insiders: Don’t Overlook CMS’s Dual-Eligibles Directive

*Editor’s note (4/30/2019): This story has been updated to include comments from Hometeam CEO Randy Klein.

Home-based care providers continue to show their support for the Centers for Medicare & Medicaid Services’ (CMS) move to better coordinate care for Americans who qualify for both Medicare and Medicaid.

CMS first announced plans to expand coverage options for dually eligible patients last week. Afterward, Addus HomeCare Corporation (Nasdaq: ADUS) Executive Vice President and Chief Development Officer Darby Anderson told Home Health Care News providers should feel encouraged by the news.


Now, Bayada Home Health Care’s Chief Government Affairs Officer David Totaro is echoing that enthusiasm. In addition to his role at Bayada, Totaro also serves as chairman of the Partnership for Medicaid Home-based Care.

“If CMS is true to its word in that they are seeking to better integrate Medicaid and Medicare programs with a focus on cost savings, then it’s likely that down the line, the integration will seek to shift more of the dual population into the [home- and community-based care] setting, though it will require Medicare to loosen its rigidity in terms of being so staunchly medically focused,” Totaro told Home Health Care News.

Currently, more than 11 million Americans are enrolled in both Medicare and Medicaid. The dual-eligible population — which has higher rates of chronic conditions and social risk factors — accounts for more than a third of state Medicaid spending in some states.


One reason for that is federal Medicare and state Medicaid programs communicate infrequently and are governed by different rules, making it difficult to coordinate care and minimize spending.

In fact, only 10% of dual-eligibles are currently enrolled in integrated care programs, according to CMS Administrator Seema Verma, who is inviting states to help change that.

In a directive to state Medicaid administrators, Verma encouraged them to test one of three integrated models to improve care and maximize savings for dual-eligibles.

The first two options are already in use in some areas across the country. One is the capitated financial alignment model, in which Medicare and Medicaid team up with health plans known as Medicare-Medicaid Plans (MMPs) to provide a one-stop contract for dual-eligibles.

The other is the managed fee-for-service model. It encourages shared savings between Medicaid and Medicare.

The third option, which both Totaro and Anderson are most excited about, is new.

It allows states to come up with their own integrated care plans.

“While Medicare and Medicaid are disjointed for a majority of the dual eligible population, there are states that have seen successes in integration,” Totaro said. “Massachusetts, Minnesota and Wisconsin were among the first states that shifted to managed care and to managed long term services and supports (MLTSS), and, if I recall correctly, all three have integrated care (MLTSS for dual eligibles).”

Apart from CMS, many home-based care organizations have long had their attention turned to the dual-eligible market. That includes New York-based home care startup company Hometeam, led by CEO Randy Klein.

“The majority of our clients are dually eligible, and we see a great deal of opportunity with this population due to the continued growth of both Medicare and Medicaid eligibility,” Klein told HHCN.

While Klein believes CMS’s move is a big step in the right direction, he says there’s still a long way to go before integration for dual-eligibles adequately improves.

“History on integration has not been great,” Klein said. “To ensure success, we believe that integrated programs should create administrative simplicity and revenue opportunities in addition to improving quality outcomes.”

Last year, when Klein assumed the CEO role, he told HHCN how the company shifted its business model from primarily private-pay home care and Medicaid reimbursement to one largely focused on dual eligibles

“[These are] the oldest, frailest members of society,” Klein said. “That also means [its] the greatest opportunity to help, where there is the most waste. We are focusing on that component.”

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