CMS to permit managed care organizations to take part in direct contracting


The Trump administration proposed a brand new initiative aimed toward enhancing care coordination amongst Medicaid managed care plans for dual-eligible Medicare and Medicaid beneficiaries.

The mannequin introduced Thursday by the Facilities for Medicare & Medicaid Providers (CMS) will permit Medicaid managed care organizations to take part within the international {and professional} choices within the company’s Direct Contracting mannequin, which gives voluntary risk-sharing agreements with suppliers.

“For too lengthy we’ve struggled to ship acceptable outcomes for this weak inhabitants, however as we speak’s mannequin is a game-changer,” CMS Administrator Seema Verma stated in an announcement Thursday. “It represents a big step towards addressing these longstanding points and making certain they obtain the coordinated care they rightfully deserve.”

The skilled direct contracting possibility gives major care capitation, which is a risk-adjusted month-to-month cost for enhanced major care providers. The worldwide possibility offers two cost choices: major care capitation or whole care capitation that provides funds for all providers made by a supplier.

RELATED: CMS rolls out geographic direct contracting mannequin aimed toward enhancing regional well being outcomes

CMS laid out some examples of how an MCO might use the voluntary direct contracting mannequin, together with:

  • Getting into into value-based buying agreements with nursing amenities that think about facility hospitalization charges;
  • Set up processes to attach beneficiaries with a major care supplier;
  • Concentrating on care coordination assets in direction of beneficiaries which have a excessive danger of Medicare spending; and
  • Have care coordinators and in-home aides that present Medicaid long-term providers to assist enrollees with managing medical appointments.

Any managed-care organizations that take part in direct contracting must get a letter of help from their state Medicaid company to make sure that participation aligns with any state-managed plans.

Additionally they must have an lively contract with the state.

An relevant MCO should additionally cowl any long-term help and providers resembling being in danger for nursing dwelling prices “and/or behavioral well being providers for individuals with severe psychological sickness/substance use dysfunction — until the state managed care program excludes such people,” in line with a reality sheet on the initiative.

Any MCO should even have a minimal of three,000 aligned beneficiaries previous to the beginning of every efficiency yr, the company added.

CMS stated that final yr there have been 12.2 million Individuals that have been dual-eligible beneficiaries and are an particularly excessive want inhabitants.

“These dually eligible people should navigate two separate packages for his or her healthcare: Medicare for the protection of most preventive, major, and acute well being care providers and medicines, and Medicaid for protection of long-term providers and helps, sure behavioral well being providers, and for assist with Medicare premiums and price sharing,” CMS stated in a launch.

The Middle for Medicare & Medicaid Innovation, which oversees cost fashions, will launch a request for functions early subsequent yr for managed care organizations. Such organizations can begin taking part within the mannequin in January 2022.



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