Duals Program Due for Changes (But Concerns Remain)

The state’s bold experiment with its dual eligible programs is getting some revisions, while raising some concerns among hospitals and physicians.

Dual eligible individuals have both Medicare and Medicaid coverage, meaning they are low-income and qualify for Medicare based on their age or disability. The One Care program serves individuals who are between 21 and 64 years old at the time of enrollment.  Senior Care Options (SCOs) are available to dual eligible individuals 65 and older.  Currently, there are approximately 68,000 individuals in both programs with another 239,000 in traditional fee-for-service.

Last August, the Executive Office of Health & Human Services (EOHHS) submitted a concept paper to the Centers for Medicare and Medicaid Services (CMS) on its proposed changes to both programs, which included plans to increase enrollment and address some of the financing aspects.  CMS and the state are expected to reach agreement on the changes sometime this fall. Last week, EOHHS released a request for responses (RFR) for health plans that want to participate in a revised One Care program.
Throughout the process, MHA and the hospital community have been involved, weighing in on the state’s concept and supporting the duals program as a way of achieving improved care at potentially reduced costs.  The One Care and SCO programs have improved the lives of many disabled and elderly Massachusetts residents, providing them with a beneficial alternative to traditional fee-for-service that also has the potential to achieve savings through enhanced care management and coordination.

But along each step of the process, MHA has cautioned against one potential element of the state plan – imposing a payment cap on certain providers.  For both hospitals and professional services, the One Care RFR allows EOHHS to direct One Care health plans to establish payment rates that are no greater than a certain percentage of the Medicare fee-for-service rate and not less than a certain percentage of the MassHealth fee-for-service rate.  Medicare is the primary funding for hospital and physician services provided to dual-eligible patients. 

“The general notion of government intervention in setting reimbursement terms between health insurance companies and providers is bad policy on a number of levels,” said Dan McHale, MHA’s senior director of State Government Finance and Policy. “These rate setting policies have the effect of tilting the playing field to the imbalanced favor of the insurers, leaving providers with little ability to negotiate. If a healthcare provider demonstrates added value to a health plan as a key network provider or through its care management efforts, the provider and health plan should be permitted to negotiate and mutually agree to contract terms.”

The new program is scheduled to take effect January 1, 2021.  Health plans interested in participating as One Care plans have until May 24 to respond to the RFR and it is expected that EOHHS and CMS will select plans in late fall 2019.