CMS launches ACO model for dual eligibles: 6 things to know

CMS is rolling out a new ACO model for patients enrolled in both Medicare and Medicaid, many of whom are among the highest-need, highest-risk beneficiaries enrolled in Medicare.

The Medicare-Medicaid ACO Model will build on CMS' existing Medicare Shared Savings Program. Many dual-eligibles are already attributed to Medicare ACOs, but the organizations are not held accountable for Medicaid costs for those patients. This model will zero in on improving the cost and quality of those services, in addition to improving the value of Medicare services.  

Here are six things to know about MMACO program.

1. CMS will partner with up to six states on the program. States must first apply and be accepted into the program, and then providers and ACOs within a state may apply. The model is open to all states with a "sufficient number" of Medicare-Medicaid enrollees in fee-for-service Medicare and Medicaid. The agency will determine on a case-by-case basis if a state's number of dual-eligible beneficiaries is sufficient, based on how many beneficiaries are needed to meaningfully evaluate progress and reliably calculate shared savings. CMS has indicated it will give preference to states with low Medicare ACO saturation.

2. Once a state is accepted, ACOs and providers may apply to participate. MMACOs must concurrently participate in the MSSP. This does not exclude new participants — new entities can be eligible if they apply to both programs at the same time. MMACOs will be responsible for dual-eligible beneficiaries, as well as those enrolled only in Medicare.

3. MMACOs will be required to hit quality and cost benchmarks under the MSSP, as well as those under the Medicare-Medicaid program. MMACO benchmarks will be set by both CMS and the state. CMS plans to waive certain MSSP regulations for organizations participating in both programs. In particular, it will assign all beneficiaries to MMACOs prospectively, no matter what MSSP track they participate in. Under the traditional MSSP, beneficiaries are assigned retrospectively for Tracks 1 and 2 of the program and prospectively only for Track 3.

4. States can elect to include additional Medicaid-only beneficiaries to the program. States will work with CMS to determine who the "target population" will include and how the additional beneficiaries will be assigned. This option gives states the flexibility to include Medicaid-only beneficiaries in the program. 

5. To make the program more attractive for safety-net providers, CMS is providing additional incentives. MMACOs that qualify as safety-net ACOs will be pre-paid shared savings to help fund infrastructure building.

6. CMS will accept three rounds of applicants to start in 2018, 2019 or 2020. To begin the first performance year in 2018, interested parties must submit a letter of intent by Jan. 20, 2017. Additional information on the model and how to apply is available here.


More articles on accountable care:

MSSP ACO to pilot partnership between PCPs, pharmacists
Leavitt Partners: ACOs strongly prefer upside-only contracts
Community Healthcare System to form collaborative care relationship with Cigna

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