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By Robin Callahan

MassHealth celebrated an important achievement in April: the agency’s application was accepted for a $1 million design contract with the Center for Medicare and Medicaid Innovation (Innovation Center) and the Federal Coordinated Health Care Office (FCHCO). As a result, MassHealth will submit a demonstration proposal in Fall 2011 to integrate care for dual eligible individuals (individuals who are eligible for both Medicare and Medicaid). The target group that will be served by this demonstration project is comprised of dual eligible adults ages 21-64 who currently receive full MassHealth benefits. The design contract will provide technical assistance and funding from the Innovation Center and FCHCO to support development of MassHealth’s demonstration proposal.

While MassHealth members without Medicare or other insurance are typically enrolled in one of MassHealth’s managed care plans (Managed Care Organization – MCO or Primary Care Clinician – PCC Plans) for acute, primary, and behavioral health, most ‘dual eligibles’ in the 21-64 age group in Massachusetts don’t have a MassHealth managed care plan to enroll in. A small portion of this group receives their Medicare benefits through a Medicare Advantage plan (Medicare’s managed care option).  Dual eligible individuals have a chronic physical illness or disability, so many of them require Long Term Services and Supports, which aren’t included in MassHealth’s MCO or PCC plans.  Typically, services that dual eligibles in Massachusetts receive are paid for one at a time under a Fee-for-Service (FFS) model. Providers for dual eligible individuals may or may not share information with other providers in a FFS system, and since individual providers are paid only for particular services rather than for coordinated care, the FFS model does not incentivize improved health outcomes and higher quality care that could come at the same or even lower cost.

In the application to the Innovation Center and the FCHCO, MassHealth proposed combining federal Medicare and state Medicaid funding for dual eligibles who enroll in Integrated Care Entities. By combining these two funding streams, MassHealth hopes to offer a broader menu of services that will meet the needs of the dual eligible population in a more cost-effective way. MassHealth proposed assuming the administration, management and oversight of all Medicare-funded and Medicaid-funded services so that it could align funding and incentives for care. MassHealth would make one global payment to Integrated Care Entities for all Medicare and Medicaid services, creating a broader continuum of behavioral health and community support services.

This unprecedented level of integration will contribute to better health outcomes for the dual eligible population through the delivery of higher quality, more cost-effective, and person-centered care. The vision for Integrated Care Entities is that they will address the health care needs of dual eligible adults, allow individuals to experience their coverage as a single, integrated care program, promote improved health outcomes and offer individuals the opportunity to live with dignity and independence in their communities.  MassHealth is very excited to be moving forward with this important project that has the potential to improve care for many of its members. To read more about our proposal for dual eligible individuals, visit our new website at: www.mass.gov/masshealth/duals.

MassHealth will be hosting an open meeting regarding Integrating Medicare and Medicaid for Dual Eligible Individuals on Tuesday, June 28, 2011 from 12pm to 2pm in Conference Rooms 2 and 3 at the State Transportation Building located at 10 Park Plaza in Boston.  Information about upcoming meetings will also be available on our new website.

Robin Callahan is director of member policy and program development for MassHealth

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