Medicare-Medicaid ACO Model launched to improve ‘dual eligible’ care

The Medicare-Medicaid Accountable Care Organization (ACO) Model, an effort to improve the quality of care and lower costs for beneficiaries who are enrolled in both Medicare and Medicaid, has been announced by CMS. Current Medicare ACOs often do not have financial accountability for the expenditures of Medicaid beneficiaries attributed to their organization. The new Medicare-Medicaid ACO Model is designed to build on current Medicare Shared Savings Program (MSSP) ACOs by allowing MSSP ACOs to take on accountability for the quality of care and both Medicare and Medicaid costs for Medicare-Medicaid enrollees (also known as “dual eligible beneficiaries”).

Background

Medicare ACOs are made up of groups of doctors, hospitals, and other health care providers and suppliers who come together voluntarily to provide coordinated, high-quality care to the original Medicare fee-for-service beneficiaries. Section 3021 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) created the Center for Medicare and Medicaid Innovation, which provides for the testing of innovative payment and service delivery models. The MSSP (established by ACA section 3022) and other ACO initiatives were created to change the incentives for how medical care is delivered and paid for, moving away from a system that rewards the quantity of services to one that rewards the quality of health outcomes.

The new model

According to a CMS fact sheet, The Medicare-Medicaid ACO Model will allow new and existing MSSP ACOs to take on accountability for the full spectrum of Medicare Part A, Part B, and Medicaid costs for their patients. If Medicare-Medicaid ACOs in a state generate Medicare savings for their Medicare-Medicaid enrollees, states (as well as the Medicare-Medicaid ACO) may be eligible to share in those savings with CMS. States may choose from three options for when to begin the first 12-month performance period for the Model ACOs in their state: January 1, 2018; January 1, 2019; or January 1, 2020.

Through the Medicare-Medicaid ACO Model, CMS also seeks to encourage participation from safety-net providers in alternative payment models. Medicare-Medicaid ACOs that qualify as “Safety-Net ACOs” will be eligible to receive pre-payment of Medicare shared savings to support the ACO’s investment in care coordination infrastructure.

Eligibility and application process

CMS is accepting letters of intent from states that wish to work with CMS to design certain state-specific elements of the model, such as the details of the Medicaid financial methodology and shared savings/shared losses arrangements, selection of additional quality measures, and additional ACO eligibility requirements. States will also have the option to include additional Medicare-Medicaid enrollees not assigned under the MSSP and Medicaid-only beneficiaries in the target population for the Model.

CMS will enter into participation agreements with up to six states with preference given to states with low Medicare ACO saturation. Once a state is approved to participate in the model, a request for application will be sent to ACOs and health care providers in that state.

In addition to applying to participate in the Medicare-Medicaid ACO Model, ACOs will be required to apply to participate in the MSSP and ultimately sign a participation agreement to participate in the MSSP in order to participate in the Medicare-Medicaid ACO Model.