CMS Announces New Model for MCOs Serving Dually Eligibles   

Situation Report | December 21, 2020

The U.S. Centers for Medicare and Medicaid Services (CMS) has announced a new opportunity for Medicaid Managed Care Organizations (MCOs) to better serve dually eligible beneficiaries.

It seeks to encourage Medicaid MCOs to partner with providers and suppliers and implement care coordination programs that can improve quality and reduce Medicare fee-for-service costs. 

These new MCO-based Direct Contracting Entities (DCEs) must be either a Medicaid MCO or the corporate affiliate of a Medicaid MCO. The Direct Contracting Model will test the MCOs’ ability to improve care for this high-risk population. CMS says it will do so by holding the MCOs or their corporate affiliates accountable for outcomes and Medicare fee-for-service costs for their full-benefit dually eligible Medicaid MCO enrollees, in addition to the risk the Medicaid MCOs currently have under Medicaid.

The CMS announcement includes several examples for doing so: program alignment processes; risk-stratification and targeting of care coordination resources; deploying care coordinators or in-home aides for active promotion of certain screenings, treatments and supports; aide training on meal preparation for individuals with nutrition-sensitive conditions; and value-based purchasing arrangements with nursing facilities that factor in facilities’ hospitalization rates. 

A Request for Applications (RFA) is expected in early 2021 with model participation beginning in January 2022.