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CMS Continues to Struggle with How to Provide High Quality Care to Dual Eligibles

Written by:  Tara E. Swenson

Last week CMS announced that it would not execute its option to terminate its 2015 contracts with Medicare Advantage Plans and Part D plans that had scored three stars or less for three consecutive years. At the same time, CMS announced that it was seeking information from insurers and others in the industry regarding how serving a disproportionate share of dual eligible enrollees causes Medicare Advantage and Part D plans to receive lower quality measure scores.  In the alternative, CMS is also seeking information regarding how certain Medicare plans that serve dual eligible achieve high performance levels.   In order to be considered, comments must be received by November 3, 2014.

While CMS seeks this information, it is continuing to confront a variety of challenges to its Duals Demonstration Project under which it is attempting to partner with states to coordinate providing care through managed care entities able to provide both Medicare and Medicaid services.  Since the start of the Duals Demonstration, CMS has seen some states exhibit interest in participating but ultimately decline to engage and some managed care organizations go through the process to be approved to provide the plans and then pull out of participating.  The Duals Demonstration is currently facing legal challenges in California where a variety of groups are claiming that the passive enrollment process violates individuals’ due process rights.

CMS’ RFI provides a good opportunity for industry participants to explain the challenges of serving and providing managed care to a low income population that can be more difficult to contact and engage than the traditional Medicare population.

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Theresa advises clients on all aspects of the pharmaceutical supply chain, including counseling industry stakeholders on a range of business, legal, transactional, and compliance matters. She provides clients with strategic counseling and creative business modeling that considers legal restrictions and regulatory risk in light of innovation and business goals.