Initial Observations on the DMAS Dual Eligible Demonstration Draft Proposal

The Virginia Department of Medical Assistance Services (DMAS) posted its Dual Eligible Demonstration draft proposal to the Center for Medicare and Medicaid Innovation (CMS) as scheduled on April 13th.


This overview is not intended to be a comprehensive assessment of the public comment draft.  Members are encouraged to review documents maintained in VHCA’s online resource library.  The library was established to hold all documents related to the evaluation of the Dual Eligible Financial Alignment Demonstration (the Demonstration) and documents the efforts of VHCA’s Ad-Hoc Committee on Medicaid Managed Care.  Members are encouraged specifically to review both the written comments dated March 19, 2012 provided to DMAS in advance of their initial stakeholder meetings as well as recommendations from the Ad-Hoc Committee to DMAS dated April 11, 2012.  The resource library is located here and requires VHCA member access to view the documents.

As anticipated, the 74-page document is very general in nature and lacks the level of detail necessary for impacted stakeholders to adequately assess how the demonstration will impact the delivery of and payment for services to Medicare/Medicaid (dual eligible) beneficiaries residing in one of the four demonstration areas.

The draft proposal confirms our basic understanding of the overall approach that DMAS intends to take with respect to implementing care coordination for Virginia’s dual eligibles.  As outlined in the draft, the goals of the demonstration are to reduce cost shifting between providers and payors; create a seamless, integrated service delivery system; align Medicare and Medicaid rules; improve accountability; produce savings for both the states and the Federal governments; and share Federal savings with the states in order to provide care coordination and other supplementary benefits.   Under the plan, contracted managed care organizations (MCOs) will be accountable for the care delivered to enrollees, including care coordination efforts.  MCO performance will be measured, and payment will be tied to measured quality goals.  Care will be delivered using integrated care teams and care management services that are based on the needs and goals of enrollees.  MCOs may offer supplemental/enhanced benefits that exceed those currently provided in either Medicare or Medicaid, in order to encourage and retain enrollment, promote health, and provide services in the most appropriate and efficient settings.

For nursing facilities, the draft proposal fails to address several concerns that had been discussed with DMAS and shared with them in our written comments and recommendations.  The two key omissions are:

  • No “any willing provider” provision;
  • No discussion or requirement that MCOs establish payment rates with current Medicaid per diems and Medicare skilled rates serving as a payment floor.
Without these provisions, we believe the demonstration will allow MCOs to implement their programs by “managing the rate” vs. “managing the care”.  Additionally, concerns expressed by VHCA and others that the demonstration areas are simply too large – encompassing geographic regions that contain approximately 60% of Virginia’s nursing facilities – were also ignored.

We will continue to meet with DMAS and other policymakers and voice our concerns related to the Duals initiative as necessary.  VHCA staff will meet with DMAS again on April 26th.  VHCA’s Ad-Hoc Committee on Medicaid Managed Care is scheduled to hold its second meeting on Thursday, May 10th .