States seeking to launch managed-care plans combining Medicaid and Medicare benefits for low-income, disabled people are facing an uphill effort finding health plans willing and able to participate.
That's because not enough plans are prepared to offer services for these complex, high-cost patients, they fear the program imposes too much financial risk, and they are deterred by what they see as the inflexibility of the CMS' star-rating system, experts say.
These issues have slowed the implementation of the CMS' three-year Financial Alignment Initiative, a demonstration mandated by the Patient Protection and Affordable Care Act to integrate Medicaid and Medicare benefits for the nation's 9.1 million dual-eligible beneficiaries. Many experts say it's vital to better coordinate care for these patients, which cost about $319.5 billion in 2011.
“While it has taken longer than originally expected to launch the demos, it's somewhat understandable given that coordinating the financing and administrative requirements between Medicaid and Medicare is a huge undertaking,” said Jeff Myers, president and CEO of Medicaid Health Plans of America, a trade group. “If rates are not sufficiently risk-adjusted to ensure that health plans are able to meet enrollees' clinical needs, some plans may decide not to participate.”