CMS Eyes Initial Voluntary Enrollment In Ohio Duals Demo After Okaying Policy In Massachusetts


Ohio is talking to CMS about leaving enrollment in the duals demonstration voluntary for the first three to six months, a private insurance official following the process tells Inside Health Policy, which would be the same approach taken by Massachusetts, the only state so far to sign a duals demo memorandum of understanding with CMS. There likely will be a one-year transition for those in the Ohio demo, during which the dual eligibles will be allowed to continue seeing their current providers.

Up to now Massachusetts is the only state to sign a duals MOU with CMS. That MOU included a three-month voluntary enrollment period, followed by “passive enrollment,” the term states use for automatically enrolling beneficiaries, then letting them opt out. Ohio also would use passive enrollment after the initial voluntary phase.

The insurance company official says the phase-in helps both beneficiaries and the plans. It lets beneficiaries participate immediately if they like while giving others time to learn about the demo. For the plans, it makes it easier to enroll a large group of people. In Ohio, one of the duals-special needs plans would have to hire about 200 employees to form the “care teams” that clinically integrate duals into the plan’s network.

However, allowing beneficiaries to stay with their current providers helps only beneficiaries, the source says, and this aspect of the demo is being pushed by patient advocates. Duals placed into managed care may be forced to move to different nursing homes or have to switch other providers if those providers are not in the network of the managed care plan. The one-year transition gives them time to either opt out or at least prepare for switching providers.

Plans do not have to contract with providers during the first year, the official says. The one-year provider grace period makes it more difficult for plans because they are being payed a capped amount, yet during the first year, plans are not allowed to shift beneficiaries to providers that the duals-special needs plans view as better or less expensive.

Duals in hospice and those receiving dialysis for liver failure likely will be included in Ohio's duals-special needs plans, the official says, although she expects the hospice services to be paid for outside the cap by traditional Medicare fee for service, just as they are today. It's less clear how the end stage renal disease services would be reimbursed.

None of these details are set in stone. Ohio is negotiating with CMS, and the memorandum of understanding between CMS and the state is not expected until the end of November, the official said. That time frame is not designed around the election, the official added. Rather, CMS has a 30-day clearance period, and that period has yet to begin. -- John Wilkerson


DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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