CMS Announces New ACO Model for Duals

The Centers for Medicare & Medicaid Services (CMS) announced last week the creation of a Medicare-Medicaid Accountable Care Organization (ACO) Model. This new model is intended to improve the quality of care, while reducing the total costs, for beneficiaries who are enrolled in both Medicare and Medicaid.

Currently, Medicare ACO initiatives, including the Shared Savings Program and the Pioneer ACO model, hold organized networks of health care providers accountable for the cost and quality of all Medicare Part A and Part B benefits. New York State law also provides for certification of Medicaid ACOs; however, only one Medicaid ACO has been certified in New York to date.

Unlike managed care programs, ACOs do not “enroll” beneficiaries or limit their choice of providers to a specified network. Nor do they control utilization through prior authorization or utilization review or directly reimburse providers for the cost of services. Instead, beneficiaries are “attributed” to a Medicare ACO based on their primary care provider. ACOs create integrated provider networks that are intended to encourage beneficiaries to receive services from ACO participating providers, by offering coordinated, accessible, and high-quality care. Providers participating in Medicare ACOs bill Medicare for services and may receive a share of any savings generated from the ACO (or pay for a portion of any excess spending incurred).

Under the new model, ACOs will take on accountability for the quality and cost of care for both Medicare and Medicaid services for dually-eligible beneficiaries. CMS intends to launch the model in six states and is accepting letters of intent from states interested in participating. To qualify, states must “have a sufficient number of dual eligibles in fee-for-service Medicare and Medicaid.” Preference will be given to states with low Medicare ACO saturation.

Letters of intent from states interested in participating in the new ACO model in 2018 are due on Jan. 20, 2017. Additional information about the new model is available here.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124