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Value of MLTSS Health Plan Participation in CMMI DC Model

The DC model is focused on giving participants the ability to take increasing levels of risk for a patient population through flexible payments and benefit enhancements. There are two tracks based on the level of risk and flexibility that CMMI has released information on to date (more information to come on a third track in late 2020 or early 2021):

  • Professional – partial risk arrangement with 50% shared savings/losses and a Primary Care Capitation payment

  • Global – full-risk arrangement with 100% shared savings/losses and option of either a Primary Care Capitation or Total Care Capitation payment

Through participation in the DC Model as a MLTSS Plan-Operated DC Entity (DCE):

  • MLTSS plans can increase the number of dual-eligibles benefiting from integrated care. MLTSS plans can take responsibility and risk for their FFS dually-eligible members which are not part of an affiliated managed care product through Medicare.

  • MLTSS plans can leverage their extensive experience with managing care for beneficiaries with complex care needs. There is significant overlap between the beneficiary eligibility criteria of the current High Needs Population DCE type and the characteristics of the population of dual eligible beneficiaries enrolled in MLTSS plans (i.e., beneficiaries with several chronic conditions and high rates of hospitalization).

  • MLTSS plans can have access to a beneficiary’s Medicare data and Medicare FFS primary care provider (PCP), allowing them to better respond to and coordinate their medical and non-medical needs. While MLTSS plans and providers gain valuable insights into dual-eligible beneficiaries’ health care needs and quality of life through LTSS interventions, fundamental system constraints limit their access to PCP and other medical utilization data. MLTSS plans generally lack access to these data and therefore are not necessarily aware of when a beneficiary is admitted or discharged from a hospital. These data will give plans a more holistic view of their members’ care.

  • MLTSS plans can enhance its care management model to better serve members’ needs. New flexibility through this model would allow plans to address many of the drivers of avoidable Medicare-funded hospitalization and skilled nursing facility usage within the target population.

Read the value proposition here.


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