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Proposed Rule from CMS Raises the Bar on Integrated Care

The evidence-based policy would make it easier for states to help people with complex medical needs, require more from plans that serve those patients.

Nurse in scrubs helps guide patient using a walking aid
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A new proposal from the Centers for Medicare and Medicaid Services (CMS) seeks to close many of the gaps in care and coordination that plague our health care system today. 

In the United States, 12 million low-income, older adults and people with disabilities get their care through both Medicare and Medicaid. The two programs cover different services and have separate rules, processes, and providers, making the system difficult for patients to navigate, sometimes with tragic results. 

One solution to reduce the fragmentation between the two programs are models that integrate care. However, only half of all dual-eligible individuals even have access to one of these models. The main reason for this reality is that states must act to make these models available, and many of them have not. Now, in proposed rulemaking, the Centers for Medicare and Medicaid Services (CMS) is trying to make it easier for states. 

Today, there are a number of integrated models that states can choose to implement. The one with the greatest degree of integration at scale, the Financial Alignment Initiative, is operated as a demonstration program through CMS. Many of the features of this demonstration were successful. CMS is now proposing to make some of those features permanent. 

We applaud CMS for their proposals to take lessons learned from a demonstration and move them onto a permanent platform so they can be available to more people,” said Arielle Mir, vice president of health care at Arnold Ventures. This is what evidence-based policy development looks like.”

In addition to trying to make it easier for states, CMS is asking more from the plans that serve people who are dual-eligible. CMS proposes to require organizations that want to operate these integrated models to have consumer advisory boards and more detailed financial reporting and to take responsibility for whole-person care inclusive of the full range of physical health, behavioral health, and long-term services and supports. 

While this proposed rule is a big step in the right direction, there is so much more we need to do,” Mir said. We must ensure that dual-eligible beneficiaries — and people with complex needs — have resources to assist them in choosing a coverage option and that they are not misled by plans that can’t provide them with the full array of benefits for which they are eligible. In short, this is the beginning, not the end.”

Read our letter to CMS in response to the proposed Medicare Advantage and Part D rule below.