Financial Alignment Demonstrations for Dual Eligible Beneficiaries: A Look at CMS’s Evaluation Plan

Enrollment in the new state demonstrations to integrate care and align financing for beneficiaries dually eligible for Medicare and Medicaid is underway.¹  As of July 2014, beneficiaries in five states (California, Illinois, Massachusetts, Ohio, and Virginia) are participating in capitated demonstrations, to be followed by five more states (Michigan, New York, South Carolina, Texas, and Washington) in the coming months.   For the last year, beneficiaries have been enrolled in Washington’s a managed fee-for-service (FFS) model, with enrollment soon to be effective in another managed FFS demonstration in Colorado.

The demonstrations are being implemented under new authority, Section 1115A of the Social Security Act, which was added by the Affordable Care Act.  Section 1115A requires the Health and Human Services Secretary to evaluate the demonstrations, and the Centers for Medicare and Medicaid Services (CMS) has contracted with RTI International to do so.  RTI will use qualitative and quantitative methods to evaluate the demonstrations overall as well as each state’s model.²   RTI’s work is in addition to any evaluations that individual states are undertaking.³There is considerable interest in the demonstration evaluation plans among federal and state policymakers, beneficiaries, and other stakeholders.  The demonstrations will affect some of the most vulnerable beneficiaries, among the poorest and sickest covered by Medicare or Medicaid, while the predominant pre-existing service delivery models for this population typically involved little to no coordination between the two programs.  In addition, the Secretary is authorized to expand the duration and scope of tested models, including on a nationwide basis, that are expected to reduce program spending without reducing care quality or improve patient care without increasing spending.  This issue brief describes CMS’s plan to evaluate the demonstrations, via its contract with RTI, in the areas of implementation, beneficiary experience, utilization and access to care, quality of care, cost, and health disparities among subpopulations, including the specific research questions identified for each area.  Details about individual state demonstration evaluations are included to the extent available.⁴