Deborah Bachrach Discusses Capitated Plans

Deborah Bachrach Discusses Capitated Plans

"Capitated Plans in Duals Demo Differ Most in Their Risk Sharing"
Medicare Advantage News

March 28, 2013 - Manatt's Deborah Bachrach, a partner in the firm's Healthcare Division, spoke with Medicare Advantage News about the differences in states' capitated plans that have been approved by the Centers for Medicare & Medicaid Services.

Medicare Advantage News reports that the capitated payment models that CMS has approved so far for its massive Medicare-Medicaid dual eligibles demonstration differ in certain key areas of the Memorandum of Understanding (MOU) between the agency and the states involved.

Those areas include care continuity during the transition to the new program, expected annual savings, "medical home" provisions and risk sharing, with the biggest differences in the last category, said Bachrach.

On care continuity, she explained, Massachusetts says individuals must be allowed to continue current care for the longer of 90 days or until the initial service assessment is complete. In Ohio, the provision calls for 90 days for high-risk individuals and 365 days for all other enrollees. The Illinois MOU calls simply for a 180-day transition period, Bachrach added.

Neither the Massachusetts nor the Ohio MOU has any requirement for a so-called "medical home" overseeing care. But the later-approved Illinois MOU, noted Bachrach, says plans must facilitate NCQA certification for medical homes that serve as primary care providers.

Each MOU has distinct provisions on financial risk sharing, according to Bachrach. Massachusetts, for instance, calls for risk corridors during the first year. If there is a gain or loss of up to 5%, the health plan involved bears 100% of the deficit or gain. Between 5% and 10%, the plan is responsible for half, and CMS and the state share the remaining half. Above 10%, CMS and the state retain 100% of the loss or gain.



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