CMS won't expand dual-eligibles pilot program

The CMS will keep enrollment in a coming national pilot project for dual-eligible beneficiaries below 2 million people, or more than a million fewer than states have proposed.

Melanie Bella, director of the Medicare-Medicaid Coordination Office at the CMS, addressed the expected size of the pilot program at a Senate Aging Committee hearing on the controversy that has arisen around it.

“Our target is 2 million; that doesn't mean that we will approve up to 2 million,” Bella testified when asked about the more than 3 million beneficiaries 26 states have proposed enrolling in the pilot program that aims to test coordinated payment and care-delivery models.

The size of the pilot project has drawn objections from a number of provider and patient advocates, who were concerned that a huge program would overwhelm the agency's ability to track its outcomes and keep it from preventing unintended negative impacts on the enrollees.

For instance, Robert Berenson, a fellow at the Urban Institute, told the committee that the numerous unknown impacts on the fragile dual-eligible population from the models should lead the CMS to limit its initial enrollment to a maximum of 50,000 beneficiaries, nationwide.

Bella acknowledged that the pilot program is larger than any previously launched by Medicare but defended it as necessary to ascertain with sufficient certainty that the tested approaches are able to improve care and lower costs.

However, the CMS plans to reduce the pilot's national enrollment to less than two-thirds of what states have proposed in their applications, she said, by denying pilot applications that include elements not allowed when the CMS proposed the program. Such disallowed elements are state-proposed “lock-out” periods, during which enrollees could not opt out of the pilot and return to the standard Medicare-Medicaid program for dual eligibles.

The agency will begin announcing which state pilots it has approved “soon,” she said, and on a rolling basis.

Bella also stood by the proposed use of auto enrollment by some of the state pilots. Critics have blasted the approach for requiring dual eligibles who do not want to participate to have to take steps to disenroll because many have serious illnesses that might hinder their ability to quickly get out of a pilot program that is restricting their ability to get needed care. An external evaluator was hired by the agency recently to analyze adverse impacts of the pilots on their enrollees, Bella noted.

She also specified that the pilot program is expected to provide savings to Medicare and Medicaid at proportional amounts to what each program is paying for each patient. Savings also will vary by state, depending on the specific patient health conditions of their proposed enrollees.