Providers, CMS at odds over dual eligible program

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Some nursing homes and other providers are engaging in “bad behavior” by trying to persuade people to opt-out of a managed care demonstration project, a top government official recently claimed. But a long-term care leader disputes that providers acted with bad intentions, and told McKnight's that guidance from the Centers for Medicare & Medicaid Services was lacking.

Five states are conducting the demonstration projects, in which people who are eligible for both Medicare and Medicaid can elect to have their benefits administered through a managed care plan. The theory is that this will lead to more coordinated, cost-efficient care.

However, providers could see reimbursements reduced under this system. For that reason, some have engaged in scare tactics to convince beneficiaries to opt out, said Melanie Bella, director of the CMS Medicare-Medicaid Coordination Office.

“We are unfortunately seeing lots of bad behavior in most of the states,” Bella said at the National Association of Medicaid Directors meeting on Nov. 4, according to Modern Healthcare. Providers are telling potential enrollees that they might lose benefits, she said.

Government officials in Virginia said that long-term care providers were engaging in this. However, it was only a single provider that communicated inappropriately with a resident in the early days of the demonstration project, Virginia Health Care Association President Steve Morrisette told McKnight's.

“One facility at the beginning of the program did suggest to the resident that they needed to opt-out, but that was quickly corrected,” he said.

The association requested that CMS provide written guidance on how facilities are to communicate with residents and family members, including residents with dementia. Although the guidance was slow in coming, it has been furnished and facilities now know they can only communicate the facts about the demonstration, Morrisette said.

Bella acknowledged that CMS should have communicated with providers better as the program launched, Modern Healthcare reported.

The Financial Alignment Initiative, as the project is officially called, has faced criticism since it was established in 2011. It soon will expand to five additional states.