January 13, 2023

The Honorable Bill Cassidy, M.D
520 Hart Senate Office Building
Washington, DC 20510 

The Honorable Tim Scott
104 Hart Senate Office Building
Washington, DC 20510    

The Honorable John Cornyn
517 Hart Senate Office Building
Washington DC, 20510 

The Honorable Thomas R. Carper
513 Hart Senate Office Building
Washington, DC 20510 

The Honorable Mark R. Warner
703 Hart Senate Office Building
Washington, DC 20510 

The Honorable Robert Menendez
528 Hart Senate Office Building
Washington DC, 20510

Submitted electronically to: [email protected] 

RE: Congressional Request for Information on the Dual Eligible Population

Dear Senators: 

The National Association of ACOs (NAACOS) appreciates the opportunity to submit comments in response to the request for information (RFI) on existing data and improving beneficiary care for dual eligible beneficiaries. NAACOS is a member-led and member-owned nonprofit of more than 400 accountable care organizations (ACOs) in Medicare, Medicaid, and commercial insurance working on behalf of health systems and physician provider organizations across the nation to improve quality of care for patients and reduce health care cost. NAACOS represents more than 8 million beneficiary lives through Medicare’s population health-focused payment and delivery models, including the Medicare Shared Savings Program (MSSP) and the ACO Realizing Equity, Access, and Community Health (REACH) Model, among other alternative payment models (APMs). We applaud the effort to reform care for dual eligibles and move away from the fragmented and disjointed system this population experiences today. Our comments below reflect concerns of our members and our shared goals to improve the quality of care and outcomes for dual eligibles while controlling rising costs by increasing coordination and accountability in the health care system. 

Currently the Medicare and Medicaid programs operate in silos and there is no true system in place to coordinate benefits, enrollment, and clinical care for dual eligible beneficiaries. Poor alignment between Medicare and Medicaid has resulted in poorer health outcomes, higher health care costs, and often significant confusion for beneficiaries in the dual eligible population. This lack of alignment makes it more difficult for value-based care providers to serve duals.

Congress should leverage value-based care models like ACOs, which offer a unique solution to improving the quality of care while controlling costs for duals. 

ACOs have a strong incentive to provide high-quality, whole-person care for individuals with complex health needs, such as duals. To control over-spending by avoiding unnecessary high-cost care such as emergency department visits or preventable hospitalizations, many ACOs identify the highest risk patients, such as those with multiple chronic conditions or co-morbid mental health conditions and provide tailored care coordination services, and ACO affiliation has been linked with greater use of care coordination strategies.[1] Under the current systems, duals often cannot access the full benefits of accountable care due to many challenges related to data, enrollment, benefits and payment.

Congress should work with the Centers for Medicare and Medicaid Services (CMS) to increase coordination between Medicare and Medicaid programs.

Encouraging the CMS Medicare-Medicaid Coordination Office (MMCO) to increase alignment between Medicare and Medicaid on data, benefits and payment, and enrollment is needed to facilitate broad reform for duals. First, there is a need to standardize information and facilitate the flow of timely and actionable data on enrollees in Medicare and Medicaid for providers serving duals. While many providers participating in Medicare’s ACO models are serving duals, they often lack key Medicaid data on these patients which inhibits the delivery of coordinated, whole-person care. Data on Medicare and Medicaid beneficiaries are frequently captured and stored differently, making it difficult to analyze the full range of care received by duals.[2]

Next, aligning payment strategies across Medicare and Medicaid will improve access to care. While most duals qualify for Medicaid coverage of Medicare cost-sharing, most state Medicaid programs have opted to not pay the full Medicare cost-sharing amount if the Medicaid payment rate is lower than the Medicare payment rate for a given service, meaning that providers can be paid up to 20 percent less to treat duals than non-dual beneficiaries. This creates a disincentive to serve duals and has been associated with reduced access to primary care for duals.[3]

Finally, the MMCO should support providers with navigating the complex Medicaid rules and eligibility criteria that vary state to state. Variation across state Medicaid programs poses challenges for ACO providers serving duals, as each state may have different Medicaid eligibility criteria, enrollment processes, and program rules. Some value-based care organizations are working to help their Medicare patients enroll in Medicaid if they appear to be eligible so that these beneficiaries have access to the full suite of benefits available to duals. This can be very difficult, particularly for ACOs that operate across multiple states and must help beneficiaries navigate different eligibility criteria and enrollment processes. Even once beneficiaries have been enrolled in Medicaid, disruptions in Medicaid coverage or Medicaid “churn” occur frequently due to the complexities of state renewal and redetermination procedures, further limiting access to benefits for duals.[4]

Congress should direct CMS to develop a fully integrated value-based care ACO model for duals that can be adopted by multiple states.

Rather than creating an entirely new and separate system of care for duals, the ACO model should be leveraged to optimize benefits and provide a financially and clinically integrated experience of care for duals. The Program of All-inclusive Care for the Elderly (PACE) provides full financial and clinical integration of benefits and can improve the quality and efficiency of care for duals. Nesting the PACE model of care within the ACO model and allowing ACOs to operate a PACE program with full financial integration for duals could be an effective strategy to achieve these goals.

To address challenges with leveraging PACE to reform care for duals, CMS should provide more implementation resources and supports to state Medicaid agencies to encourage adoption of this program, which could include additional funding or dedicated staff time.

While PACE is a Medicare program, states can elect to provide PACE services to Medicaid beneficiaries. For states that have elected this option, PACE coordinates all care needs and benefits under Medicare and Medicaid and integrates financial, clinical, and social needs for PACE participants. A 2021 report from the Department of Health and Human Services (HHS) found that full-benefit dual eligible beneficiaries in PACE had better outcomes than duals not participating in PACE.[5] Because PACE is optional at the state level, only 32 states currently offer PACE and many of these states impose limits on the number of PACE organizations, the number of individuals who can be served, or both, leading to limited availability for many duals who could benefit from participation. Lack of Medicaid funding is often cited by states as a reason for limiting or not electing participation in PACE.

In addition to funding concerns, state Medicaid agencies lack the needed capacity to implement new programs for duals. Currently, states are still grappling with effects from the COVID-19 pandemic as well as preparing for the unwinding of the public health emergency (PHE). This was exemplified by the lack of applicants to the Community Transformation Track of the CMS Innovation Center’s Community Health Access and Rural Transformation (CHART) Model, which was designed for up to 15 Lead Organization participants. CMS was unable to recruit a sufficient number of applicants for the model to proceed with the first implementation year in 2023, likely due to the requirement for state Medicaid agency participation. 

Leveraging ACOs to expand the PACE model of care to meet the unique and diverse needs of the dual eligible population and provide a financially integrated approach that promotes high-value care addresses each of the core principles of reforming care for duals outlined in the RFI. Due to the constraints currently faced by many state Medicaid agencies that may limit their ability to implement significant reforms and given the importance of this priority at the federal level, shared by Congress and the Administration, lawmakers should ensure that appropriate funding and technical assistance are available to states to facilitate broad reform.

Thank you for the opportunity to provide feedback on existing data and improving care for dual eligible beneficiaries. NAACOS and its members are committed to providing the highest quality care for patients while advancing population health goals for the communities they serve. We look forward to our continued engagement on reforming the system of care for dual eligibles. If you have any questions, please contact Aisha Pittman, senior vice president, government affairs at [email protected]