July 13, 2023

The Honorable Bill Cassidy, M.D.
United States Senator
455 Dirksen Senate Office Building
Washington, DC 20510 

Re: Discussion Draft Legislation to Improve Care for People who are Dually Enrolled in Medicare and Medicaid 

Dear Senator Cassidy, 

On behalf of Accountable for Health, we appreciate the opportunity to provide feedback on the discussion draft to improve care for people who are dually enrolled in Medicare and Medicaid. Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to support policymakers to advance the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs. Consistent with that, we support the goals of increasing access to accountable care delivery options for dual eligibles and see opportunities to increase enrollment in integrated models. 

Individuals enrolled in Medicare and Medicaid frequently experience fragmented care and poor health outcomes due to inadequate coordination of services and misaligned financial incentives across programs. The lack of coordination in combination with the population’s overall higher health needs contributes to disproportionate spending – although duals made up 19 percent of Medicare enrollment and 14 percent of Medicaid enrollment, they accounted for 34 percent of Medicare spending and 30 percent of Medicaid spending in 2020.1 People enrolled in Medicare and Medicaid are more likely to have disabilities and often also experience functional limitations and challenging social needs.2 These individuals often experience fragmentation in care delivery, contributing to poorer outcomes and increased expenditures.3 Accountable for Health supports integrated coverage and accountable care delivery for this population. 

Briefly, the discussion draft would require all states to establish integrated care programs for dual eligibles. Under a new title of the Social Security Act, the Department of Health and Human Services would develop and publish a range of program models for providing integrated care to duals within 180 days. States would then be required to choose at least one integrated care model for full-benefit duals and one model for partial duals to implement within a year of HHS’s publication of the options. States would then be required to implement their selected models on a timeline allowing for enrollment within four years. 

State Strategies to Integrate Care for Duals 

Accountable for Health supports expanded access to integrated care for individuals enrolled in Medicare and Medicaid supported by accountable care delivery systems. Today, states are at different stages of integrating coverage and the availability of integrated models and the level of integration varies substantially. This is also true of accountable care delivery across the country. While there is broad bi-partisan support for the move to greater levels of accountability for cost and patient outcomes, adoption must be accelerated for all people to have access to coordinated care. This is particularly important for duals, arguably the most complex and costly population. 

To support a timely transition to integrated coverage and accountable care delivery, we recommend adding a provision to the legislation to require that states develop a strategy to achieve these goals. Specifically, The Medicaid and CHIP Payment and Access Commission (MACPAC) has recommended that Congress authorize the Secretary of the Department of Health and Human Services to require that all states develop a strategy to integrate Medicaid and Medicare coverage for full-benefit duals within two years with a plan to review and update the strategy. The strategy would include the following elements – integration approach, eligibility and benefits covered, enrollment strategy, beneficiary protections, data analytics and quality measurement. We believe that this approach, developed in partnership with stakeholders including accountable care providers, should be incorporated as part of legislation that encourages states to invest in new integration models. 

The development of these plans would provide an important opportunity to evaluate existing options at the state level, many of which are at different levels today, ranging from high levels of integration to offering few or no integrated coverage options. It would also provide an opportunity for accountable care providers and stakeholders to provide detailed input as to the best opportunities to integrate coverage and coordinated care for dual eligibles. In addition, the development of the plans will create the necessary forum to consider potential disruption to existing integrated care delivery for duals and any potential disruption from new model options. 

Accountable Care Offerings for Individuals Eligible for Medicare and Medicaid 

The draft legislation would require that the Federal Coordinated Health Care Office (FCHCO) develop and publish a range of program models that achieve integrated care 

for people who are eligible for Medicare and Medicaid. Accountable for Health suggests that Congress instruct FCHCO to develop a limited set of options and: (1) require that one of the model options is a model that allows providers to take full clinical and financial responsibility for dual eligibles; and (2) that there is an option for states to propose an alternative to the menu of model choices, provided that the alternative meets the goals of offering integrated care and coverage, integrates medical, behavioral, long-term care, and social needs of duals, and meets specified threshold criteria for quality and cost. Additional requirements for this state alternative option could be specified in the legislation and we would be pleased to discuss that further. 

Accountable care delivery mechanisms bring providers together to provide coordinated, high quality care for their populations. Accountable care encourages greater care coordination and ensures that people, particularly those with multiple chronic conditions, get the right care at the right time in the right setting, while avoiding duplication of services. However, in current ACO initiatives, typically the provider does not have financial accountability for the Medicaid expenditures for individuals who are eligible for both Medicare and Medicaid. An accountable care delivery and integrated coverage model under this new legislation should explicitly enable this type of model, and where possible, build on existing ACO infrastructure. This legislation can accelerate the adoption of accountable care delivery by requiring a model option that allows accountable care entities to take full risk for this population. 

As models are developed and model design features are finalized in this legislation, accountable care delivery should be a priority regardless of the integrated coverage model selected. This includes incorporating accountable care delivery perspectives into the development of quality metrics, care coordination, risk adjustment, health risk assessments, and data collection. These elements will be critical to successful implementation and achieving the goals of better care and improved outcomes for this population and must be thoughtfully and thoroughly considered. 

Finally, we note that the new model options discussed in this legislation will be added to a complex array of options available for duals today. We recommend additional consideration of incumbent options and how they will be considered and evaluated alongside development of these new offerings. 


Accountable for Health appreciates the opportunity to weigh in on the discussion draft legislation. If you have any questions about our comments or need more information, please do not hesitate to contact Mara McDermott, mmcdermott@accountableforhealth.org. 


Mara McDermott signature

Mara McDermott
Accountable for Health 


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