AIS Newsletter Examines Potential Fixes to Massachusetts Medicare-Medicaid Duals Demo

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In the wake of Fallon Total Care’s announcement that it will exit the Massachusetts Medicare-Medicaid dual-eligibles demo, Atlantic Information Services’ Medicare Advantage News takes a look at what CMS might do to make duals demos more viable.

Last month, Fallon Total Care announced that it would leave the Massachusetts Medicare-Medicaid dual-eligibles demonstration program, or demo, raising doubts about the viability of the program. The Centers for Medicare & Medicaid Services (CMS) would not comment on the Fallon departure, but CMS’s Medicare-Medicaid Coordination Office (MMCO) and the agency as a whole are known to be actively seeking ways to help demo plans succeed, Atlantic Information Services, Inc.’s (AIS) Medicare Advantage News (MAN) reports in its July 2 issue, which examines some of the specific changes that have been made and could be made in the future to the duals program.

Actions being considered include streamlining reporting requirements, implementing administrative changes, and perhaps even changing the current risk-adjustment system, which lumps full duals served by the demo in the same category as less-expensive partial duals served by other plans for payment purposes.

One major fix could be continuing risk-protection programs such as risk corridors. Kit Gorton, M.D., president of the public plans division of Tufts Health Public Plan, notes to MAN that MMCO has extended risk corridors to the second and third years, which has the effect of boosting pay for the demo plans. But Lois Simon, the president of Commonwealth Care Alliance (CCA), tells MAN that she would like to see it extended through the whole length of the duals initiative. Tufts Health and CCA are the two plans remaining in the Massachusetts duals demo.

Another specific problem Gorton cites is having to submit encounter data in two different formats, one for CMS and one for Massachusetts. There are also two sets of regulations for handling appeals and grievances, two sets of timelines to meet, and the continuation of a system where the Medicare claim must be paid before Medicaid pays the balance.

Visit to read the article in its entirety, which includes a table counting Massachusetts duals-demo enrollment as of May 1.

About Medicare Advantage News
Medicare Advantage News is the health care industry’s #1 source of timely news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in this hotly contested area of health insurance. Published biweekly since 1994 (when it was Medicare+Choice), the newsletter exists to help plans boost revenues, increase enrollees, cut costs and improve outcomes in Medicare Advantage and Medicaid managed care. Visit for more information.

About AIS    
Atlantic Information Services, Inc. (AIS) is a publishing and information company that has been serving the health care industry for more than 25 years. It develops highly targeted news, data and strategic information for managers in hospitals, health plans, medical group practices, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, websites, looseleafs, books, strategic reports, databases, webinars and conferences. Learn more at

Jill Brown, Executive Editor
Atlantic Information Services, Inc.    
(202) 775-9008, ext. 3058

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Jill Brown, Executive Editor
Atlantic Information Services
+1 (202) 775-9008 Ext: 3058
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