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CMS Offers Grants to Create Ombudsman Programs for Duals Demos

By Rebecca Adams, CQ HealthBeat Associate Editor

June 27, 2013 -- Federal officials plan to provide $12 million over three years to help states create ombudsman programs for demonstration projects that will shift people who are dually eligible for Medicare and Medicaid into managed care.

The ombudsman programs could quell some concerns that the move to managed care could be confusing for elderly or frail beneficiaries. The ombudsman programs in states that have been approved for the dually eligible demonstration projects are intended to make sure that patients can get help with any problems in the transition and to keep government officials informed of any problems.

The Centers for Medicare and Medicaid Services (CMS) demonstration projects, which were announced in 2011, drew national attention because of the scale and the population of patients involved. CMS officials, led by Melanie Bella, have said that they hope that moving more patients to managed care will improve the coordination of care, lower costs and offer higher-quality medical services. About 10 million people are eligible for both Medicare and Medicaid, and they represent some of the sickest and most vulnerable patients in the country. As many as 2 million people could be part of the three-year demonstration projects, although the scope is expected to be much smaller than that because of the work involved in setting each one up.

So far, CMS has given six states the go-ahead to launch the demonstrations. Five states—Massachusetts, Ohio, Illinois, California and Virginia—will test out the use of managed care plans. One state, Washington, will experiment with a fee-for-service system that is designed to better coordinate and manage beneficiaries' care.

The CMS funding announcement estimates that $4.8 million is projected to be given to states in fiscal 2013 and $4 million in fiscal 2014. The total amount expected for each state ranges from $275,000 to $3 million over three years.

The grants for the ombudsman programs will come from the budget of the CMS Center for Medicare and Medicaid Innovation.

States can apply in one of three rounds, depending on the schedule of their launches. Those that are launching soon should get in their applications by July 30. The other due dates are in October and January.

The proposed ombudsman programs will be overseen by CMS and the Administration for Community Living.

Sen. Jay Rockefeller, D-W.Va., who has kept a close watch on the duals demonstration projects, praised the action.

"Trying to find the best way to provide care for seniors and people who are disabled eligible for both Medicare and Medicaid has not been an easy task," said Rockefeller in a statement. "But because of the Department of Health and Human Services' (HHS) decision today, independent watchdogs in every state will be able to provide us with a reliable snapshot of the care being provided to these men, women and children, who are often among our most vulnerable populations, so we can make informed improvements to these programs. I'm glad to see HHS take this step forward—it's one I've long advocated for—and I'll be monitoring the reports closely to make sure these programs are putting patient care first."

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