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TriZetto is Helping Payer Clients Prepare for CMS State Pilots for Dual-Eligible Beneficiaries

TriZetto Corporation today announced that at least 20 payer clients are leveraging their TriZetto core administration systems to enable them to participate in the state pilots with the Centers for Medicare and Medicaid Services (CMS). Several TriZetto clients have already passed their CMS readiness reviews as part of their participation requirements.

Under the Affordable Care Act, CMS has launched a three-year demonstration aimed at bringing changes to care delivery for beneficiaries eligible for both the Medicare and Medicaid programs. The demonstration program could touch up to 2 million of the nearly 10 million seniors or disabled individuals across the nation who are eligible for these programs.

“The CMS pilots, now underway with enrolled beneficiaries in four states, are in place to improve care and control costs for beneficiaries who are dually eligible for Medicare and Medicaid,” explained Becky Erbe, vice president, Government Programs for TriZetto. “Dual-eligible beneficiaries account for an inordinate share of spending in Medicare and Medicaid because they often have complex and costly healthcare needs. TriZetto is playing a key a role in helping its payer clients manage this population, with a goal to provide more efficient and effective care to those who need it most.”

Demonstrating the health plan’s ability to administer benefits for both Medicare and Medicaid accurately is a key component of passing the readiness reviews. TriZetto’s core administration systems coordinate the claims payment to automatically process both Medicare and Medicaid benefits for dual-eligible individuals with one claim submission, claim payment and remittance advice. In addition, TriZetto’s Medicare solutions help support separate reporting for Medicare and Medicaid as well as functionality such as reconciliation and member true-up with CMS.

TriZetto’s core administration systems are designed for flexibility to accommodate the changing requirements of CMS and evolving enrollment needs of health plans. Erbe said, “TriZetto invests in compliance and uses agile development processes to keep pace with changes to federal and state regulations. We support clients who serve more than 60 percent of managed Medicaid lives and more than 30 percent of Medicare Advantage lives on TriZetto’s core administration systems, as well as 46 clients with dual eligible special need lines of business. TriZetto has invested more than 50 percent of its research and development dollars to enhance functionality and support compliance requirements in order to rapidly respond to federal and state developments and keep our clients a step ahead.”

TriZetto’s Erbe said, “Although dual eligibles represent the potential of $200 billion to $300 billion in organic premium growth for health plans1, successfully mitigating the challenges and risks associated with this population requires the creation and administration of truly coordinated programs that integrate requirements from both Medicare and Medicaid. TriZetto is focused on helping our clients to align with government priorities while also creating a positive and high-quality experience for their members.”

About TriZetto Corporation

TriZetto Corporation provides world-class information technology and service solutions that help payers and providers work more efficiently and collaborate to deliver better health. TriZetto solutions touch over half the U.S. insured population and reach 245,000 care providers. TriZetto helps healthcare organizations enhance administrative efficiency; improve the cost, quality and delivery of care; address compliance; and compete to win in an emerging retail market. Payer solutions include benefits administration, care management, network management and portal platforms, as well as consulting, application management and business management services. Provider solutions include real-time eligibility assurance, claims editing, revenue cycle management technology and services that help providers get paid quickly and accurately. For more information, visit

1 Alicia Caramenico, “Payers can thrive in dual-eligible market,” Fierce Health Payer. October 10, 2012.

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