Brief
Policy Brief: Forging a Path Toward Integrated Care for Dually Eligible Individuals
Six Recommendations to Accelerate Access to and Enrollment in High-Quality Integrated Care Models
This Policy Brief is based on a public conference and closed-door expert convening co-hosted by the Leonard Davis Institute of Health Economics at the University of Pennsylvania and Health Affairs. More information can be found in the companion white paper.
People who qualify for full benefits in both Medicare and Medicaid—commonly known as “dually eligible” individuals—must navigate two separate programs with different and often misaligned rules and incentives. This can lead to poor outcomes and high costs for this population, as well as confusion and frustration for individuals trying to access care. The financial stakes are high, given the roughly $500 billion per year spent on dually eligible individuals; the human stakes are even higher, given the many beneficiaries with complex care needs who are at high risk for poor outcomes.
There have been decades of efforts to address these challenges, most recently with numerous pilot demonstrations under the Affordable Care Act, with little meaningful progress. There is now a pivotal policy window to make material changes that address the needs of dually eligible individuals, enabled by these demonstrations winding down, the rapid expansion of Medicare managed care, and bipartisan interest in Congress to reign in health care spending and reform care for those who are dually eligible.
Building on lessons learned, we highlight opportunities to substantially integrate care across Medicare and Medicaid with the goal of improving care, reducing costs, and making it easier for beneficiaries to access their benefits and navigate their care. In this brief, we present six recommendations for Congress, CMS, and states to take meaningful action to align incentives across Medicare and Medicaid and deliver the “whole-person” care that dually eligible people want, need, and deserve.
Recommendations
Informed by recent policy activity and proposals, we offer recommendations that build on the existing structures of Medicare and Medicaid and promote substantially integrated models of care for dually eligible individuals. These policy recommendations seek to align financial incentives for beneficiaries, providers, plans, and government through models that feature substantial financial integration (that is, one entity bearing risk for both Medicare and Medicaid spending). We also seek to center the experience of individuals who are dually eligible in all recommendations and ensure that more beneficiaries have one insurance card, one comprehensive set of benefits, and one provider network.
1. CREATE AN INTEGRATED OPTION FOR ALL, AUTHORIZE FUNDING, AND DECREASE NON-INTEGRATED OPTIONS: Require states to offer at least one substantially integrated Medicare-Medicaid option to all dually eligible individuals, and provide the funding to support its creation and administration; use carrots and sticks to reduce the prevalence of non-integrated plans serving disproportionate numbers of this population.
- Congress should require states to offer a substantially integrated care option to all dually eligible individuals, and provide dedicated resources for states to do so, through higher federal Medicaid funding matching rates and planning grants.
- To help states with this strategy, CMS should develop a menu of integrated program models, all of which should include financial integration. Each model should aim to integrate the coverage and care experience, and provide comprehensive benefits in each state, with features such as:
- A single set of enrollment materials and enrollee notices;
- A unified plan of care and a single care coordinator with access to information on all aspects of care and who can represent a beneficiary’s interests in reviews and appeals of coverage decisions;
- A core set of quality measures and targeted assessment of the dually eligible patient experience.
- CMS and states should implement a regulatory strategy to ensure that integrated options are prioritized over non-integrated options, and to reduce the competitive disadvantage integrated options may face in the marketplace.
- CMS should require all Medicare Advantage plans serving a substantial number (e.g., 20%) of dually eligible individuals to have a formal relationship with state Medicaid agencies and provide payment incentives for plans that have more integration with Medicaid.
- States should use their procurement processes to decrease, over time, the number of non-integrated or non-aligned plans with which they contract.
2. DEVELOP ACOs: In fee-for-service Medicare, create new Accountable Care Organizations (ACOs) that are at risk for both Medicare and Medicaid spending; in the interim, phase in requirements that risk-bearing entities serving dually eligible individuals have a formal relationship with the states in which they operate.
- CMS should require that all risk-bearing entities (such as ACOs) serving a substantial number of dually eligible individuals have formal relationships with state Medicaid agencies, delineating their responsibilities to coordinate care and share information.
- CMS should work with states and provider groups to develop and test an ACO model that would bear risk for both Medicare and Medicaid costs and would share costs and savings.
- CMS should develop an evaluation framework that compares program results to non-integrated care and includes measures of long-term quality, patient experience, integration, costs, and value.
3. IMPLEMENT CONTINUOUS ELIGIBILITY: Simplify and improve Medicaid eligibility and enrollment processes to promote continuous coverage.
- Congress should require 12-month continuous Medicaid eligibility for dually eligible individuals and help states simplify and streamline Medicaid redeterminations by, for example, maximizing the use of ex parte renewals based on data from other means-tested programs.
4. IMPLEMENT IMPROVED CHOICE RESOURCES AND LIMIT BROKERS: Provide dually eligible individuals with meaningful and easier-to-navigate choices around integrated coverage options.
- Congress and CMS should improve beneficiaries’ ability to understand and choose an integrated plan using the following strategies:
- Standardize information on benefits and coverage for dually eligible individuals on the Medicare Plan Finder site, develop a connected resource hub that includes information on Medicaid benefits, and provide trained navigators to help explain plan options.
- For Medicaid beneficiaries newly eligible for Medicare, change the default enrollment option from fee-for-service Medicare to substantially integrated plans that meet minimum star ratings, with an easy opt-out option.
- Provide additional resources to train impartial state-level navigators in dual eligibility coverage options, through State Health Insurance Assistance Programs (SHIPs) or state-contracted independent enrollment brokers.
- Further regulate independent brokers’ commissions to eliminate incentives to steer dually eligible individuals into non-integrated Medicare plans.
5. AUTHORIZE SHARED SAVINGS: Apply and build upon the lessons from the CMS Financial Alignment Initiative to develop a new shared savings structure between the federal government and states that incentivizes clinical, financial, and administrative integration for dually eligible individuals.
- With authority from Congress and in consultation with states, CMS should design and implement a shared savings structure that captures the long-term savings or slower cost growth across both programs that can be achieved by aligning financial incentives. Key features of this structure include:
- Upfront investment in state-level care coordination and supportive services, targeted to high-need, high-cost dually eligible individuals, with adequate administrative funding.
- Incentives for states (e.g., enhanced federal match rates) to consolidate or carve-in all Medicaid benefits in an integrated model.
- A methodology for shared savings that sets and rebases Medicare and Medicaid benchmarks based on trends in an entire market (including non-integrated options) and avoids making it harder for successful participants to continue to achieve savings in subsequent years (the ratchet effect).
- An evaluation framework that compares program results to non-integrated care and goes beyond short-term savings to include quality measures, patient experience measures, measures of integration, and cost-effective use of federal and state resources.
6. DEVELOP QUALITY MEASURES, ESTABLISH OMBUDSPERSONS, AND IMPLEMENT JOINT OVERSIGHT: Hold programs and plans accountable for meeting the needs of beneficiaries through structures and processes that promote person-centered, “whole-health” care.
- States should establish dedicated ombudsperson offices to address access issues, complaints, and systemic barriers in delivering care to dually eligible individuals.
- To assure financial accountability, CMS should require integrated plans to calculate and report a combined Medical Loss Ratio (MLR) for both Medicaid and Medicare spending and require minimum MLRs for each program.
- CMS should work with other agencies to develop measures of plan quality that capture what matters most to dually eligible individuals. CMS should adapt elements of existing instruments, and design specific measures that address health-related social needs of this population.
- CMS and states should establish and maintain joint oversight of integrated care models through dedicated staff charged with strengthening oversight tools and data sharing.
ACKNOWLEDGMENTS
This work and an accompanying white paper were funded by The SCAN Foundation and Arnold Ventures.