Editor’s Note: Dual eligibles—those eligible for both Medicare and Medicaid—are among the most costly and complex enrollees in both programs. Though they represent 20% of Medicare enrollees and 15% of Medicaid enrollees, they account for about a third of total spending in both programs.

Given that dual eligibles include both older adults and people of all ages with disabilities, they are, by definition, a costly population. The disproportionate spending on their behalf, however, is reflective of misalignments between the Medicare and Medicaid programs that can result in uncoordinated care and poor outcomes. In a recent webinar, Manatt Health examined the unique challenges of navigating and accessing care across the Medicare and Medicaid systems—and explained the newest initiatives being implemented to drive improved coordination of care and benefits. In of our article summarizing the webinar, published in the August “Health Update,” we looked at key background information on dual eligibles, the status of integration and recent federal initiatives to advance integration. In part 2 of our summary below, we focus on state innovation in integrated care and key takeaways.

Click here to view the full webinar free on demand—and here to download a free copy of the presentation.

Integrated Care Programs Fall Along a Continuum

Integrated care programming for dual eligibles has evolved over the years. Today, states are pursuing different approaches to aligning or integrating Medicare and Medicaid benefits, administrative processes, financing, and quality measurements based on their policy goals, political and financial situations, Medicaid population dynamics, and the availability of Dual Eligible Special Needs Plans (D-SNPs).

When we look across the states, we see wide variations in the level of integration, the scale of enrollment and the savings being achieved. The states with the highest levels of integration are those with Programs for All-Inclusive Care for the Elderly (PACE) and/or Financial Alignment Initiatives (FAIs)/duals demonstrations in place.

While PACE and FAI should be an important part of any state’s integrated care strategy, both include limitations, at least in the near term, on their ability to scale enrollment. Therefore, most of the state innovation today focuses on efforts to pursue alignment between D-SNPs and Medicaid managed long-term services and supports (MLTSS) programs. Because Congress has permanently authorized D-SNPs, they are likely to be the predominant platform for integrated care programs going forward.

About half of the states in the country have MLTSS programs—and about half of those require their MLTSS plans to become a D-SNP or Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP). On the flip slide, some states require that all D-SNPs in the state participate as an MLTSS plan. Which approach a state chooses often depends on whether D-SNPs predated MLTSS in the state or vice versa.

Four Strong Examples of State Innovation

New Jersey, Arizona, Tennessee and Massachusetts offer examples of how states are innovating based on their own needs and existing delivery system structures.

  • New Jersey uses Medicaid state plan and 1115 waiver authority to auto-assign beneficiaries who elect FIDE-SNP enrollment to the same issuer’s Medicaid plan. After launching its MLTSS program, New Jersey made its D-SNPs incrementally responsible for the provision of LTSS.
  • Arizona uses default enrollment flexibility to identify members who will be newly Medicare-eligible 90+ days in advance of their Medicare effective enrollment date. Plans then reach out to potential enrollees within 60 days of their effective enrollment date.
  • Tennessee leverages Medicare Improvements for Patients and Providers Act (MIPPA) agreements to help ensure continuity of care for dual eligibles through default enrollment, providing a 30-day continuity of care period for all seamlessly enrolled dual eligibles. The state requires plans to report on continuity of care for primary care providers and certain specialists.
  • Massachusetts is proposing using an 1115 waiver to better align two of its existing integrated care programs: the Senior Care Options (SCO) program (a FIDE-SNP model in place since 2004 for duals who are over 65) and a newer One Care program (an FAI program in place since 2013 for dual eligible beneficiaries under 65). The state is negotiating now with the Centers for Medicare and Medicaid Services (CMS) on proposals that would ensure stronger enrollment growth and long-term sustainability for both programs. Proposals include passive enrollment across both programs (it is currently available only for One Care), fixed enrollment periods with built-in beneficiary protections, unified member materials, a consolidated and streamlined appeals and grievance process, an enhanced financing model, and shared savings methodologies.

A Deep-Dive Look at Arizona

Arizona has had an MLTSS program since the late 1980s. The state requires its MLTSS program to offer companion D-SNPs. It then leverages 1115 waiver authority and D-SNP contract requirements to promote aligned enrollment for its dual eligible population, using default enrollment to enroll new dual eligibles into the companion D-SNP (with the ability to opt out). Using default enrollment, the state successfully enrolls more than 400 newly eligible Medicare beneficiaries into aligned D-SNPs each month.

In Arizona, plans can use periodic mailings to Medicaid beneficiaries to encourage their enrollment into companion D-SNPs. The state limits D-SNP marketing activities by only allowing direct marketing to those enrolled in a plan’s own Medicaid products.

Arizona exemplifies an effective integrated care program that is a “win” for everyone:

  • Beneficiaries benefit from a seamless enrollment experience via default enrollment as well as an easier time understanding and navigating the care delivery system.
  • States benefit by using their Medicaid authority and CMS flexibilities to improve care coordination; decrease program costs; and promote administrative, financial and clinical alignment among plans.
  • Plans benefit from limitations on marketing activities that ease competition while ensuring D-SNP growth. Plans also are able to leverage their information systems, staff training and other administrative functions across several products.
  • Providers benefit from a more comprehensive view of enrollees’ health and service use.

Five Critical Success Factors for Integrating Care for Dual Eligibles

When we look at the states that are successfully integrating care, we can identify five key drivers of success:

  1. Beneficiary education. States and health plans should prioritize ongoing, targeted beneficiary education to help people understand the value of integrated care models.
  2. Provider engagement. Providers should be invited, when possible, to take part in program design and should have access to training/technical assistance related to providing integrated care to dual eligibles.
  3. Data collection. States and health plans should partner on data collection for planning, resource allocation and evaluation purposes.
  4. Flexibility. States should leverage available federal flexibilities to design programs that work best for them and should allow for additional flexibility in program requirements, such as care management.
  5. Sufficient rates. States need to set sufficient reimbursement rates to ensure adequate plan and provider participation.

What’s Next?

CMS and states will continue to pursue initiatives to better organize, manage and finance care for dual eligibles. Dual eligibles are a very high-need, high-cost population, so all states have an interest in figuring out an effective integrated care strategy. Progress on implementation of integrated care models, however, is likely to be incremental to ensure that these highly vulnerable beneficiaries receive high-quality, accessible care without disruption. 

States always have been innovators in the dual eligibles space, but, particularly in recent years, CMS has introduced new and enhanced flexibilities to encourage even greater state innovation in developing integrated care models. States are taking advantage of the new flexibilities to implement different approaches to improve care coordination, enhance quality and manage costs for dual eligibles.

D-SNPs operate in most states today and will continue to be the predominant platform for integration programs, especially in states with MLTSS programs. More plans are likely to invest in D-SNP models—but the “devil is in the details.” There are still a lot of details to work out around the best care management models for dual eligibles, as well as the optimal benefit design, provider network and health information exchange (HIE) support.  

Finally, the level of provider and beneficiary awareness and engagement is key to whether any integrated care model will succeed or fail. Education and involvement are critical to achieving both enrollment growth and long-term sustainability.