Policy options for integrating care for individuals with both Medicare and Medicaid

Policy options for integrating care for individuals with both Medicare and Medicaid

Collection:
Health Policy and Services Research
Contributor(s):
Bipartisan Policy Center, issuing body.
Publication:
Washington, DC : Bipartisan Policy Center, April 2020
Language(s):
English
Format:
Text
Subject(s):
Delivery of Health Care, Integrated
Dual MEDICAID MEDICARE Eligibility
United States
Genre(s):
Technical Report
Abstract:
The Bipartisan Policy Center is continuing its efforts to improve quality of care through the integration of Medicare and Medicaid services for individuals who are eligible for both programs. These Medicare-Medicaid beneficiaries, commonly known as “dual-eligible individuals,” must navigate two separate programs with different benefits and eligibility requirements. For most individuals, this would be daunting, but for dual-eligible individuals and their families, who are often dealing with chronic conditions and functional limitations, these challenges can be overwhelming. In recent years, policymakers have sought to better integrate Medicare and Medicaid services, including clinical health, behavioral health, social services, and LTSS for the estimated 12.2 million people that are eligible for both programs. Federal and state governments have implemented approaches that vary in the degree of integration. Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) have sought to integrate care for nearly two decades, and the Program of All-Inclusive Care for the Elderly (PACE) has a long history of integrating care. Other efforts have included Medicaid waivers and demonstrations, some of which have gone on to become permanent programs, while others continue as demonstrations. More than a decade ago, Congress developed bipartisan ideas to integrate care for dual-eligible individuals. Those ideas, which were included in the Affordable Care Act (ACA), authorized Fully-Integrated Dual-Eligible Special Needs Plans (FIDE-SNPs) and directed the Department of Health and Human Services (HHS) to establish a single office dedicated to the coordination of coverage and payment of Medicare and Medicaid services for dual-eligible individuals. That office, the Medicare-Medicaid Coordination Office (MMCO), led agency efforts to implement the Financial Alignment Initiative (FAI) demonstration, authorized by the ACA for dual-eligible individuals through the Center for Medicare and Medicaid Innovation. Those demonstrations are discussed in detail in part I of this two-part series. More recently, the Bipartisan Budget Act of 2018 directed the secretary to better integrate the two programs. Integration of care for dual-eligible individuals is especially challenging, given the heterogeneity of the population and the unique and significant needs of the various sub-populations. Many have multiple chronic conditions and may need assistance with activities of daily living (ADLs), such as bathing or dressing. They may have a mental illness, cognitive impairment, physical limitations, or a combination of these conditions. They may have safe living arrangements, or they may be homeless. Dual-eligible individuals reside in urban, rural and frontier areas, and while the majority are older Americans, 39% of dual-eligible individuals are under age 65. Less than 10% of dual-eligible individuals are enrolled in programs or care models that integrate Medicare and Medicaid services. As a result, they or their family members must navigate two separate programs--one administered by the federal government and the other by the state--with different eligibility requirements and different benefits. When beneficiaries have a problem with access to care, such as a coverage denial, they must appeal to the federal government for Medicare-covered benefits and the state for Medicaid-covered benefits. Enrollees in managed care plans that are not integrated must navigate two enrollment periods, two plan points of contact, and may have different in-network providers for each plan. Because dual-eligible individuals are sicker than the average Medicare beneficiary, Medicare spending for dual-eligible individuals is higher than spending for their non-dual-eligible counterparts. While 20% of Medicare beneficiaries are dual-eligible individuals, 34% of Medicare spending is historically attributed to this population. The potential for improved outcomes and savings in the short-term is unclear, however many state and federal policymakers believe integration is worthwhile as a means of simplifying and better coordinating care for dual-eligible individuals. Many policymakers believe integration of the Medicare and Medicaid programs has the potential to reduce spending and improve outcomes over the long-term. Despite the integration efforts listed above, Medicare and Medicaid continue to operate as separate and distinct programs for the majority of dual-eligible individuals across the country. BPC health care leaders agree on the importance of streamlining services for dual-eligible individuals to make the programs more user-friendly and accountable. Leaders also believe integration of care will improve patient outcomes and lower costs over the long-term. In addition, early evaluations suggest positive findings for certain quality and cost measures. Without changes in federal policy, however, the ability or willingness of more states to move forward is limited. BPC is working to finalize short-term recommendations designed to remove federal barriers. At the same time, stakeholders have expressed a need for longer-term solutions to incentivize states to integrate services. This white paper identifies policy barriers, and outlines policy options as a starting point for discussion and will inform our final report. In the coming months, BPC health care leaders and staff will seek feedback from stakeholders and will issue final recommendations in the summer of 2020. These policy options were prepared based on research and discussions with stakeholders, including organizations representing consumers, providers, health plans, as well as state and federal policymakers. The list includes both short-term and long-term recommendations that build on our previous work and recommendations. These recommendations fall into four categories: (1) Eliminate regulatory barriers to alignment. (2) Provide incentives and assistance to states. (3) Improve the enrollee experience. (4) Require full integration of Medicare and Medicaid.
Copyright:
The National Library of Medicine believes this item to be in the public domain. (More information)
Extent:
1 online resource (1 PDF file (16 pages))
NLM Unique ID:
101769495 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/101769495