Report Profiles 15 States’ Plans for Dual Eligibles
States continue to move forward with efforts to better coordinate care for people who have both Medicare and Medicaid, also known as dual eligibles. A new report from the Kaiser Family Foundation, “Proposed Models to Integrate Medicare and Medicaid Benefits for Dual Eligibles,” provides an overview of plans in the 15 states that received design contracts of up to $1 million in April 2011 from the Center for Medicare and Medicaid Innovation (CMMI) and the Medicare-Medicaid Coordination Office (MMCO). The MMCO, created by the Affordable Care Act (ACA), aims to better align and coordinate Medicare and Medicaid coverage for dual eligibles, a group that accounts for 15 percent of the Medicaid population but 39 percent of Medicaid spending, in part due to the population’s high health needs.
Some states prefer to incorporate duals into ongoing implementation of managed care solutions. For example, Colorado plans to include all state Medicaid recipients in its Accountable Care Collaborative Program, which will emphasize medical homes and primary care case management. Other states, such as Massachusetts, Michigan and South Carolina, propose using a combination of managed care organizations, accountable care organizations and medical homes to integrate care for duals. North Carolina plans to build upon the existing Community Care of North Carolina program (CCNC), which includes primary care medical homes.
In Medicare Rights’ experience, advocates and policymakers should look beyond the four corners of a single proposal to understand the trajectory of a policy’s implementation. Though New York State’s duals proposal includes a variety of options, the state’s larger programmatic goal of transitioning all Medicaid recipients into managed care plans has shaped its planning. New York is currently transitioning beneficiaries who receive 120 days of community-based care into managed long-term care plans, and the state has indicated that this effort will inform future decisions regarding the dual-eligible population.
While the integration of benefits for dual eligibles creates opportunities to improve patient experience while promoting efficiency and cost savings, there are still some outstanding issues that states may need to address as they move forward with coordination plans. Five states have not yet decided whether enrollment for duals will be voluntary or mandatory, and in two states, enrollment would be mandatory for a significant portion of duals. Also, no state has suggested coordinating the divergent Medicare and Medicaid grievance and appeals processes, which could become an obstacle for some duals who attempt to receive care. Beneficiary protections such as these are critical components of integrated delivery of quality care. States must ensure that their final plans remove inefficiencies that prevent the poorest and sickest residents from easily accessing health care.
Read the Kaiser report.
More Details Released on Health Insurance Exchange
Last Friday, the administration released three sets of proposed rules that cover eligibility and enrollment for Medicaid plans offered in the exchange and premium tax credits under the Affordable Care Act (ACA) that can be used to help people purchase insurance. The rules envision a simplified and largely automated system that allows people to apply through multiple points of entry for all programs, including Medicaid, exchange plans, and related tax credits and subsidies. The “no wrong door entry” is intended to help ensure that people are enrolled in the appropriate insurance and assistance programs regardless of where they begin their application.
Another way the ACA and the regulations achieve simplification is by creating a standardized income eligibility threshold and universal Modified Gross Adjusted Income (MAGI) calculation to be applied across most populations applying for Medicaid, exchange plans, premium tax credits and other insurance affordability programs. The rules also set forth parameters for electronic data exchanges between state and federal agencies, most specifically the IRS, that will allow state Medicaid offices and exchanges to verify information supplied by applicants without requiring the applicant to provide additional information. Only when there is a discrepancy in the data or where no data match is available will a person be required to submit further documentation to confirm the information supplied on the initial application.
Medicare Rights Center is working with states, the federal government and fellow stakeholders to ensure that people with Medicare who are eligible for Medicaid programs are also able to benefit from streamlined enrollment systems. Enrollment and system reforms would help prevent bureaucratic disentitlement for the Medicare population eligible for Medicaid programs and smooth transitions to Medicare by helping to eliminate data matching errors, onerous documentation and other requirements that often block access to benefits.
Read the proposed rule on exchange functions and enrollment.
Read the proposed rule on Medicaid eligibility changes.
Read the proposed rule on health insurance premium tax credits.
All states offer a variety of Medicaid programs, and several can help people with Medicare. If you qualify for a Medicaid program (no matter which one), Medicaid can help pay for costs and services that Medicare does not cover. Medicare is the primary payer and Medicaid pays second.
For services that both Medicare and Medicaid can cover (such as doctors’ visits, hospital care, home care and skilled nursing facility care), Medicare will pay first and Medicaid will pay second, by covering your remaining costs, such as the Medicare coinsurances and copayments.
Medicaid can cover much more long-term care than Medicare does. Medicare requirements for coverage of long-term care services, such as home care and skilled nursing facility (nursing home) services, are generally stricter than Medicaid’s and the coverage itself is much more limited.
Medicaid will also pay for medical services not covered at all by Medicare as long as they are covered by Medicaid. Such services may include routine dental services and transportation to and from doctors’ appointments.
Learn more about Medicaid and Medicare at www.medicareinteractive.org.
The Medicare Rights Center today released a report on its volunteer model called Seniors Out Speaking (SOS), which enlists older volunteers to lead brief, regularly scheduled Medicare presentations—called Medicare Minutes—for audiences of their peers. SOS promotes civic engagement and arms older adults with clear, accurate Medicare information—outcomes that are particularly relevant as the first baby boomers begin to turn 65. SOS started in Westchester County, New York but has since been successfully replicated in states across the country.
Read the report.