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Evolving Integrated Managed Care Models for Medicare-Medicaid Dual Eligible Beneficiaries: Key Considerations for Health Plans

This week we are providing a brief recap of our January 8th webinar Evolving Integrated Managed Care Models for Medicare-Medicaid Dual Eligible Beneficiaries: Key Considerations for Health Plans presented by Principals Sarah Barth, JD and Ellen Breslin, MPP.

Many states, in collaboration the federal government, are focused on the development of integrated care models through health plans that strive to create a better system of care that addresses dually eligible individuals’ diverse needs in a comprehensive and holistic way.

There are currently over 12 million people nationwide who are dually eligible for Medicare and Medicaid[i]. They are a diverse population in age, race, ethnicity and language, with high rates of chronic conditions, behavioral health, long term services and supports (LTSS) and social determinant of health (SDOH) needs. They account for a disproportionate share of spending for the Medicare and Medicaid programs. Dually eligible beneficiaries are:

  • 20 percent of the Medicare population accounting for 34 percent of program spending; and,
  • 15 percent of the Medicaid population accounting for 33 percent of program spending.[ii] 

Access and navigational issues for this population often contribute to health disparities and equity issues, higher rates of hospital emergency department and inpatient use and lower quality of life.

There is widespread recognition among states and federal governments, health plans, providers and community-based organizations that dually eligible individuals and their family, friends, and caregivers must be at the center of integrated care program models that support their needs and goals. These goals include health, quality of life, and their ability to engage in the communities in which they live.

Over 20 states have Medicaid managed long-term services and supports (MLTSS) programs serving Medicaid beneficiaries with higher needs, many of whom are dually eligible. MLTSS programs are a pathway for states to integrate care across Medicare and Medicaid. In some states, health plans that operate a Medicaid MLTSS plan must also operate a Medicare Advantage (MA) dual eligible special needs plan (D-SNP).

Dually eligible individuals are more often choosing a Medicare managed care option. From 2006 to 2017, we saw a 24 point increase in the percentage of individuals choosing to enroll in Medicare Advantage, increasing from 11% to 35%.[iii]

HMA anticipates continued growth in the integrated managed care market. The December 2018 Centers for Medicare & Medicaid Services (CMS) State Medicaid Director Letter Ten Opportunities to Better Serve Individuals Dually Eligible for Medicaid and Medicare (SMDL # 18-012) announced that CMS will be outlining new Medicare-Medicaid Financial Alignment Initiative-related opportunities for current demonstration states “and other states in the coming months.” Additionally, Contract Year (CY) 2020 Medicare Advantage and Part D Flexibility Proposed Rule (CMS-4185-P) seeks to implement D-SNP provisions of the Bipartisan Budget Act of 2019 which permanently authorized Medicare Advantage Special Needs Plans, including D-SNPs.

Health plans are adapting business models and models of care to meet the diverse needs of dually eligible individuals. They are working to understand the diverse needs of the population, develop community-based approaches to locate and engage individuals to assess and serve them, and build care coordination systems and workflows to coordinate care across all services – primary, acute, behavioral health, LTSS and social services. Effectively serving dually eligible individuals includes thinking broadly about provider networks and building partnerships with community-based organizations. HMA outlined a list of key considerations for health plans in the January 8, 2019 webinar. These key considerations are informed by our work in the market with health plans, providers, community-based organizations and dually eligible individuals.

The webinar is also a useful resource for health plans that wish to better understand the key differences across state and federal programs and the different types of integrated health plans, including MA dual eligible special needs plans – D-SNP, a MA fully integrated special needs planFIDE SNPs, the proposed designation of a highly integrated dual eligible special needs plan – HIDE SNPs, and Medicare-Medicaid Plans (MMP). These are terms defined during the January 8th webinar.  Link to Webinar

For more information, contact Sarah Barth at sbarth@healthmanagement.com and Ellen Breslin ebreslin@healthmanagement.com


[i] CMS State Medicaid Director Letter #18-012, Ten Opportunities to Better Serve Individuals Dually Eligible for Medicaid and Medicare, December 2018.
[ii] Ibid.
[iii] Data Analysis Brief: Managed Care Enrollment Trends among Dually Eligible and Medicare-only Beneficiaries, 2006 through 2017, CMS Medicare-Medicaid Coordination Office, December 2018.

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