View all blogs

Medicare-Medicaid Integration: Essential Elements, Policy Recommendations for Integrated Dual Eligible Care Programs

This week, our In Focus section releases a new brief from Health Management Associates, Medicare-Medicaid Integration: Essential Program Elements and Policy Recommendations for Integrated Care Programs for Dually Eligible Individuals. The authors are Sarah Barth, Ellen Breslin, Samantha DiPaola and Narda Ipakchi.[1]

This issue brief is part of a multi-phased research initiative to increase enrollment in integrated care programs (ICPs)[2] that meet full benefit dually eligible individuals’[3] needs and preferences. Dually eligible individuals have a range of chronic conditions and disabilities requiring both Medicare and Medicaid services, which makes integrated programs important to their lives.

  • Phase 1, ICP Enrollment. Consistent with other research, we found only 1 in 10 dually eligible individuals is enrolled in an ICP. See Issue Brief #1 for more information on Phase 1.
  • Phase 2, ICP Successes and Barriers. To better understand the factors influencing ICP enrollment, our next phase of research summarized the features for success and the barriers encountered by ICPs. See Issue Brief #2 for more information on Phase 2.
  • Phase 3, ICP Essential Elements. To encourage ICP enrollment and retention, our third phase of research identified the essential elements of ICPs centered around, informed by, and made available to dually eligible individuals. Issue Brief #3.

This work was produced with support from Arnold Ventures.

ICPs are a promising model to provide integrated services and supports to dually eligible individuals to enable them to achieve higher quality of life and preferred outcomes – to live independently and engage in their communities. Federal and state policymakers have long been working to expand enrollment in ICPs, however there is more to do to make ICPs attractive to consumers. To increase ICP enrollment and availability, continued partnership with consumers is needed to design programs that meet the diversity of dually eligible individuals’ needs and preferences, and address health equity. Additionally, states play an important role in the establishment and oversight of ICPs and need federal support to undertake this important and complex work. 

Informed by stakeholder interviews, Issue Brief #3 identifies 10 essential elements and related state, federal and ICP policy recommendations for establishing and simplifying ICP programs in which consumers want to enroll. The 10 essential elements are organized into three categories as follows:

Eligibility and enrollment into ICPs

  • Element 1. Simplified Medicare and Medicaid eligibility processes and paperwork
  • Element 2. Comprehensive and expert consumer choice counseling and/or enrollment assistance

Delivery of care and supports in ICPs

  • Element 3. Diverse consumer engagement to inform tailored delivery systems and integrated programs
  • Element 4. Robust data infrastructure to tailor and adapt program approaches and drive health equity
  • Element 5. Coordinated efforts to maximize capabilities to address unmet social needs
  • Element 6. Single process for assessments and plans of care, and one care team for each consumer
  • Element 7. Meaningful and transparent quality measurement to empower consumers and stakeholders
  • Element 8. Payment models to incentivize consumer quality of life improvements

Critical consumer access in ICPs

  • Element 9. Adequate, engaged, and diverse workforce to support consumer needs and preferences
  • Element 10. Access to needed services in rural areas

For a succinct overview of the essential elements and policy recommendations, please access the brief fact sheet. For a full discussion of the elements and policy recommendations, please access the full brief.

For further information or questions, contact Sarah Barth at [email protected], Ellen Breslin at [email protected], or Samantha DiPaola at [email protected].

[1] Narda Ipakchi was formerly a Senior Consultant with HMA.

[2] Integrated Care Programs (ICPs): For this research, we defined ICPs as financing and care delivery organizing entities or programs that coordinate and integrate Medicare and Medicaid-covered services and supports for dually eligible individuals.They include the Centers for Medicare & Medicaid Services (CMS) Financial Alignment Initiative (FAI) capitated and fee-for-service models; the Program of All-Inclusive Care for the Elderly (PACE); Medicare Advantage (MA) Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs); Medicaid Managed Long-Term Service and Supports Program (MLTSS) managed care organizations and aligned MA dual eligible special needs plans (D-SNPs); and state-specific programs that may be proposed to CMS.

[3] Dually Eligible Individuals: When using the term dually eligible individuals, we are referencing Medicare-Medicaid full benefit dually eligible individuals (FBDEs), those who qualify for full Medicaid benefits.