67th Annual HSFO Conference Louisville, KY 12/26/2018 67th Annual HSFO Conference Louisville, KY July 30, 2014 Stephanie McCladdie, M.P.A. Regional Administrator Region IV (AL, FL, GA, KY, MS, NC, SC, TN)

Who are dual-eligible beneficiaries? Dual-eligible beneficiaries are eligible for both Medicare and Medicaid benefits. Medicare beneficiaries age 65+ who meet their state’s Medicaid income and asset criteria Medicare beneficiaries <65 who qualify based on disability, and whose incomes are low enough to qualify for SSI 10.2M people dually eligible for Medicaid and Medicare Of these, 7.4M eligible for full Medicare and Medicaid benefits http://www.medpac.gov/chapters/Jun13_Ch06.pdf Medicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from 2006 through 2011. February 2013.

http://kff.org/medicaid/slide/9-million-dual-eligible-beneficiaries-are-covered-by-both-medicare-and-medicaid/

What are the specific needs of this population? >50% have cognitive or mental impairments Due to these complex needs, duals require higher levels of medical care, long-term care, behavioral health services, and social services than other Medicare and Medicaid enrollees http://www.medpac.gov/chapters/Jun13_Ch06.pdf

Medicare and Medicaid Benefits for Dual-Eligible Beneficiaries Medicare is the primary payer for dual-eligible beneficiaries. These beneficiaries are eligible for the same Medicare benefits as other Medicare beneficiaries. For Medicaid, there are certain services that states must cover for dual-eligible beneficiaries including nursing home care, Medicare cost sharing, coverage for inpatient hospital and nursing facility services, and non-skilled home health care. States have the option to cover other services- such as dental, vision, hearing, and transportation to medical appointments. Medicare coverage lacks social support services, so Medicaid provides services that wrap around Medicare’s acute care benefit. There is considerable variation across states in the services covered, resulting in different benefits for dual-eligible beneficiaries depending on where they live. According to the 2011 data for the FFS Medicare population

Behavioral Health Services for Dual-Eligible Beneficiaries Medicare currently covers reasonable and necessary partial hospitalizations and traditional outpatient and inpatient visits to behavioral health providers. Compared with Medicare, Medicaid programs can cover a broader range of behavioral health services, which can include: Social work Personal care Rehabilitation and preventive services Targeted case management intended to help beneficiaries access social, medical, educational, and other services http://www.medpac.gov/chapters/Jun13_Ch06.pdf

Why are policymakers concerned about dual-eligible beneficiaries? Separate funding streams and different payment rates and coverage rules create conflicting financial incentives for the federal and state governments and for health care providers States don’t have a strong financial incentive to reduce spending on acute care for dual-eligible individuals because that spending is largely covered by the federal government through Medicare. Separate payment and approval procedures increase the chances that duals will be treated by a variety of healthcare providers who are not coordinating their care, potentially increasing costs and worsening outcomes. http://www.cbo.gov/publication/44308

What strategies are being used to reduce costs and improve quality of care? States’ efforts include: Initiatives under which Medicare, Medicaid, and private insurers pay fees to the same primary care practice to manage care for patients Contracting with MA plans to provide services covered by Medicaid Coordinating physical and behavioral health care for duals with SMI Developing managed LTSS programs CMS has encouraged the creation of Medicare Advantage plans to target duals ACA created two new offices within CMS: Medicare-Medicaid Coordination Office (MMCO) Center for Medicare and Medicaid Innovation (CMMI)

State Integrated Care and Financial Alignment Demonstrations Two financial models to align Medicare and Medicaid benefits for dual-eligible beneficiaries: Capitated – health plan receives set risk-based payments from Medicaid and Medicare under a three-way contract Managed fee-for-service - providers receive a payment to coordinate duals’ care, must achieve performance benchmarks related to improved outcomes The demonstrations should provide integrated benefits packages that include all primary, acute, pharmacy, BH, and LTSS currently covered by Medicare and Medicaid States can also use §1115 waivers to create demos to integrate care for duals http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8368.pdf

http://kff.org/medicaid/fact-sheet/state-demonstration-proposals-to-integrate-care-and-align-financing-for-dual-eligible-beneficiaries/

CMS Demonstration Challenges Operational partitions within CMS between Medicare and Medicaid Difficulties and delays for states in obtaining and analyzing Medicare data from CMS Uncertainties about how shared-savings arrangements will function in both the capitated and FFS models Implementation of care coordination and integration, especially during the transition to the new system Education of potential enrollees in demo programs

Looking Forward Large number of states planning to reform the financing of services for duals Most will be statewide, will include both duals who are 65+ and those who receive SSI, and will include a wide range of LTSS and BH services Total number of states participating exceeds expectations, in part because states have historically hesitated to use state funds to implement care coordination programs for duals Many states also planning to implement duals initiatives outside of the CMS financial alignment models http://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/2013/states-integrating-medicare-and-medicaid-AARP-ppi-health.pdf