2. 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)

3. 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
Medicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from 2006 through February 2013.

5. 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

6. 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

7. 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

8. 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.

9. 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)

10. 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

12. 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

13. 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