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While the "duals" represent only 16 percent of the total Medicare population and 18 percent of the total Medicaid popula- tion, they account for almost 25 percent of total Medicare spending and 46 percent of total Medicaid spending.1 The health care status of the dually eligible population is quite diverse; many of these indi- viduals have substantial and costly medical and long-term service and s. [...] The variation in duals' health status can present challenges to providers and poli- cymakers trying to meet their needs and contain costs in both the Medicare and Medicaid programs. [...] Approximately 80 percent of the population qualifies for full Medicaid benefits, including long-term services and supports, and are often referred to as "full duals." The rest of the du- als have slightly higher incomes and qualify only for Medicaid assis- tance with Medicare premiums and cost-sharing. [...] There are duals receiving just Medicaid assistance for Medi- care premiums and cost-sharing, and there are duals receiving the full gamut of acute and long-term care services the two programs have to offer. [...] The benefits and challenges of coordinating care across Medicare and Medicaid providers, including how different program and provider incentives can affect duals' care and costs, will be dis- cussed.
Often overlooked, however, is the heterogeneity of health care needs and spend- ing of the dual eligible population and the potentially different approaches to addressing care delivery and costs for specific subgroups. [...] The rest of the spending went toward Medi- care premiums (9.2 percent), Medicare acute care cost-sharing (14.9 percent), acute care not covered by Medicare (4.7 percent), and pre- scription drugs (1.1 percent).13 INITIATIVES TO INTEGRATE CARE AND FINANCING Some experts have argued that better coordination of care protocols and integration of financing streams for the dual eligible population http:. [...] The Patient Protection and Affordable Care Act (PPACA) required that that the Centers for Medicare & Medicaid Services (CMS) work with states to improve the delivery system and seek ways to lower health care costs for this population. [...] As CMS and the states work to integrate Medicare and Medicaid financing streams and control costs of caring for the dual eligible population as a whole, specific attention may need to focus on the various subpopulations in order to develop care strategies that will target the highest need and highest cost groups. [...] KEY QUESTIONS • What are the various subcategories of dual eligibles? How do their care needs differ, and what care protocols might need to be devel- oped to target services and financing streams efficiently? • What are the respective roles of the federal and state governments in financing the various types of care needed by different subgroups of the dual eligible population? • What barriers exis.
Designed to encourage greater access to Medicare Advantage (MA) plans for special needs individuals and to allow plans to tailor their benefits to meet unique needs, the SNP authority to limit enrollment has generated intense interest in the Medicare managed care market. [...] Despite this potential for a better coordinated system of care and the presence of a large number of dual eligible SNPs, there has not been as much coordi- nation between plans and Medicaid programs as many anticipated.1 The challenges in aligning different administrative, financial, marketing, and contracting requirements have contributed to the disconnect be- tween SNPs and states, as has state. [...] In addition, some see the potential for an incentive for plans to "cream" by identifying the healthiest of the targeted populations, particularly the dual eligible population, thereby benefiting from the additional payment but not enrolling the sickest beneficiaries. [...] Key QueStionS What expectations were inherent in the initial authorizing language regarding SNP coordination of care for special needs beneficiaries? How well is the current market meeting these expectations? What are the challenges to CMS, states, and SNPs in aligning Medicare and Medicaid benefits, care oversight, and financing for advancing integration? According to MedPAC's March 2007 report,. [...] Cohen has been responsible for the company's Medicare Advantage Chronic Care Special Needs Plan strategy, development, and implementation activities; for beneficiaries with diabetes, heart conditions, and end-stage renal disease; and for what are now the largest Chronic Care Special Needs Plans in the United States.
Medicare and Medicaid Demonstrations: Experimenting for the Future oVerVieW Demonstrations have been a critical part of the evolution of the Medicare and Medicaid programs. [...] for more information - See Background Papers, "The Fundamentals of Medicare Demonstrations"and "Shaping Medicaid and SCHIP Through Waivers: The Fundamentals." See also two Basics publications on the same topics, "The Basics: Medicare Demonstrations" and "The Basics: Medicaid and SCHIP Waivers." SeSSion Medicare and Medicaid policy and operations have been informed and shaped by the hundreds of dem. [...] This Forum session will offer a range of perspectives on the history and policy context of Medicare and Medicaid demonstrations and waivers, and the role of these demonstrations now and in the future. [...] Kuhn is the acting deputy administrator of the Centers for Medicare & Medicaid Services (CMS) and is also currently the acting director of the Center for Medicaid and State Operations within CMS. [...] Ebeler has been a senior vice president and director of the health care group at the Robert Wood Johnson Foundation and was deputy assistant secretary for planning and evaluation for health and acting assistant secretary for plan- ning and evaluation at the U.
The Massachusetts demonstration, for example, is the only model focused solely on duals under the age of 65, many of whom have behavioral health and substance abuse problems.11 Texas's demonstration will serve adult duals with disabilities who qualify for Supplemental Security Income or Medicaid waiver home- and community-based services.12 Duals in Virginia13 can opt out of the demonstration for b. [...] Each agreement with states choosing the capitated model includes the terms under which anticipated aggregate program savings are deducted up front from both CMS and state payments to health plans.15 In anticipation of greater savings over time, the deduction increases over the three-year life of the demonstration, starting at 1 percent and ending between 2 and 5.5 percent. [...] Illinois plans, for example, will incur deductions of 1, 3, and 5 percent over the three years of the demonstration.16 In addition, all of the states participating in the capitated model withhold a portion of plan payments that are returned if quality metrics are met. [...] Consumer advocacy groups are actively involved in monitoring the implementation of the duals demonstrations, with several providing a steady stream of educational materials for advocates and families.21 In response to early concerns about beneficiary rights, CMS has made funds available to states with approved MOUs to plan and provide ombudsman services for beneficiaries in the demonstration. [...] KEY QUESTIONS • What have been the main implementation challenges faced by CMS and the Medicare-Medicaid Coordination Office in getting the duals demos started? What is the outlook for the future? • What challenges have the states faced? How do these vary by the type of model (capitation or managed fee-for-service) chosen? What other factors at the state level have made it easier or harder for s.
Forum Session Announcement - Targeting High-Cost Medicare Beneficiaries to Improve Care and Reduce Spending: Finding the Bull's-Eye F O R U M S E S S I O N Targeting High-Cost Medicare Beneficiaries to Improve Care and Reduce Spending: Finding the Bull's-EyeMARCH 9, 2012 In 2011, Medicare spent approximately $560 billion to provide health insurance coverage to 49 million elderly and disabled benef. [...] The Patient Protection and Af- fordable Care Act (PPACA), for example, created a new Center for Medicare and Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) and provided $10 billion in funding over nine years to conduct an array of demonstrations whose goals are to reduce costs and improve care for Medicare and Medicaid beneficiaries. [...] In the Demonstration of Care Management for High-Cost Beneficiaries, the programs were not allowed to keep the entire fee unless they reduced Medicare spending for their beneficiaries by at least 5 percent, net of the fee. [...] This Forum session described the characteristics and spending pat- terns of high-cost Medicare beneficiaries, examined the track record of targeting within Medicare demonstrations and pilots, and pro- filed the experience of one health system's efforts to target and man- age high-cost Medicare beneficiaries. [...] Randall Brown, PhD, a vice president at Mathematic Policy Research, Inc., and director of health research for the New Jersey office, has participat- ed in the evaluation of several demonstrations/pilots at the Centers for Medicare & Medicaid Services.
Recently, both the Committee on Ways and Means and the Committee on Energy and Commerce of the U. [...] In its June 2012 report, the Medicare Payment Advisory Commission recommended that Congress instruct the Secretary of Health and Human Services to redesign traditional Medicare Part A and B cost sharing.2 And over the past three years, staff of the Con- gressional Budget Office and researchers from think tanks, founda- tions, and academia have modeled various restructuring proposals to assess thei. [...] Other proposals seek to include catastrophic protection and structure Medicare's cost sharing to more closely resemble commercial health insurance.3 Re- gardless of their underlying goals, these proposals typically include a unified deductible for Parts A and B, coinsurance or copayments for all services, a cap on out-of-pocket expenses, and the creation of incentives or restrictions to reduce the. [...] (See Table 1 for a description of the MSP programs' benefits and their eligibility criteria.) TABLE 1 Medicare Savings Programs: Eligibility Criteria and Benefits, 2013 PROGRAM INCOME ASSETS (Individuals/Couples)† BENEFITS Qualified Medicare Beneficiary (QMB) Above Medicaid levels and at or below 100% of the FPL* $7,080/$10,620 Pays premiums, deductibles, coinsurance for Parts A and B; Full LIS‡ f. [...] Stephen Zuckerman, Baoping Shang, and Timothy Waidmann, "Policy Op- tions to Improve the Performance of Low Income Subsidy Programs for Medicare Beneficiaries," The Urban Institute Health Policy Center, January 2012, available at www.urban.org/UploadedPDF/412494-Policy-Options-to-Improve-the- Performance-of-Low-Income-Subsidy-Programs-for-Medicare-Beneficiaries.pdf; Stan Dorn and Baoping Shang, "S.
OvervIew With the ever-growing concern about costs in Medicaid and across the health care sector, many state officials and others aim to find savings and deliver more efficient and effective care. [...] What has been the experience among the states with serving this group of vulnerable people through managed care? In what ways are different states approaching this issue? This Forum session will review these questions and address the chal- lenges facing the nation and states in providing efficient and accessible medical care to persons with disabilities through Medicaid managed care arrangements. [...] For example, the estimated average spending on a person eli- gible for Medicaid on the basis of disability status was about $16,600 in fiscal year (FY) 2009, compared with average spending of $2,900 on non-disabled children, and $4,100 on adults without disabilities un- der 65 years of age.1 Expenditures for persons with disabilities under age 65 are the fastest growing segment of Medicaid costs.2. [...] The increasing number of people with chronic conditions and the amount of care needed grows each year; for exam- ple, people with five or more chronic conditions see about 14 physi- cians per year.3 Even if persons with disabilities have a stable chronic condition, they may be more at risk of infection, falls, and other com- plications and difficulties. [...] Speakers will review the background and history of coverage through managed care, studies that have evaluated states' experi- ences with managed care for persons with disabilities, the different types of managed care used by states, and the problems encountered in delivering care in this way.
The Secretary of the Department of Health and Human Services must provide a single, standardized, simplified form for states to use to determine eligibility for the programs. [...] States are required to screen applicants for all health subsidy programs and enroll them in the appropriate program, in the process requiring a minimum of paper-based data directly from the potential beneficiary and coordi- nating seamlessly across the programs. [...] SPEAKERS Carol Steckel, Medicaid commissioner in Alabama and president of the National Association of Medicaid Directors, will describe the history and current functioning of Medicaid eligibilty and enroll- ment in Alabama and across the nation, commenting on the many current challenges and issues that states face as they move toward health reform implementation in January 2014. [...] Cindy Mann, depu- ty administrator of the Centers for Medicare & Medicaid Services and director for the Center for Medicaid, CHIP, Survey and Certi- fication, will comment on what has been learned in the last decade about CHIP and Medicaid outreach and enrollment, as well as the administration's vision for the future of enrollment processes under http://www.nhpf.org F O R U M S E S S I O N S E P T. [...] KEY QUESTIONS • What is the history of Medicaid enrollment processes? What are the essential components of eligibility and enrollment systems? How extensive are changes that states will be required to make to enroll the millions of people who will be newly eligible under the PPACA? • How greatly do states vary in terms of the design and operation of their eligibility and enrollment processes? Can.