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As states are increasingly looking to integrate Medicaid and Medicare services for people who are dually eligible, this policy document developed by CHCS summarizes options for integration. Annual costs of caring for the nine million Americans who are dually eligible are estimated at $250 billion -- equaling half of all Medicaid and a quarter of all Medicare expenditures. Integrating care offers tremendous potential to both improve care and control costs for this population. Through The SCAN Foundation, CHCS developed this resource per a request from the California Department of Health Care Services to support discussions around the state's 1115 Medicaid waiver development. The document outlines options for integration in four broad categories: 1) Special Needs Plans (SNPs); (2) Program for All-Inclusive Care for the Elderly (PACE); (3) Shared Savings Models; and (4) States as Integrated Care Entities. The document suggests that these options must include the following core elements to provide beneficiaries with the right care at the right time: strong patient-centered care; interdisciplinary care teams; provider networks capable of meeting a full range of patient needs; enhanced use of home- and community-based services; robust data sharing; consumer protections; and financial alignment that supports integration. This resource offers a valuable reference for other states looking to integrate Medicare and Medicaid services to deliver higher-quality and more cost-effective care for this vulnerable population.
Individuals dually eligible for Medicare and Medicaid are among the most vulnerable, highest-need, and highest-cost beneficiaries in the US health care system. One of the most challenging aspects of providing care for this population is that responsibility for administration, oversight, and financing for their services is split between the federal and state governments. With the passage of the Patient Protection and Affordable Care Act (ACA), there are significant new opportunities to integrate these two programs and vastly improve service delivery and financing for duals. This roadmap culls from state best practices across the country to offer guideposts for improved integration of services for dual eligible beneficiaries with the goal of high-quality, consumer-focused, and cost-effective care. To this end, the Center for Health Care Strategies (CHCS) has developed three Profiles of State Innovation roadmaps to help states explore and understand emerging options, best practices, and proven models of success in three areas: (1) rebalancing LTSS care options to support home- and community-based services; (2) the development and implementation of a managed LTSS program; and (3) integrating care for adults who are dually eligible for Medicaid and Medicare.
Disabled Dual-Eligible Beneficiaries: Integration of Medicare and Medicaid Benefits May Not Lead to Expected Medicare Savings

Dual Eligibles

United States. Congress. House. Committee on Energy and Commerce. Subcommittee on Health

Published: 2012

Total Pages: 340


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Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health was released in September 2019, before the World Health Organization declared COVID-19 a global pandemic in March 2020. Improving social conditions remains critical to improving health outcomes, and integrating social care into health care delivery is more relevant than ever in the context of the pandemic and increased strains placed on the U.S. health care system. The report and its related products ultimately aim to help improve health and health equity, during COVID-19 and beyond. The consistent and compelling evidence on how social determinants shape health has led to a growing recognition throughout the health care sector that improving health and health equity is likely to depend â€" at least in part â€" on mitigating adverse social determinants. This recognition has been bolstered by a shift in the health care sector towards value-based payment, which incentivizes improved health outcomes for persons and populations rather than service delivery alone. The combined result of these changes has been a growing emphasis on health care systems addressing patients' social risk factors and social needs with the aim of improving health outcomes. This may involve health care systems linking individual patients with government and community social services, but important questions need to be answered about when and how health care systems should integrate social care into their practices and what kinds of infrastructure are required to facilitate such activities. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health examines the potential for integrating services addressing social needs and the social determinants of health into the delivery of health care to achieve better health outcomes. This report assesses approaches to social care integration currently being taken by health care providers and systems, and new or emerging approaches and opportunities; current roles in such integration by different disciplines and organizations, and new or emerging roles and types of providers; and current and emerging efforts to design health care systems to improve the nation's health and reduce health inequities.
States have been seeking federal waivers since the early 1990s to use managed care approaches to integrate the delivery of acute & long-term-care services for certain dual eligiblesÓ -- low-income Medicare beneficiaries who also quality for full Medicaid benefits. Dual eligibles often receive their Medicare & Medicaid benefits from two different sets of providers. This report determines: (1) the status & key features of state initiatives to integrate care for dual-eligible beneficiaries; & (2) factors that have contributed to the length of the waiver negotiation process & implementation time frames.
Caring for the 9 million low-income elderly or disabled adults who are eligible for full benefits under both Medicare and Medicaid can be extremely costly. As part of the federal Financial Alignment Initiative, states have the opportunity to test care models for dual-eligibles that integrate acute care, behavioral health and mental health services, and long-term services and supports, with the goals of enhancing access to services, improving care quality, containing costs, and reducing administrative barriers. One of the challenges in designing these demonstrations is choosing and applying measures that accurately track changes in quality over time -- essential for the rapid identification of effective innovations. This brief reviews the quality measures chosen by eight demonstration states as of December 2013. The authors find that while some quality domains are well represented, others are not. Quality-of-life measures are notably lacking, as are informative, standardized measures of long-term services and supports. This brief was funded by the Commonwealth Fund and is available from their website.
The balance between state and federal health care financing for low-income people has been a matter of considerable debate for the last 40 years. Some argue for a greater federal role, others for more devolution of responsibility to the states. Medicaid, the backbone of the system, has been plagued by an array of problems that have made it unpopular and difficult to use to extend health care coverage. In recent years, waivers have given the states the flexibility to change many features of their Medicaid programs; moreover, the states have considerable flexibility to in establishing State Children's Health Insurance Programs. This book examines the record on the changing health safety net. How well have states done in providing acute and long-term care services to low-income populations? How have they responded to financial incentives and federal regulatory requirements? How innovative have they been? Contributing authors include Donald J. Boyd, Randall R. Bovbjerg, Teresa A. Coughlin, Ian Hill, Michael Housman, Robert E. Hurley, Marilyn Moon, Mary Beth Pohl, Jane Tilly, and Stephen Zuckerman.