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This research, based on a survey of 50 states and the District of Columbia conducted in the fall of 2012, finds that two-thirds of the states either have or will launch new initiatives to better coordinate care for people who are dually eligible for Medicare and Medicaid services, the so-called "duals," over the next 2 years. To contain the growth of costs and improve care, the federal government, in partnership with many states, is exploring models to better serve duals and align the Medicaid and Medicare programs to remove adverse incentives and improve care coordination. This research also finds that some states are taking the opportunity extended by the Centers for Medicare & Medicaid Services (CMS) to test new models, but a number of states are exploring or implementing alternative approaches to dual services integration outside of the CMS models.
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.
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.
The Medicare and Medicaid programs spent an estimated $300 billion on dual-eligible beneficiaries-those individuals who qualify for both programs-in 2010. These beneficiaries often have complex health needs, increasing the need for care coordination across the two programs. In 2013, CMS began the Financial Alignment Demonstration, with the goal of integrating Medicare and Medicaid services and financing and improving care coordination. Thirteen states are participating. GAO was asked to examine care coordination under the demonstration. GAO examined (1) how integrated care organizations-which are health plans or other entities-are implementing care coordination and (2) what, if any, challenges organizations have encountered in implementing care coordination and the extent to which CMS oversees these care coordination activities. GAO interviewed officials from CMS and, during site visits to a nongeneralizable sample of the first five states to implement the demonstration, interviewed state officials, organizations, advocacy groups, and providers. GAO also reviewed CMS guidance outlining CMS's oversight role and the measures it uses to monitor the demonstration.
In 2009, the federal and state governments spent a total of more than $250 billion on health care benefits for the 9 million low-income elderly or disabled people who are jointly enrolled in Medicare and Medicaid. Those eligible to receive benefits from both programs at the same time are “dual-eligible beneficiaries.†All of those beneficiaries qualify for full Medicare benefits, but they differ in the amount of Medicaid benefits for which they are eligible. Seven million are “full duals,†who qualify for full benefits from both programs. The other 2 million are “partial duals,†who do not meet the eligibility requirements for full Medicaid benefits but qualify to have Medicaid pay some of the costs they incur under Medicare. This report examines the characteristics and costs of dual-eligible beneficiaries, focusing on 2009. It also examines the different payment systems that Medicare and Medicaid use to fund care for dual-eligible beneficiaries and recent efforts at the federal and state levels to integrate those payment systems and to coordinate the care that such beneficiaries receive from the two programs. Figures and tables. This is a print on demand report.
"About 9 million of Medicare's over 48 million beneficiaries are also eligible for Medicaid because they meet income and other criteria. These dual-eligible beneficiaries have greater health care challenges than other Medicare beneficiaries, increasing their need for care coordination across the two programs. In addition to meeting all the requirements of other MA plans, D-SNPs are required by CMS to provide specialized services targeted to the needs of dual-eligible beneficiaries as well as integrate benefits or coordinate care with Medicaid services. GAO was asked to examine D-SNPs' specialized services to dual-eligible beneficiaries. GAO (1) analyzed the characteristics of dual-eligible beneficiaries in D-SNPs and other MA plans, (2) reviewed differences in specialized services between D-SNPs and other MA plans, and (3) reviewed how D-SNPs work with state Medicaid agencies to enhance benefit integration and care coordination. GAO analyzed CMS enrollment, plan benefit package, projected revenue, and beneficiary health status data; reviewed 15 D-SNP models of care and 2012 contracts with states; and interviewed representatives from 15 D-SNPs and Medicaid agency officials in 5 states."
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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.
The Medicare and Medicaid programs spent an estimated $300 billion on dual-eligible beneficiaries -- those individuals who qualify for both programs -- in 2010. These beneficiaries often have complex health needs, increasing the need for care coordination across the two programs. In 2013, the Centers for Medicare & Medicaid Services (CMS) began the Financial Alignment Demonstration, with the goal of integrating Medicare and Medicaid services and financing and improving care coordination. Thirteen states are participating. This report examined (1) how integrated care organizations -- health plans or other entities -- are implementing care coordination; and (2) what, if any, challenges organizations have encountered in implementing care coordination and the extent to which CMS oversees these care coordination activities. Tables and figures. This is a print on demand report.