Managed Care for Dual-Eligible Population

Arlington, Virginia—Of all of the budget issues facing states, among the most pressing is how to pay for healthcare services. States are particularly concerned with providing adequate services and lowering costs of delivering care for dual eligibles, people who are enrolled in both Medicare and Medicaid.

At the Leadership Summit on Medicaid Managed Care, executives from California and Minnesota discussed their approach to managing dual eligibles during a session titled Identifying Early-Implementer Challenges from the Dual-Eligible Population.

In California, dual eligibles receive benefits from Medi-Cal for Medicaid plus a traditional Medicare program. Medicare covers traditional services such as hospital care, physician and ancillary services, home healthcare, prescription drugs, and durable medical equipment, while Medi-Cal covers Medicare cost sharing, long-term nursing home benefits after Medicare benefits are exhausted, and prescriptions and durable medical equipment that Medicare does not cover.

For years, the system has been criticized for a lack of coordination between the programs, according to Jane Ogle, deputy director of healthcare delivery systems at the California Department of Health Care Services (DHCS). In July 2012, the state enacted a Coordinated Care Initiative (CCI) for Medicaid beneficiaries in 8 counties: (1) Los Angeles, (2) Orange, (3) San Diego, (4) San Mateo, (5) Alameda, (6) Santa Clara, (7) San Bernardino, and (8) Riverside.

In late March, California’s governor and the Centers for Medicare & Medicaid Services (CMS) signed a memorandum of understanding regarding the CCI. It includes 2 parts: (1) the Medi-Cal Managed Long-Term Services and Supports for nearly all Medi-Cal beneficiaries, which will require beneficiaries to join a managed care plan; and (2) Cal MediConnect, a voluntary, 3-year demonstration program for coordinated Medicare and Medi-Cal benefits through an organized delivery system. The former program is expected to start no sooner than October, while the demonstration project will start after January 2014.

Ms. Ogle said the CCI wants to improve the teamwork between groups, decrease healthcare costs, and help people stay in their homes and out of hospitals and nursing homes. Of 1.2 million dual eligibles in the 8 counties, 527,000 are eligible for the demonstration project. Exclusion criteria include dual eligibles who are <21 years of age, have partial benefits, have developmental disabilities, and have end-stage renal disease.

The legislation established numerous protections for beneficiaries, according to Margaret Tatar, chief of the Medi-Cal managed care division at DHCS. The state and CMS will send beneficiaries information on their rights and plan choices at least 30, 60, and 90 days before enrollment. People are allowed to visit their Medi-Cal providers for another 12 months after the program begins, and they can see their Medicare doctors for an additional 6 months. They can also self-direct their care, including the ability to hire, fire, and manage their in-home supportive services workers. CMS and the state are also implementing an appeals process for beneficiaries and will have strong oversight and monitoring of the program, according to Ms. Tatar.

The success of California’s coordinated care initiative, Ms. Tatar said, will be based on “inclusive and transparent stakeholder engagement.” All documents and meetings are open to the public via a website (www.calduals.org) maintained by a consulting firm. Ms. Tatar noted that the documents include edits that show changes made during the process, which, she said, would make it transparent.

When implementing the CCI, leaders will be focused on ensuring that enrollment runs smoothly, enough providers agree to participate, plans share reliable data with the state, and rates are consistent with the program’s fiscal and quality incentives.

Ms. Ogle said “people do not want change when it comes to their healthcare,” thus there is a need for an “assertive outreach program” to educate patients and providers about the program’s benefits.

Minnesota’s Perspective

Whereas California is now just starting a coordinated care program, Minnesota has been on the forefront of innovation in healthcare. The state has had Medicaid managed care since 1985. Ten years later, Minnesota became the first state approved for an integrated Medicaid/Medicare demonstration project.

Today, 90% of seniors in Minnesota are in a managed care plan, according to Pam Parker, director of senior health options for the state’s Department of Human Services. Ms. Parker said seniors in the state have 2 options: (1) Minnesota Senior Care Plus (MSC+), the default program that has less intensive care coordination because Medicare is not integrated; and (2) Minnesota Senior Health Options (MSHO), an integrated Medical Assistance/Medicare program based on special needs plans. Both programs are available throughout the state. Of people ≥65 years of age, 35,800 are in MSHO and 12,800 are in MSC+.

The MSHO features integrated patient-centered care coordination, the same enrollment requirements for both programs, a single enrollment form and card, and integrated coverage decisions, provider billing, member services, and provider networks. Ms. Parker said the MSHO has been successful. The average plan has a rating of 4.0 on a scale of 5.0. Satisfaction scores for the MSHO are the highest among all of the state’s managed care programs; >98% of enrollees remain in the program each year and 98% of seniors in the MSHO visit their primary care doctor on an annual basis.

Minnesota has other payment and delivery reform initiatives, as well, such as a Health Care Home project in which clinics and providers receive additional payments if they are certified. There are also several accountable care organizations in the state, and legislation has focused on tying providers’ pay to meeting quality and financial metrics.

The state has proposed a demonstration project with CMS to further integrate Medicare and Medicaid in Minnesota. If completed, seniors will enroll later this year and people with disabilities will enroll next year.

Still, there are some drawbacks in the government programs, according to Ms. Parker. She said that the financial alignment demonstration project is “too complicated” and the special needs plans are “too fragmented.”

As the deadlines to implement the program approach, Ms. Parker said details were scarce, contributing to the uncertainty and difficulties for states. She added that the measurements for quality and other benchmarks are “very ambitious” and may be tough to meet for plans, even the ones that would normally be deemed as successful.

“Everybody is going to have challenges [with the demonstration projects],” Ms. Parker said. “There are so many details to be determined. It is so overwhelming…We could have made it simpler, but we did not. I hope we can get there one day.”