Policymakers Push States to Focus on Fully Integrated Care for Dual Eligibles

For policy professionals focused on dual eligibles, integration has been a buzzword for more than a decade.1 But only recently has it more clearly entered the mainstream conversation. Still, current efforts to integrate care are only reaching a relatively small percentage of dual eligibles, and as a result, stakeholders are pushing to change that reality. Luckily, there are many levers that state and federal policymakers can pull to achieve a truly integrated care environment for this population. 

Earlier this summer, the Medicaid and CHIP Payment and Access Commission (MACPAC) published its annual report to Congress on Medicaid and CHIP, with two chapters dedicated solely to integrating care for dually eligible beneficiaries.2 The Bipartisan Policy Center (BPC) also recently released its new report “A Pathway to Full Integration of Care for Medicare-Medicaid Beneficiaries” in July, which presents creative proposed policy changes.3 By exploring these proposed changes, states can better see how they could significantly speed up integration efforts and create large structural shifts to the health care environment for dual eligibles. 

Preparing for a federal fallback program

Many of the changes proposed in the BPC report would substantially increase the pressure on states to integrate care using both “carrots” to incentivize states to prioritize integration and “sticks” if states fail to take action. The most dramatic change presented is the proposal to create a federal fallback plan for states that do not implement an integrated program within an eight-year timeframe. This is meant to ensure that all full dual eligible individuals have access to fully integrated care models. Essentially, BPC is proposing that if states do not set up a fully integrated program like a Fully-Integrated Special Needs Plan (FIDE SNP), Program of All-inclusive Care for the Elderly (PACE), Medicare-Medicaid Plans (MMP) or a different state-specific fully integrated program within a reasonable amount of time, the federal fallback program will step in to set up a FIDE SNP to ensure that full dual eligibles have access to at least one integrated option.

Fully integrated products like FIDE SNPs and Medicare-Medicaid Plans (MMP) are focused on full dual eligibles

Partial dual eligibles: Individuals who are eligible for Medicaid coverage for some of the expenses incurred under Medicare, but are not otherwise eligible for Medicaid benefits. These expenses include the premiums for Part B and Part A, if applicable. Medicaid may also pay for some other cost-sharing amounts owed under Medicare (e.g., deductibles, coinsurance, and copayments).

Full dual eligibles: Individuals who are eligible for similar financial coverage as partial duals, and also quality for full Medicaid benefits covered under the Medicaid State plan.

While the federal fallback program would ensure that all full dual eligibles eventually have access to at least one fully integrated product, duals would still retain the option to choose Medicare fee-for-service or other Medicare managed care products.

There are still plenty of details that will need to be worked out in the federal fallback program design. And though it is just a policy proposal in a report, it is important for states to prepare for federal policymakers to become more assertive regarding access to fully integrated products. Even if the federal fallback program isn’t realized, other levers will likely be pulled, pressuring states to take action.

Clearly defining “full integration” standards

When we think about the number of possible combinations for how dual eligibles can access their Medicaid and Medicare benefits, the options (shown in Figure 1) quickly become overwhelming.

Figure 1. ATI Advisory - Medicaid and Medicare Delivery Options4

These varied combinations are in addition to the differences in state Medicaid program design, including what services states choose to carve in or out of managed care. Federal policymakers’ emphasis on program flexibility has led to a proliferation of nuanced programs that meet states where they are in terms of comfort with managed care, integration and caring for complex populations. This has been helpful for states that feel comfortable and empowered to take on program design, but it has made it more confusing for others that might need more guidance. While federal policymakers are still encouraging flexibility and state-driven design, the BPC report suggests policymakers clearly define federal standards for full integration. The standards outlined in the BPC report would represent a significant change in program design and financing and require Congressional action, and it remains to be seen if federal policymakers will be willing to go that far. However, this suggestion, along with the federal fallback program, provide a roadmap for ways policymakers could take a more hands-on approach to integration in the future.

Proposed policies prompt questions

While these forward-leaning policy proposals look to improve care access for dual eligibles, they also raise questions.

  1. What will happen to partial duals? Most integrated products only enroll full dual eligibles. While partial dual eligibles typically don’t receive Medicaid-covered benefits, they often have greater social needs than regular Medicare beneficiaries and benefit from the more intensive care coordination that Dual Special Needs Plans (DSNPs) provide. It will be important to be thoughtful in designing products for partial duals as well as full duals.
  2. How can federal policymakers support state efforts to improve Medicare education? While states continue to rely on the Centers for Medicare & Medicaid Services (CMS) for education and technical help regarding Medicare rules and regulations, it is critical that states feel empowered to design and implement fully integrated programs if they are to become more common. CMS currently offers technical assistance to states, but there is ample opportunity for federal policymakers and other stakeholders to further invest in long-term educational opportunities for state Medicaid directors and agencies. For example, helping states fund a Medicare-focused FTE will signal to other providers, beneficiaries and community-based organizations (CBOs) that states are willing to make serious investments in long-term integration. As states become more comfortable with Medicare-Medicaid integration, they can encourage further provider, beneficiary and CBO investment and education. 

COVID-19 amplifies the need for integration

The COVID-19 public health emergency has further exacerbated the vulnerability of dual eligibles and highlighted the pitfalls of navigating multiple health care systems. Even before the public health emergency, integration was becoming more prevalent in State and Federal policies. Becoming more knowledgeable about Medicare, Medicaid, and the many permutations of integration will help stakeholders address gaps in care and have a say in future program design and legislation.

As these policies undergo review, UnitedHealthcare Community & State will continue to follow their development, as well as the potential impact they will have on state programs, as we seek to find efficient ways to improve care for dual eligibles.  

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