A few weeks ago, I posted Part 1 of my reaction to MedPAC’s (“the Commission”) June report to Congress in which they made several recommendations regarding integration and alignment in Dual Eligible Special Needs Plans (DSNPs). My first post focused on MedPAC’s suggestion that DSNPs be required to have a comprehensive Medicaid contract. In this post, I focus on another recommendation the Commission made: that federal policymakers consider requiring aligned enrollment in DSNPs to improve integration for dual eligibles.
What is aligned enrollment?
Aligned enrollment occurs when a dual eligible enrolls with the same organization for both DSNP and Medicaid. A key advantage to aligned enrollment, particularly for dual eligible beneficiaries (duals) who access Medicaid-only services such as Long-Term Services and Supports (LTSS), is that a single organization can “see across the whole person” when coordinating and managing care regardless of whether a benefit is covered through Medicare or Medicaid. Several studies have shown that aligned enrollment may have a positive impact on the experiences of dual eligibles. For example, Minnesota compared aged duals enrolled in a Medicaid-only-program-without-DSNP with those enrolled in an aligned Medicare-Medicaid program. Results showed that aligned duals had significantly lower rates of hospital and emergency department visits, as well as significantly higher rates of primary care and home and community-based services (HCBS) utilization. To the best of my knowledge, however, no published studies compare duals in an aligned Managed Care Organization (MCO)-DSNP with those in an unaligned DSNP in the same service areas. And, across all the studies on integrated care for dual eligibles, results are mixed. The Medicaid and CHIP Payment and Access Commission (MACPAC) published a report in July that provides a good overview on this topic.
But if aligned enrollment improves utilization, why not require it?
Aligned enrollment may improve utilization and experiences for some dual eligibles (although again, results are mixed). However, policies that promote aligned enrollment without other programmatic considerations may unintentionally push duals into fragmented and/or fee-for-service (FFS) environments.
For example, a dual eligible may prefer the benefits and/or provider network associated with a DSNP not aligned to his or her Medicaid organization, especially an individual who primarily accesses services covered by Medicare. Limiting that individual’s choice to a single DSNP may result in the individual foregoing a DSNP altogether, instead choosing a non-DSNP Medicare Advantage plan or a Medicare FFS program. This possibility always exists in Medicare but is exacerbated when the “choice” includes only a single DSNP.
In addition, Medicaid benefits for duals often are administered across multiple programs and organizations in a state, or may be administered exclusively through FFS for some or all duals. Aligned enrollment in these instances is difficult to define and the value will vary for each individual depending on what Medicaid benefits are most meaningful to them.
As MedPAC points out, a policy requiring aligned enrollment would result in 688,000 dual eligibles having to choose either a new DSNP or Medicaid plan, which likely would create considerable disruption and confusion within an already complex system.
Don’t throw alignment out with the bath water…
This isn’t to say states and the Centers for Medicare and Medicaid Services (CMS) shouldn’t strive for alignment between Medicare and Medicaid; they absolutely should. But it is important to recognize there can be value in DSNP regardless of alignment and as a result, alignment should be pursued in a manner that doesn’t inadvertently decrease the number of duals enrolled in DSNPs. This is particularly true for the 58% of full duals who don’t use LTSS and for whom Medicare covers nearly all their services. Dual eligibles comprise an incredibly heterogeneous population, and “integration” and alignment should be defined differently based on how one interacts with the health care system.
What are the enrollment methods states and CMS should consider?
With these challenges in mind, there are enrollment methods states can use (and to MedPAC’s point, some already do) to promote alignment and integration while minimizing disruption. These methods are flexible based on the unique features of a state’s Medicaid program design and the maturity of their DSNP program, as well as the needs of their local dual eligible population.
1. Medicaid auto-assignment. Several states have pursued aligned enrollment for duals by leveraging Medicaid auto-assignment after a dually eligible individual enrolls in the DSNP of their choice. This approach maximizes the number of duals enrolled in DSNP in a state and also increases alignment overtime. Standalone DSNPs do not have a Medicaid plan to auto-assign into, but states can leverage other methods to promote integration and coordination for these enrollees, such as enhanced information sharing between unaligned MCOs and DSNPs, or by passing a cost-share wrap through to DSNPs to reduce provider burden.
2. Default enrollment. For individuals who become newly eligible for a DSNP, states can use default enrollment into an MCO’s DSNP when a Medicaid-only individual enrolled with that Medicaid MCO attains Medicare eligibility. As of 2019, two states (Arizona and Tennessee) use this enrollment approach with their aligned contractors and several more are implementing in 2020. UnitedHealthcare participates in default enrollment in both of these states and has seen positive member experience metrics; in both markets the opt-out rates are around 6% and member satisfaction scores are high, with DSNP net promoter scores at 79 and 87 respectively. (For context, Apple’s net promoter score was 72 in 2017.)
3. Passive enrollment. Passive enrollment is a process by which an eligible individual is automatically enrolled into a specific program. It’s used frequently in Medicaid programs but it’s uncommon in Medicare. Current federal policy generally limits DSNP passive enrollment to instances where an individual’s existing aligned experience is involuntarily disrupted – for example, an aligned organization is not re-procured for Medicaid – and there’s another aligned option available with a comparable provider network and benefit package. Expanding a DSNP passive enrollment policy, such as allowing DSNPs that serve as a dual’s Part D plan and/or Medicaid organization to passively enroll the individual into the corresponding DSNP (when he or she is in Medicare FFS) would increase the number of duals served in duals-specific programs and increase alignment overtime. This would require federal policy change.
There is a considerable amount of focus right now on integrating across Medicare and Medicaid for dual eligibles, as there should be: this population often experiences multiple chronic conditions, functional limitations, and unmet social needs. This complexity can be exacerbated by the disparate programs, benefits, and providers they must navigate. However, alignment at the cost of pushing duals into non-dual programs is not in the best interest of this population, and policies that aim to achieve integration and alignment while minimizing disruption in existing relationships, such as the approaches listed above, will be the most successful long-term.
Next up: partial duals. Yes, there’s value to serving them in DSNPs too.
 “Full” duals are duals with access to full Medicaid benefits in their state. As I will discuss in more detail in my next post, “partial” duals receive Medicare cost sharing support through their state Medicaid program but otherwise don’t qualify for Medicaid benefits.
 Net Promoter Score (NPS) is a metric to measure customer satisfaction with a particular brand or company.