Key Steps to Improve Coverage Integration for Dually Eligible Individuals

In its June 2022 report to Congress, MACPAC laid out ways that states can improve the integration of Medicare and Medicaid coverage for dually eligible individuals.

“Fully integrated models are not available in all states. We define fully integrated care as an approach that is intended to align the delivery, payment, and administration of Medicaid and Medicare services,” the report explained. “Ideally, this would involve a single entity covering all Medicaid and Medicare benefits for full-benefit dually eligible beneficiaries.”

Most states have no, minimal, or low integration of Medicare and Medicaid coverage and processes for dually eligible beneficiaries.

Minimal integration means that states’ dual special needs plans only serve to coordinate Medicaid services, instead of providing coverage. A state with low integration might have some highly-integrated or fully-integrated dual eligible special needs plans—known as HIDE SNPs and FIDE SNPs, respectively—but lacks an integration initiative.

The report counted dual eligible special needs plans that are coordination-only. There are 17 HIDE SNPs and 12 FIDE SNPs, as of January 2022.

A fully-integrated dually eligible special needs plan boasts four main features. 

First, it covers all Medicare and Medicaid benefits. Second, it offers care coordination through individualized care plans. Third, it seeks beneficiary input and establishes beneficiary protections. Finally, a fully-integrated dually eligible special needs plan requires financial alignment, with one entity receiving one payment for all Medicaid and Medicare services.

States and the Commission have identified numerous barriers to integration, such as restricted state capacity and limited Medicaid managed care experience, but MACPAC continued to urge integration.

When seeking to integrate Medicare and Medicaid coverage, states should first identify whether they plan to use a managed care or fee-for-service delivery system. MACPAC called on CMS to offer technical assistance and decision-making support for this part of the process.

States also have to identify the populations that will be eligible for integrated coverage. They should use a phased approach, making more beneficiaries eligible over time, with a particular emphasis on covering full-benefit dually eligible beneficiaries. 

However, partial-benefit dually eligible beneficiaries should also be considered along with subpopulations of dually eligible beneficiaries and previously excluded populations, such as individuals with intellectual or developmental disabilities.

States have to be clear about which Medicaid benefits might be excluded from coverage as well as coverage for Medicare Advantage non-medical supplemental benefits.

In order to integrate coverage, states may need to streamline and improve their enrollment processes. Some states may decide to use automated enrollment or pursue aligned enrollment. These adjustments should also affect outreach strategies, ensuring that they are culturally competent and comprehensive and that they engage providers.

States may need to rework their appeals and grievances processes to create a more unified system for dually eligible beneficiaries. Employing an ombudsman program that assigns a point of contact to beneficiaries is a popular approach. States should also welcome feedback from beneficiaries through channels such as enrolled advisory committees.

Consolidating data for an integrated care strategy is complex but necessary. This will require data-sharing arrangements between states and dual special needs plans. States should be clear about what they will require dual special needs plans to submit for state oversight, such as encounter data or Medicare Part D coverage data as well as demographic data.

Integration will also require states to re-evaluate their quality measurement strategies. To appropriately measure quality of care in integrated dual eligible special needs plans, states might use a model of care that is required for special needs plans in the Social Security Act. States need to consider long-term services and supports as part of their quality measurement.

“Congress should authorize the Secretary of the U.S. Department of Health and Human Services to require that all states develop a strategy to integrate Medicaid and Medicare coverage for full-benefit dually eligible beneficiaries within two years with a plan to review and update the strategy as needed, to be determined by the Secretary,” the report recommended. 

“The strategy should include the following components—integration approach, eligibility and benefits covered, enrollment strategy, beneficiary protections, data analytics, and quality measurement—and be structured to promote health equity. To support states in developing the strategy, Congress should provide additional federal funding to states to assist with these efforts toward integrating Medicaid and Medicare coverage for full-benefit dually eligible beneficiaries.”

The 2022 report’s content on this subject matter serves as a follow-up to the 2021 mid-year report, which unpacked the problem and promised Congress further information on how states could address it. The previous mid-year report also covered topics such as non-emergency medical transportation benefits.

The report contains six chapters, as is traditional for the annual mid-year MACPAC report to Congress. Separate MACPAC reports have outlined certain steps that Medicaid programs can take.

This year, the sections cover monitoring access to care for Medicaid beneficiaries, oversight and transparency around managed care directed payments, enabling vaccine access, improving health IT adoption for behavioral healthcare to promote behavioral-physical care integration, integrating Medicaid and Medicare for dually eligible individuals, and advancing health equity in Medicaid.