How to Protect Integration Progress As Medicare-Medicaid Plans Sunset

As CMS sunsets the Medicare-Medicaid plan model, Congress and the agency will need to take steps to expand the Medicare-Medicaid Coordination Office (MMCO) oversight capabilities and protect the previous years’ Medicare-Medicaid integration progress, researchers explained in a Health Affairs article.

CMS is sunsetting the Medicare-Medicaid plan model nationwide. The agency found that the program was inconsistent. In some cases it increased utilization while in other cases it decreased utilization. The Medicare-Medicaid plan will be dissolved nationwide by the end of December 2025.

States will have to determine how to transitioin their Medicare-Medicaid plan populations into meaningfully integrated dual eligible special needs plans, such as highly integrated dual eligible special needs plans (HIDE SNP) and fully integrated dual eligible special needs plans (FIDE SNP).

There are 11.5 million individuals with access to a dual eligible special needs plan or Medicare-Medicaid plans. Less than half are enrolled in one of these options (5.1 million). The sunsetting of the Medicare-Medicaid plan model in one state (California) drove down enrollment in meaningfully integrated programs.

Some states have models that will provide a more natural transition into meaningfully integrated plans. For example, eight states offer a capitated Medicare-Medicaid plan and certain counties in two of these states offer parallel Medicare-Medicaid plans and FIDE SNPs. By expanding the FIDE SNPs, the plans could absorb Medicare-Medicaid plan beneficiaries.

Most states will have to design a pathway from Medicare-Medicaid plans to meaningfully integrated plans.

Also, the sunsetting of the Medicare-Medicaid plan model may require CMS to rethink the role of the MMCO.

The researchers pointed out that the MMCO’s functions extend beyond the Medicare-Medicaid plans. The office should continue to be responsible for overseeing Medicare-Medicaid integration and it is the only office that is dedicated to both programs, as opposed to other oversight bodies that focus on either Medicare or Medicaid.

“As the end of the MMP nears and the future of MMCO is uncertain, it is important to ensure Medicare-Medicaid integration successes are not lost,” the researchers underscored.

They suggested four administrative and regulatory changes that could support integration of Medicare and Medicaid as CMS sunsets the Medicare-Medicaid plans.

First, policymakers should address the role of MMCO and the extent of its authority. MMCO leaders have expressed that they do not have the power to engage more broadly in Medicare-Medicaid integration. But the researchers urged Congress to formalize MMCO’s authority over the Financial Alignment Initiative, dual eligible special needs plan endeavors, and other related programs.

Second, as states are required to sunset their Medicare-Medicaid plans, they should also be required to set up integrated programs.

“States face competing priorities and political pressures that inhibit a shift to an integrated program. Absent a mandate, dual eligible individuals in many states and counties will continue to lack access to an integrated option,” the researchers stated.

States can use dual eligible special needs plan State Medicaid Agency Contract (SMAC). Additionally, they should be required to formulate an integration plan and should receive planning grants and technical assistance, with MMCO oversight.

Third, policymakers should remove the financing and payment barriers to integration. Funds should be fungible between Medicare and Medicaid services and siloes should be disintegrated. States should be allowed to participate in Medicare savings that are a result of integration investments.

Finally, lawmakers and CMS should create training of enrollment support providers so that they can share the value of integration. There should also be incentives for enrolling dual eligibles in meaningfully integrated programs.

“CMS should work with the Administration for Community Living (ACL) and states to ensure the aging and disability network (including SHIPs) is equipped to serve dual eligible individuals, and Congress should ensure sufficient resourcing,” the researchers added.

For payers who are considering entering the dual eligible market during this sunset period, separate research has outlined five factors to keep in mind.