MACPAC Highlights Dual Eligible Challenges in CMS Proposed Rule

Transitioning Medicare-Medicaid plans into dual eligible special needs plans may pose challenges that the proposed rule for 2023 Medicare Advantage and Medicare Part D policy and technical changes fails to address, Medicaid and CHIP Payment and Access Commission (MACPAC) explained in a comment letter to CMS.

“It is our strongly held view that furthering integration has the potential to improve beneficiary outcomes and promote more effective and efficient coordination between Medicaid and Medicare, potentially reducing spending and promoting equity,” the commission stated.

“Our work has focused on three goals: increasing enrollment in integrated products, making integrated products more widely available, and promoting greater integration in existing products.”

MACPAC pointed out a couple of areas where it found that the CMS proposed rule fell short and offered recommendations for additional actions that CMS could take to more holistically address the needs of dually eligible beneficiaries.

Medicare-Medicaid plans are plans that operate under a demonstration in specific states. These plans are different from special needs plans because their contracts bring together the health plan, CMS, and the state Medicaid agency. In contrast, dual eligible special needs plans involve one health plan contracting with Medicaid and contracting separately with Medicare.

In the proposed rule, CMS would offer states the chance to transition their Medicare-Medicaid plans to dual eligible special needs plans, after meeting certain qualifications.

However, MACPAC noted three potential problems with this model.

First, whereas in Medicare-Medicaid plans states receive some of the Medicare savings—which was a key motivator for states to participate in the Medicare-Medicaid plan demonstration—dual eligible special needs plans do not enable Medicaid programs to retain those savings.

Additionally, dual eligible special needs plans may not be as rich in consumer support processes as Medicare-Medicaid plans are. Whereas the Medicare-Medicaid plans must offer benefits counseling and an ombudsman program, the dual eligible special needs plans do not have to include these tools.

“Given that dually eligible beneficiaries often lack access to a single, impartial advisor to help them compare a complex set of coverage options, the Commission is concerned about the loss of these important consumer protections and the resources that support them,” the letter stated.

Lastly, dual eligible special needs plans may employ default enrollment but cannot feature passive enrollment, which has been critical to retaining enrollees in Medicare-Medicaid plans.

Default enrollment allows a state to enroll Medicare-eligible individuals who are in a payer’s Medicaid managed care plan into the payer’s aligned dual eligible special needs plan.

Passive enrollment occurs when an individual is automatically enrolled in a plan for which they are eligible and is notified after enrollment with the possibility of opting out of the plan.

The end result is similar but, according to MACPAC, states have indicated that the default enrollment process is more involved and requires more resources and staffing. States have to acquire a system that allows them to identify eligible individuals, which can be expensive.

The letter recommended that CMS reinforce states’ efforts through providing technical support and guidance as states implement new technologies for the transition into a dual eligible special needs plan model. The agency could also push the existing Medicare-Medicaid plan demonstration termination deadlines past 2023 to give states more time to transition.

MACPAC also addressed other aspects of the proposed rule, which included making adjustments to certain definitions and leveraging Medicare Improvements for Patients and Providers Act of 2008 contracts.

MACPAC is a vocal advocate for improving the integration of Medicare and Medicaid benefits for dually eligible individuals. In 2021, the commission offered six recommendations for integrating dual eligible beneficiaries' benefits, touching on eligibility, beneficiary protections and enrollment, benefits, delivery system and care coordination, administration, and financing.

Aligned enrollment is crucial for dual eligible beneficiaries, the Government Accountability Office has noted. So far, efforts to align benefits have failed to fully rectify this issue.