6 Key Considerations for an Integrated Dual Eligible Program

Dual eligible beneficiaries—individuals who are eligible for both Medicaid and Medicare benefits—still experience challenges navigating the two programs and would benefit from an integrated dual eligible program, MACPAC asserted in its most recent report.

The existence of Medicare-Medicaid plans, the financial alignment initiative, and dual eligible special needs plans all emphasize the extent to which Congress has been focused on this problem, but none of these programs have come close to providing a meaningful, permanent solution.

“Given that Medicare and Medicaid are administered and financed differently, and were designed to accomplish different goals, the ability to fully integrate is difficult,” the report explained.

MACPAC based its recommendations on the work of two organizations that have advocated for better Medicare-Medicaid integration: the Dual Eligible Coalition and the Bipartisan Policy Center (BPC).

The MACPAC report proposed that Congress would have to address six key areas for integration: eligibility, beneficiary protections and enrollment, benefits, delivery system and care coordination, administration, and financing.

Policymakers would first have to determine who would qualify for this program. Whereas Medicare eligibility standards are universal, Medicaid eligibility criteria differ based on each state’s preferences.

MACPAC noted that Congress would need to decide whether eligibility would be limited to full-benefit dually eligible beneficiaries or whether partial-benefit dually eligible beneficiaries would be included. Current models vary on this issue. The BPC proposal specified that only full-benefit dual eligibles would qualify.

Offering continuous eligibility and maintenance of effort are other eligibility considerations.

Both BPC and the Dual Eligible Coalition supported continuous eligibility for twelve months. Studies have shown that continuous enrollment may prevent beneficiaries from experiencing coverage gaps. Currently, Medicaid must provide continuous coverage during the pandemic, but when the waivers end so will that provision.

Congress would also have to determine whether certain patient populations—such as those with intellectual or developmental disabilities—would be carved out and considered ineligible for the integrated program. The proposals differ on this point, with the Dual Eligible Coalition suggesting a phased approach to integrating typically carved-out groups and BPC not presenting a strong stance.

In regard to beneficiary protection and enrollment, Congress would have to determine whether to allow for automatic enrollment, which is commonplace in Medicaid but is seen as inhibiting beneficiaries’ coverage choice in Medicare.

Protecting beneficiaries’ access to their current care provider is another important issue.

Policymakers would need to establish the enrollment process—for example, beneficiaries could enroll through Medicaid or their local State Health Insurance Assistance Program (SHIP).

For the beneficiaries’ protection, the new program would require an integrated appeals and grievances process.

Policymakers would have to consider how they would consolidate Medicare and Medicaid benefits into a single benefits package. For the sake of simplicity, this package might be uniform across all states—unlike Medicaid benefits. States could choose from multiple models or could embrace a standard set with some flexibility to provide additional benefits.

As with eligibility qualifications, the program would have to take a stance on whether or not states can make carve-outs for certain benefits, such as behavioral health benefits.

Provider participation and care coordination requirements would be the key considerations related to care delivery in a unified program.

Both the Dual Eligible Coalition’s and BPC’s proposals use managed care organizations for care delivery. These organizations would have to ensure network adequacy and educate providers about integrated dual eligible care.

When developing a care coordination approach for this model, policymakers would have to consider how to rally around partial-benefit dually eligible individuals, if that population was determined eligible for the unified program.

Policymakers would also have to establish administrative parameters around federal oversight and how much flexibility states would have in participating in this program.

Lastly, the program would need to have a steady and unified source of funding. Medicaid and Medicare draw funding from different places. Both the Dual Eligible Coalition and the BPC proposals pursued unifying funding streams, which included state and federal shares of funding.

The model could establish a shared savings program through Medicare savings. It could also engage in risk mitigation through risk corridors. Policymakers would also have to identify levels of funding directed to each state.

Despite the complexities, MACPAC affirmed the need for an integrated solution for dual eligibles.

“In the Commission’s view, a unified program designed specifically for the dually eligible population has the potential to address the fragmentation and poor outcomes that result
from having two uncoordinated programs,” the report concluded.

Since none of these suggestions would be immediately actionable, the MACPAC commission promised a set of more proximate recommendations in the June 2021 report to Congress.