Aligned Enrollment Improves Dual Eligible Care Coordination

Dual eligible beneficiaries who are in “aligned enrollment”—or are enrolled in both a dual eligible special needs plan and a Medicaid managed care organization under the same company—may have better access to certain services, but aligned enrollment needs more CMS oversight, a recent report from the Government Accountability Office (GAO) said.

“Better care for dual eligible beneficiaries is one of CMS’s strategic initiatives, and the agency has supported states’ decisions to encourage aligned enrollment in order to encourage better coordination of care. However, CMS lacks quality information on the experiences of beneficiaries who have aligned enrollment as the result of the use of default enrollment,” the report said.

“Quality information on the experiences of these dual eligible beneficiaries would allow CMS to better identify the extent to which beneficiaries are facing challenges as a result of default enrollment and to determine how, if at all, to address those challenges.”

Dual eligible beneficiaries often face fragmented care services because they are receiving healthcare attention from both Medicare and Medicaid.

To resolve this issue, Congress implemented a dual eligible special needs plan under their Medicare Advantage plans. These plans can offer health risk assessments, individualized care plans, and other services that are specifically tailored to dual eligible beneficiaries’ unique needs.

Sometimes, dual eligible beneficiaries combine these dual eligible special needs plans with a Medicaid managed care organization, at which point, it is considered an “aligned enrollment.”

Congress wanted to see how dual eligible beneficiaries were experiencing aligned enrollment and how CMS is involved in such care coordination between Medicaid and Medicare.

CMS has encouraged states to find new ways of improving care coordination for dual eligible beneficiaries.

However, those efforts have not been sufficient in regard to aligned enrollment. For the 386,000 individuals in aligned enrollment, CMS needs to provide greater oversight, GAO found.

Currently, the role of CMS in aligned enrollment is to help states promote aligned enrollment with measures such as the Integrated Care Resource Center. The agency can approve default enrollments of dual eligible beneficiaries into dual eligible special needs plans. The process requires that the dual eligible special needs plans have at least three stars, which institutes a faint quality check.

“Despite its direct role in default enrollment, CMS lacks quality information on the experiences of dual eligible beneficiaries after they are default enrolled,” GAO explained. “This is inconsistent with federal internal control standards on information and communication, which state that management should use quality information to achieve the agency’s objectives.”

Furthermore, since dual eligible special needs plans must contract with the state in which the plans are available, CMS also may review aligned enrollment contracts. But CMS does not look at states’ implementation of the contract requirements and Medicare Advantage plan audits do not investigate aligned enrollment reviews.

The GAO report outlined Medicaid programs’ challenges when dealing with aligned enrollment.

One state that GAO interviewed had trouble extracting necessary information from CMS that was needed in order to arrange for default enrollment when the state first started aligned enrollment. While the process has simplified since that first attempt, the delays made it difficult to notify beneficiaries of their default enrollment.

Data on dual eligible special needs plans can be difficult for states to parse since a dual eligible special needs plan may be present in multiple regions.

Some states have had trouble issuing information to beneficiaries. This could be due to miscalculating the bandwidth of state enrollment brokers to work with dual eligible special needs plans while also managing Medicaid beneficiaries or the challenge of marketing for such a niche segment of the Medicare and Medicaid populations.

Medicaid teams have limited knowledge of the Medicare system so their efforts may fall short of providing beneficiaries with truly aligned support.

Some Medicare Advantage plans that are not dual eligible special needs plans have been created to serve dual eligible beneficiaries. These plans do not have to engage in aligned enrollment, taking away from the number of aligned enrollment beneficiaries.

Furthermore, while these Medicare Advantage plans operated by private payers have a track record of lower healthcare spending, including for dual eligible beneficiaries, Medicare Advantage plans do not have the capacity or the incentive to coordinate with Medicare for dual eligible beneficiaries in the same way that aligned enrollment does, states argued.

Lastly, Medicaid officials may have networks that do not overlap with Medicare and have trouble coordinating care between the disparate networks.

Despite these difficulties, states have shown strong support for aligned enrollment and have engaged in multiple strategies to promote aligned enrollment, including

• Supporting informative dual eligible special needs plan marketing
• Implementing default enrollment
• Bringing on counselors who can help dual eligible beneficiaries navigate their options with aligned enrollment

In response to the GAO report, HHS directed CMS to start gathering quality information regarding dual eligible beneficiaries’ patient experiences.

“HHS concurs with GAO’s recommendation. HHS will evaluate opportunities to obtain more information on dual eligible beneficiaries who disenroll from a D-SNP after default enrollment,” HHS committed.