Healthcare advocates for seniors are trying to stop a managed care expansion for the country's largest Medicare-Medicaid dual eligible population, in what could be a precedent for other states.
The Independent Living Center of Southern California and several other advocacy groups are suing the state and federal governments, trying to halt a waiver demonstration currently in the midst of moving almost half of California's 1.1 million dual-eligible seniors into managed care plans.
According to the Independent Living Center and the Medicaid Defense Fund, the program, Cal MediConnect, is creating upheaval for dual-eligible seniors with changes in primary care providers and a passive health plan enrollment system, where seniors are automatically enrolled in a plan if they fail to choose one or opt out and keep traditional Medicare.
As many as 40 percent of California's dual eligible seniors are cognitively impaired, according to the groups, and may be unable to navigate the new process and provider changes. And, they argue, the current terms of the program, based on waivers from federal Medicare and Medicaid provisions, don't account for several beneficiary protections.
"'Passively enrolling'" cognitively impaired duals, and those who do not receive notices or cannot read English, into managed care for Medicare services, violates both § 1802(a) freedom of choice of Medicare provider as well as federal due process right of duals not to be deprived of this statutory § 1802(a) right without due process," they write in the lawsuit.
The Department of Health and Human Services believes that passive enrollment is consistent with Medicare's freedom of provider choice provision, and state regulators and health organizations see the managed care demonstrations as a way to consolidate a web of Medicare and Medicaid benefits in an integrated care system.
Advocacy groups in California and elsewhere, though, have tried to limit a range of dual eligible managed care policies, and some argue that even if the managed care transitions go forward, the demonstrations should be voluntary for seniors.
Nationally, more than 60 percent of dual eligibles have a mental or cognitive impairment, and more than 20 percent need assistance with two or more activities of daily living, according to a nonprofit group called Community Catalyst.
With the goal of transitioning seniors expeditiously into new integrated care plans, passive enrollment is "compelling as a mechanism for accelerating the adoption of an approach to care delivery and financing that could be a 'win-win' all around," writes Renée Markus Hodin, program director at the Community Catalyst.
"At the same time though, it will be employed with a population for whom there is very little margin of error where access to care is concerned," she argues. "Given these risks and the overall lack of experience among plans in serving dual eligibles through an integrated approach, we conclude it would be preferable to launch these demonstration projects using a fully voluntary enrollment approach."