Improving healthcare for the nation's Medicare-Medicaid dual eligible population seems to be just as complex as the beneficiaries' health needs, so state leaders are seeking help and more flexibility from the feds.
For many state medicaid directors, long-term services and support programs are a major priority, especially aligning Medicare and Medicaid services for residents dually eligible for both programs.
Twelve states are embarking on or are in the midst of three-year dual eligible demonstration programs with the Centers for Medicare & Medicaid Services, using a variety of models broadly aimed at integrating the financing, delivery of benefits and overall experience.
California, Illinois, Massachusetts, Michigan, New York, Ohio, South Carolina, Texas, and Virginia are testing a capitated financial alignment model. Colorado is trying a managed fee-for-service model, Washington both a capitated model and managed FFS model, and Minnesota an integration of administration but not financing.
In all those states and others that are trying to improve services for duals outside of the demonstration program, Medicaid leaders want to work with CMS on a number of issues -- from strategic visioning to flexibility on enrollment methods to "seamless conversion."
Nationally, CMS needs to "articulate next steps for existing financial alignment demonstrations," write Darin Gordon and Thomas Betlach, Medicaid directors for Tennessee and Arizona, respectively, and president and vice president of the National Association of Medicaid Directors (NAMD), in a letter to the federal agency.
While early experiences in states like California and Massachusetts have shown some challenges with the dual demonstrations, NAMD is expecting that "evaluations will reveal early successes, areas for improvement and other opportunities."
But, Gordon and Betlach write, "States are eager to understand CMS' long-range work plan for the demonstrations, including whether these will continue during the CMS evaluation period." States need to be able to start continuity of care planning to prevent or minimize beneficiary disruptions, such as provider changes, and they also need to do their own budgeting, Gordon and Betlach write.
In the near-term, NAMD is urging CMS to let states use managed care services without requiring a demonstration approval.
"A growing number of states are interested in leveraging the D-SNP pathway," the Dual Eligible Special Needs Plans, and about 1.7 million Medicare-Medicaid beneficiaries are already served by D-SNPs, Gordon and Betlach write. "These current contracts do not require demonstration authority and thus are well suited to become a preferred pathway to achieve meaningful improvements for beneficiaries."
Offering that and other flexibilities to states, of course, requires some level of administration for CMS, and NAMD concedes that the agency "cannot accommodate each individual state's specific issues and program nuances."
Thus, they have a suggestion: that CMS offer a menu of administrative flexibilities and options for states who are trying to integrate services outside of demonstration authority.
"States and health plans will need additional resources and clear guidance on these tools, including through enhancement of their Medicare Improvements for Patients and Providers Act contracts," Gordon and Betlach write. "In particular, many states have or are building Medicaid managed long-term services and support programs that they could leverage to drive alignment with D-SNPs via the MIPPA vehicle."
Among other suggestions NAMD has for CMS on duals programs are enrollment continuity, beneficiary communications streamlining and program conversion.
State Medicaid agencies currently have authority with passive enrollment, mandatory enrollment and lock-in policies for the Medicaid portion of the beneficiary's services, and NAMD believes states should also have that authority for the Medicare component of the benefit package.
"Today beneficiaries may enroll in different health plans for their Medicare and Medicaid benefits or they may be required to enroll in a Medicaid health plan but remain in the unmanaged Medicare fee-for-service program," Gordon and Betlach write. "These situations make it difficult for states to facilitate better-coordinated and beneficiary-centered care that could be available by combining the full continuum of services dual eligibles need into a single benefit package, delivered by a single organization responsible for coordinating all services."
In terms of streamlining beneficiary notices and communications, NAMD understands that Medicare is a single national program that cannot deviate, but does want to try to make beneficiary information notices less confusing. "We believe that state Medicaid agencies can leverage their extensive experience and ongoing collaborations with plans, providers and consumer advocacy organizations to tailor letters to this vulnerable population to accomplish this goal."
NAMD also wants to get CMS to advance requests for "seamless conversion" between program components and waiting periods, such for Medicare disability.
"We request that CMS allow states and plans to move forward with seamless conversion for both or either the aging and persons with disabilities, even when there are technical barriers in the process to identify all individuals who are aging into Medicare," Gordon and Betlach write. "Enrollees would still have the option to decline to participate in a D-SNP, thereby preserving the important beneficiary protections already in place to allow for disenrollment without penalties to the health plan or member."