New Report Provides Overview of Ongoing Work to Improve Care for Dual Eligibles

The Medicare-Medicaid Coordination Office released its 2013 Report to Congress providing an overview of activities and accomplishments and ongoing work to improve care for Medicare-Medicaid enrollees.  MMCO made three legislative recommendations to Congress:

  • Streamline the appeals mechanisms available to beneficiaries through health plans and other qualified entities offering Medicare and Medicaid services;
  • Improve access to needed prescription drugs for Medicare-Medicaid enrollees by making the LI NET demonstration permanent; and
  • Develop a pilot for the Program for All-Inclusive Care for the Elderly (PACE) Eligibility for individuals between Ages 21 and 55.

In the report, MMCO identified two areas for further exploration that it believes may have potential to improve the experience of Medicare-Medicaid enrollees:

  • Coverage standards for Medicare-Medicaid enrollees; and
  • Cost-sharing rules for Qualified Medicare Beneficiaries (QMBs).

Update on California and Kansas

California’s Cal MediConnect demonstration to integrate and coordinate healthcare for individuals dually eligible for Medicare and Medicaid will not move forward as planned in one of eight pilot counties.  The Centers for Medicare and Medicaid Services (CMS) performed a performance audit of the sole insurer selected for the duals demonstration in Orange County and found numerous problems.  Orange County has the second largest population (57,000) of dually eligible individuals in the state.  The demonstration is to begin April 1 in the remaining seven counties.

CMS approved the Kansas 1115 Waiver Amendment allowing the state to provide long term supports and services (LTSS) to individuals with intellectual and developmental disabilities (I/DD) through managed care.  Kansas contracts with three for-profit health insurance companies for the delivery of all Medicaid services.  The Kansas legislature delayed the inclusion of I/DD long term services and supports (LTSS) for one year after the start of KanCare, the Kansas managed care program.  CMS imposed an additional one-month delay on the start of KanCare for I/DD LTSS due to questions it had about the program, including concerns about individuals receiving some but not all of the waiver services they need.  Kansas is the first state to use private health insurers as managed care organizations for managed LTSS for individuals with I/DD.

South Carolina Enters MOU With CMS to Coordinate Care for Dual Eligibles

South Carolina entered into a memorandum of understanding (MOU) with the Centers for Medicare and Medicaid Services (CMS) to begin implementing its demonstration to align financing and coordinate care for individuals dually eligible for Medicare and Medicaid.  Individuals receiving services in intermediate care facilities for individuals with intellectual and developmental disabilities (ICF/ID) or through a home and community-based waiver will not be included in the demonstration.  South Carolina is the seventh state with an MOU.

The Centers for Medicare and Medicaid Services and Minnesota to Conduct Demonstration for Dual Eligibles

The Centers for Medicare and Medicaid Services (CMS) and Minnesota have successfully negotiated a memorandum of understanding (MOU) to move ahead with a demonstration to integrate and coordinate health care for individuals who are eligible for both Medicare and Medicaid. Minnesota will use a program that has been in place since 1997, Minnesota Senior Health Option (MSHO). Under the program, health plans, which operate as Dual Eligible Special Needs Plans (D-SNPS), will continue to provide integrated care for members and provide information to them about all of the benefits available in a more integrated manner. The MSHOs will use integrated grievance and appeals processes. Minnesota’s demonstration is different from the previous seven that CMS has approved in that it is neither a managed fee-for-services model, such as Washington State, nor a capitated model, such as Massachusetts, Illinois, California, Ohio, Virginia, and New York. Minnesota’s demonstration is a set of administrative improvements designed to simplify the process of obtaining benefits under Medicare and Medicaid for beneficiaries.

CMS Announces Availability of $12 Million for Ombudsman Programs for Demonstrations to Integrate and Coordinate Healthcare for Dual Eligibles

The Centers for Medicare and Medicaid Services (CMS) announced availability of $12 million for Ombudsman programs for demonstrations to integrate and coordinate healthcare for individuals who are dually eligible for Medicare and Medicaid.  States that have negotiated memoranda of understanding with CMS for the demonstrations are eligible to apply for funds.  Advocates who have been pushing for dedicated, funded, independent ombudsman programs in the dual demonstration states welcome the announcement.

Virginia Enters Agreement on Dually Eligible Individuals

Virginia is the 6th state to enter into a memorandum of understanding (MOU) with the Centers for Medicare and Medicaid Services to coordinate health care and long term services and supports for individuals who are eligible for both Medicaid and Medicare. 78,000 Virginians will be eligible to participate in the program slated to begin January 1, 2014. The program will operate in five regions of the Commonwealth and will be phased in over eight months. Individuals who reside in ICFs/IDD or who receive I/DD waiver services will not participate in the program. However, some individuals with I/DD who participate in the Elderly or Disabled with Consumer Direction waiver will be included. All six of the MOUs can be found on the Medicare-Medicaid Coordination Office website.

California to Test Model of Providing Health and Long Term Services to Dual Eligibles

California is the fifth state to negotiate a memorandum of understanding (MOU) with the Centers for Medicare and Medicaid Services (CMS) to test a capitated model of providing health care and long term services and supports to individuals dually eligible for Medicare and Medicaid. California expects to enroll about 450,000 individuals in eight counties into Medicare-Medicaid plans beginning in October 2013. Individuals receiving services through California’s regional centers or state developmental centers or intermediate care facilities for people with developmental disabilities will be excluded from participation.

Illinois to Begin Implementing State’s Proposal to Integrate Medicare and Medicaid Funding

The Medicare-Medicaid Coordination Office in CMS negotiated a memorandum of understanding (MOU) with Illinois to begin implementing the state’s proposal to integrate Medicare and Medicaid funding and to coordinate health and long term care for individuals who are dually eligible for Medicare and Medicaid. Individuals with intellectual and developmental disabilities who reside in an institution or who receive home and community based services through a waiver are excluded from the project.

New Report Concerning Dual Eligibles

The Centers for Medicare and Medicaid Services (CMS) released a new data report concerning individuals who are dually eligible for Medicare and Medicaid.  The number of dually eligible individuals in 2011 was 10.2 million.  The number of individuals under the age of 65 who are dually eligible for Medicare and Medicaid grew more quickly than those over the age of 65, representing 41.3% of the total number of dually eligible individuals.

News for individuals who are dually eligible for Medicare and Medicaid in Ohio

The Centers for Medicare and Medicaid Services (CMS) negotiated the third Memorandum of Understanding (MOU) with Ohio to test a new model for providing person-centered, coordinated care to individuals who are eligible for both Medicare and Medicaid (dually eligible). Ohio’s demonstration will cover individuals who are dually eligible in 29 counties and will begin in September 2013. Over 100,000 dually eligible individuals will be eligible to receive their health care and long term services through managed care. Individuals with developmental disabilities, who reside in intermediate care facilities for individuals with intellectual disabilities (ICFs/ID) or receive services through a Medicaid waiver, will not be eligible for the program. The companies chosen by Ohio to manage the program are Molina Healthcare, Aetna, UnitedHealthGroup, the Buckeye Community Health Plan run by Centene, and an alliance between Humana and CareSource, a non-profit health plan. People will be able to leave the program at any time or choose another plan. Ohio follows Massachusetts and Washington in negotiating MOUs with CMS.