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Policy Brief on Dual Eligibles

Policy Brief on Dual Eligibles

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for caring communities


A Brief on Dual Eligibles



ince January, Massachuse s has been engaged in an ini a ve to integrate the care and financing for “Dual Eligible” adults – people between the ages of 21-64 who are eligible for Medicaid (MassHealth) and Medicare. Through these ini a ves, Massachuse s seeks to ensure access to appropriate services, integrate comprehensive services at the person level, improve care coordina on across the health care and long-term support delivery systems and create payment systems that hold providers accountable for the care they deliver. Massachuse s is one of 15 states to receive planning grants from the Center for Medicaid and Medicare (CMS), which is funding these ini a ves as part of the Obama administra on’s plans to reduce Medicare costs in the Healthcare Reform plan and improve care.

The broader Massachuse s’ global payment reform efforts are expected to include ini a ves to develop paent-centered medical homes, bundled payments, accountable care organiza ons, and state legisla on to require a transi on from fee-for-service provider payments to global payment methodologies. The duals inia ve fits within this picture. ICEs would receive one actuarially developed, blended capita on rate for the full con nuum of benefits provided to an enrollee. This statewide system plans to serve 115,000 people. Through a bidding process, MassHealth will use combined Medicare and Medicaid funding to contract with the care en es to integrate comprehensive care at the person level. These en es will be asked to ensure that all of the health needs of individuals in the target popula on are met and coordinated across the health care and long term support delivery system. Services covered will include: 1. Medicare Part A, Part B and Part D coverages; current Medicaid State Plan Services such as: Dental, Adult Day Health, Adult Foster Care, Day Habilita on, Personal Care Services, Transporta on services, Outpa ent Behavioral Health, and a broad array of substance abuse services – to start the list. The program design states that the ICE must employ community-based service providers (directly or through contracts) that advance independence of members and redirect to least restric ve se ngs and to have “adequate connec ons to community-based agencies with popula on exper se.”

Through a demonstra on with the federal government, MassHealth proposes to combine Medicare and Medicaid funding for Dual Eligibles. MassHealth then expects to procure contracts with “integrated care enes” (ICE) to integrate comprehensive care to provide both MassHealth and Medicare funded services. This is expected to be er meet the needs of the target popula on in the most cost effec ve way. It is projected that $3.5 billion will be spent on Duals in 2011. Data also indicates that 60 percent of this group is between the ages of 45-64; only 3 percent resided in ins tu ons, 19 percent used a high level of long-term support services and 65 percent had a behavioral health or substance Research and policy data which support poten al abuse diagnosis. Duals with diagnoses in two or more improvements in care and reduc ons in costs have major diagnos c areas accounted for more than 80 per- come from modest-sized studies in which resources are cent of spending. added to exis ng systems (such as nurse coordinators)

who are able to work directly with other providers and individuals served to improve care. There are no naonal data on large scale managed care models such as those being proposed in the Massachuse s or other state models. and fragile system. They have requested that selected Medicaid services be excluded from ICE management, or that if they are included, regula ons be established to prevent reduc ons in service access or u liza on, or reduc ons in rates. The lack of data upon which to build a program that includes community services means that most of the actual delivery planning will be done by the ICE. Without data, there is no way to build a plan and no way for the public to comment on the efficacy of one. Further, it is unclear but likely that any services included in the ICE benefits menus would have allowed ICEs to set their own rates for services that might be supported by Chapter 257.

Clearly, there are many interests scru nizing these efforts and providing feedback to the Commonwealth. Many of the cri cal opera onal issues are s ll not fully formed, which makes it difficult to comprehend what the final package will be and to assess its impact. For many individuals, this could improve their access to coordinated care. For others already in the system, cri cal ques ons involve what happens to consumer protecon for services, access, u liza on management, and rates when the two pools of money are blended and • Other groups, including Disability Advocates Advancing our Healthcare Rights, sees integra on – managed care en es are allowed to manage these isassuming there are adequate consumer protec ons sues. and funding – as cri cal to improving health and integra on outcomes. There is con nued discussion on whether or not to include Long Term Support Services (LTSS) from the ICE for members in HCBS waivers. Recently the EOHHS has • There are also concerns that CMS would like to enroll as many people as possible to achieve “scale” verbally assured providers and advocates that some quickly. This means that all eligible people would be services, including DDS LTSS waiver services and DMHimmediately included and then have to opt out. This funded Community Based Flexible Support services, will compounds concerns about the importance of be excluded from the benefits menus of managed care. “consumer choice.” There are also ques ons about the ability of an ICE to be able to assess the complex Key public policy issues at this point are: needs of many dual eligibles and addi onal ques ons need answering to clarify the important • All par es recognize the poten al benefits in issue of “choice.” improving quality and reducing costs of Medicare expenditures for unnecessary acute and hospital Timelines: medical and pharmacy services. A dra applica on has been submi ed by EOHHS to • All par es recognize major problems in the current Secretary Bigby. It is expected to be released for a 30 system’s integra ng and coordina ng care to avoid day public comment period shortly. the unnecessary services and costs referenced above. It is expected the final Design Proposal will be submi ed later in FY 2012-for contract awards in FY 2013 • Community providers and some advocacy groups and implementa on in FY 2014. It is an cipated that (such as The Arc) are concerned that including this proposal will be circulated for final comment by all Medicaid community services in the ICE benefits interested par es. The Council will be monitoring this may mean that rates, access, and authoriza ons will process and providing feedback which supports the be reduced, threatening an already underfunded community-based service system.

Should you have any questions or comments, please send them to Michael Ripple (mripple@providers.org) or call him at 617.428.3637 x112. Michael is a special consultant for the Providers’ Council.



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