Medicaid faces obstacles to integrating care for duals

Integrating care for dual-eligibles clearly presents many opportunities for state Medicaid programs. Unfortunately, progress has been slow, according to The Commonwealth Fund's November 2009 policy brief "Supporting Alternative Integrated Models for Dual Eligibles: A Legal Analysis of Current and Future Options."

One of the biggest challenges, according to Sara Rosenbaum, JD, one of the brief's authors and chair of the Department of Health Policy at the School of Public Health and Health Services at The George Washington University Medical Center in Washington, DC, is "the development of provider capacity to act as medical homes, and eventually, accountable care organizations, for the population."

Another major challenge, as noted in the brief, is developing integrated financing arrangements with Medicare. This way, bundled payments, medical homes, and gainsharing models can be put to work across the two programs.

MN first with dual-eligibles

Minnesota was the first state to establish integrated programs for dual-eligibles, starting with a Medicare demonstration approved by the Centers for Medicare & Medicaid Services (CMS) in 1995. "We have continued to build on that early demonstration. We now have statewide coverage for two integrated programs for dually eligible seniors and people with disabilities," reports Brian Osberg, Minnesota state Medicaid director.

The state contracts with 14 Medicare Advantage Special Needs Plans (SNPs) to provide integrated Medicare and Medicaid services for dual-eligibles in two special programs, both of which operate in all 87 counties in Minnesota. Enrollment in these programs is voluntary.

Minnesota Senior Health Options, the first and largest program, operating since 1997, serves about 37,000 seniors under contracts with eight SNPs. This group comprises about 70% of all dually eligible seniors in the state. The SNPs provide all Medicare and Medicaid services, including behavioral health, long-term care, and home- and community-based services.

Special Needs Basic Care, which began in 2008, has now enrolled about 4,000 people with disabilities ages 18 to 64 under contracts with six SNPs. This program doesn't include home- and community-based services, but it does cover extensive behavioral and mental health services. "It serves as a platform for a special mental health initiative designed to improve coordination of physical and mental health," says Mr. Osberg.

Minnesota has worked with the SNPs to implement numerous administrative processes designed to integrate enrollment, member materials, and coverage decisions. This includes Part D Medicare drugs, networks, care coordination, access to health care homes, and oversight and reporting requirements. The goal is to simplify and streamline access to care for dual-eligibles.

For example, enrollees sign a single enrollment form and receive a single set of materials that explains all benefits under Medicare and Medicaid. Each member has a personal care coordinator or a health care navigator to assist them with appropriate care and services.

National policy lacking

"Our biggest challenge has been lack of a clear and consistent policy at the national level that supports the integration and coordination of care for dual-eligibles on a permanent basis," says Mr. Osberg.

Mr. Osberg says, however, that over the years, CMS support for integration of care for dual-eligibles has expanded. "They have been very supportive of our efforts to integrate care under SNP contracts. However, more clarity about the future viability of SNPs under Medicare Advantage financing, more flexibility to align operational policy between Medicare and Medicaid, and additional resources for assisting states and SNPs to accomplish integration are needed to provide a stable platform for continued integration," he says.

In addition, most state efforts to improve care under integrated models will provide more immediate savings to Medicare. There is currently no mechanism for states to share directly in that savings. "Until these issues are addressed, many states will find it difficult to implement such integrated programs," says Mr. Osberg.

Contact Mr. Osberg at (651) 431-2189 or and Ms. Rosenbaum at (202) 994-4232 or