Vermont steps into a first-ever approach to manage duals

Vermont is looking to take an innovative Medicare waiver approach to advance integration of care for dual-eligibles — one that has never been done anywhere in the country.

Vermont already has two different 1115 waivers in place. One is the Choices for Care Long-Term Care Medicaid Waiver, which gives eligible individuals a choice of nursing home and home and community-based care.

The other is a Global Commitment to Health 1115 Medicaid waiver, which includes all Medicaid services except Children's Health Insurance Plan and long-term care. Both have been in place for five years and are coming up for renewal.

"We are asking CMS [the Centers for Medicare & Medicaid Services] for extensions on both," says Brendan Hogan, MSA, acting commissioner for Vermont's Agency of Human Services' Department of Disabilities, Aging and Independent Living. "We have been able to manage high-cost populations with both because of the flexibility we have in 1115 waivers, as they are research and demonstration waivers."

Without this flexibility, the expenditures for services would have been higher. "We believe we have been very efficient in operating the two waivers," adds Mr. Hogan. "That allowed us to avoid higher costs."

Better integration

The new approach involves integration of dually eligible individuals. "What we'd like to do on the dual-eligible front is for the state to act as the Medicare managed care entity," says Mr. Hogan. "That is extremely innovative and has never been done in the country before."

This would mean that the state would receive Medicare funds directly from the federal government and administer both Medicare and Medicaid programs for individuals who are dually eligible for both programs.

With other Medicare managed care plans, CMS contracts with a commercial health plan. "We do have some history with being a Medicaid managed care entity, under Global Commitment to Health," says Mr. Hogan. "Since 2005, Vermont has been a Medicaid managed care entity. We are exploring the possibility of doing the same for Medicare."

Vermont is currently the only state that acts as a Medicaid managed care entity. "With the duals approach, we want to add Medicare funding to that model," says Mr. Hogan. "The state already manages the care for the Medicaid side. If we were able to manage the funding and services through our existing networks on our Medicare side, we'd be able to integrate care in a better way."

Vermont is a recipient of the Hamilton, NJ-based Center for Health Care Strategies' Transforming Care for Dual-Eligibles grant. In working with other states, Mr. Hogan says that several have expressed interest in taking a similar approach.

"Specifically, we would like to work to enhance the community-based approach Vermont has had for years by adding Medicare funding to the mix and linking existing case management systems for severely and persistently mentally ill, developmentally disabled and elderly, and physically disabled Vermonters with our existing multipayer efforts," says Mr. Hogan.

Less expenditures

"The next step is for the Medicare waiver options to be brought forward by CMS," says Mr. Hogan. "We will have to work with CMS to negotiate this." However, Mr. Hogan says, the Center for Medicare and Medicaid Innovation that was established by health care reform is a very hopeful sign.

"We believe that health care reform has given us the opportunity for the coordination of the duals. We look forward to talking with CMS about whatever possibilities there may be under that new office," says Mr. Hogan.

Vermont's dual-eligible population, which totals about 18,000, [is] "certainly a concern, like they are for every other state," says Mr. Hogan. "The dually eligible population are one of the frailest, but also one of the highest cost for both Medicare and Medicaid."

Ultimately, Mr. Hogan says he expects to see reductions in both Medicaid and Medicare expenditures, as well as better coordinated care for the beneficiaries. "I do see opportunities coming forward at the federal level; I am optimistic," he says.

Contact Mr. Hogan at (802) 241-2326 or