Simplifying Coverage for Dually Eligible Individuals Through State Contracts with Dual Eligible Special Needs Plans

Simplifying Coverage for Dually Eligible Individuals Through State Contracts with Dual Eligible Special Needs Plans

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Imagine if you had to remember to take two different health insurance cards with you every time you went to a doctor and a third, separate card to pick up prescriptions at a pharmacy. Suppose those insurance cards cover different sets of health care providers and different benefits, and they also have different customer service hotlines.

Even for savvy health consumers, this situation is complicated and frustrating. And yet, it is the standard for dually eligible individuals–those who are simultaneously eligible for Medicare and Medicaid–a population with particularly high rates of disabilities and chronic conditions. Because Medicare and Medicaid were designed as separate programs with separate sets of rules and benefits, dually eligible individuals face hurdles navigating both systems and accessing needed care and supports. Consequently, federal and state policymakers have sought to streamline and integrate Medicare and Medicaid benefits for this vulnerable group of people.

With support from the Medicaid and CHIP Payment and Access Commission, Mathematica recently released a report on strategies that state Medicaid agencies can use to promote integration of Medicare and Medicaid benefits through Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) and factors influencing state use of those strategies. Detailed findings from that analysis are described in the report and in a corresponding issue brief.

State contracting with D-SNPs

To improve health outcomes for dually eligible individuals and reduce costs for Medicare and Medicaid, the Centers for Medicare & Medicaid Services (CMS) and states have implemented a variety of initiatives in recent years designed to coordinate or cover Medicare and Medicaid benefits under a single entity. The most popular model leverages D-SNPs, which exclusively serve dually eligible individuals.

Federal rules require D-SNPs to coordinate their enrollees’ Medicaid benefits and hold a contract with the state Medicaid agencies in states where they operate that meets a minimum set of requirements. However, to achieve true integration of Medicare and Medicaid benefits for D-SNP enrollees, states must go beyond these minimums. To make care more seamless for dually eligible individuals, D-SNPs can cover state Medicaid benefits through either the D-SNP or an affiliated Medicaid managed care plan offered by the same parent company in the same service area. It also helps if D-SNPs can enroll only dually eligible individuals who are entitled to full Medicaid benefits, or at least enroll those full-benefit dually eligible individuals into separate plans from dually eligible individuals who qualify only for coverage of Medicare cost sharing.

Key findings

From our discussions with CMS officials, state Medicaid agencies, health plan executives, and consumer advocates, we found that states can use a variety of strategies to improve integration through their contracts with D-SNPs.  But not every state can, or should, use every strategy.

  • Context matters. The types of D-SNP contracting strategies that a state may use depend on the state’s current situation. For example, if a state already enrolls dually eligible individuals into Medicaid managed care, they can choose to contract only with D-SNPs whose parent companies also offer Medicaid managed care plans, which would promote the opportunity for alignment in Medicare and Medicaid plan enrollment. On the other hand, if a state does not use managed care to serve its dually eligible population, the state could choose to contract directly with D-SNPs for coverage of Medicaid benefits.
  • States need resources and long-term commitment to integrated care initiatives. States need to invest significant time and resources to advance integrated care initiatives successfully. But many states do not yet have the Medicare policy expertise needed to navigate the complexities of D-SNP contracting. Additionally, leadership buy-in and staff champions often play a critical role in advancing D-SNP contracting strategies, so turnover in key staff can interrupt or derail state progress.
  • D-SNP contracting often involves trade-offs between the level of Medicare-Medicaid benefit integration and the number of individuals enrolled in the D-SNPs. Some contract requirements that increase integration of Medicare and Medicaid benefits may decrease the share of dually eligible individuals enrolled in D-SNPs—at least in the short term. For example, limiting D-SNP enrollment to dually eligible individuals who receive full Medicaid benefits can streamline integration, but it may also result in fewer dually eligible individuals enrolled overall.
  • States face challenges to contracting with D-SNPs for coverage of rural or frontier areas. D-SNPs sometimes have difficulty meeting CMS network adequacy requirements in rural areas because of insufficient numbers and types of providers. One potential remedy is to loosen network adequacy requirements to allow D-SNPs to operate more easily in these areas if requirements can be adjusted without jeopardizing enrollee access to care.
  • Stakeholder engagement is critical. Health plans, providers, and beneficiary advocates often influence enrollment into integrated (or nonintegrated) health plans. If states do not successfully engage these stakeholders and gain their support when implementing integrated care programs, they may use their influence to steer potential enrollees away from integrated plans.

Integrating care for dually eligible individuals is a complex endeavor that varies substantially by state. By taking into account the factors that influence state decisions, and understanding which D-SNP contracting options are best suited to each state, federal and state policymakers can advance integration through the D-SNP contracting strategies that are most feasible and likely to succeed.

The full report provides a detailed summary of findings regarding 11 D-SNP contracting strategies that states can use to integrate Medicare and Medicaid benefits. Report appendices contained within the full report include a decision tree and specific state scenarios to help state and federal policymakers understand which D-SNP contracting strategies may be easiest and most appropriate to implement in different state contexts.