Just a few years ago, nearly all of the 11 million people in the U.S. who are dually eligible for Medicare and Medicaid had to navigate two separate, almost entirely disconnected systems of care. In 2012, the nation spent more than $300 billion on care for the members of this high-need group who often have multiple chronic conditions, physical or behavioral health disabilities, and functional limitations. This results in:
Now — spurred by significant state innovation and investment and the creation of the Medicare-Medicaid Coordination Office in the Centers for Medicare & Medicaid Services (CMS) — nearly 750,000 dually eligible individuals are enrolled in integrated health plans. These include two types of plans: (a) Medicare-Medicaid Plans (MMPs) in the Financial Alignment Initiative demonstrations; and (b) Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) that are aligned with a Medicaid managed long-term services and supports plan (LTSS) to coordinate both Medicare and Medicaid services.
States and the federal government have made considerable progress with implementing integrated models of care for individuals dually eligible for Medicare and Medicaid but, with the exception of Washington State’s managed fee-for-service approach, they would not have done it without innovative health plan partners at the fulcrum of most integrated care models. For nearly four years, CHCS has facilitated a learning collaborative of high-performing health plans through PRIDE (PRomoting Integrated Care for Dual Eligibles), a national initiative supported by The Commonwealth Fund to develop best practices for integrating care. PRIDE plans believe that combining Medicare and Medicaid financing and services into one integrated benefit allows them to address the full range of their dually eligible members’ needs. Managing both acute care and LTSS can, for example, avoid further medical or functional decline that would require an individual’s admission to a hospital or nursing facility.
The PRIDE plans — BlueCare Tennessee (Tennessee), CareSource (Ohio), Commonwealth Care Alliance (Massachusetts), Health Plan of San Mateo (California), Independent Care Health Plan (Wisconsin),Inland Empire Health Plan (California), UCare (Minnesota), and VNSNY CHOICE Health Plans (New York) — each offer an MMP and/or a D-SNP that provides all Medicaid services including LTSS. Examples of innovations being pursued by PRIDE plans include:
Sustaining and expanding integrated care programs is a high priority for PRIDE plans. Last March, plans submitted a letter to the Secretary of Health and Human Services to underscore the importance of these programs and suggest policy options to sustain them. The recommendations included:
Opportunities are emerging to further the growth of integrated care programs. On September 26, the U.S. Senate unanimously passed the CHRONIC Care Act of 2017 (S. 870), which gives Medicare Advantage better tools to improve care for beneficiaries with chronic conditions, including permanently authorizing Special Needs Plans and requiring that D-SNPs plans meet new administrative requirements that advance alignment and assume greater responsibility for covering Medicaid LTSS and/or behavioral health services. The House is considering similar legislation. While there is still much work ahead, PRIDE plans are encouraged by the unprecedented progress that integrated care platforms achieved in recent years and by the bipartisan support for expanding integrated care options for millions of additional dually eligible individuals.