_{By Pamela J. Parker, MPA, Medicare-Medicaid Integrational Consultant, SNP Alliance}

When individuals participate in both Medicare and Medicaid, it would be ideal for them to be enrolled in one plan that integrates both programs and coordinates the benefits. And in some cases, this is already happening. But too often, these individuals—who are already highly vulnerable—are enrolled in entirely different, uncoordinated plans for each program. This further complicates an already fragmented delivery system for this high-needs group.

To achieve the quality and cost outcomes we seek, Medicare and Medicaid services must be coordinated through one unified plan.

Medicare-Medicaid Beneficiaries: Caught in the Middle

As they try to access needed care through both programs, Medicare-Medicaid beneficiaries face a maze of confusing, fragmented, duplicative and often conflicting administrative processes. These 11.4 million individuals are more likely to have multiple chronic health conditions requiring long-term community supports and services (LTSS) and behavioral health services. In addition to their health needs, they often have to handle multiple cards and make numerous phone calls. Their care incurs more than a third of total costs in both programs. The Centers for Medicare and Medicaid Services (CMS), states, and health plans have made great strides to address these problems. Promising approaches have included Medicare Medicaid Plans (MMPs) that are participating in integrated care demonstrations in 13 states, and policies that promote integration through Medicare Advantage Dually Eligible Special Needs Plans (D-SNPs) that now enroll over 2 million Medicare-Medicaid beneficiaries.

Yet, a relatively small proportion of Medicaid-Medicare beneficiaries are enrolled in aligned plans sponsored by the same parent organization. CMS estimates that in 2017, only about 8 percent of dually eligible enrollees (780,000) were enrolled in fully or partially integrated plans for both sets of services (MMCO 2018 Report to Congress).

As more states turn to Medicaid managed care, and more Medicare options are available to all Medicare beneficiaries, an unknown number of Medicare-Medicaid beneficiaries are actually enrolled in two (or possibly three) unrelated plans. An already confusing system is made more difficult when vulnerable enrollees are subject to separate and conflicting assessment and care coordination systems, different networks and financial incentives with two or three sets of eligibility cards, member materials, benefit determination processes, and multiple member services call centers.   

Integration is much more feasible when individuals are enrolled in linked Medicare and Medicaid products. When the same entity is financially responsible for all Medicare and Medicaid benefit policies and operations, the two programs can appear nearly seamless to enrollees and to providers. Financial incentives can be aligned, allowing Medicaid benefits to complement efforts to reduce hospitalizations and Medicare benefits to complement efforts to reduce long-term nursing home stays. Provider payments, including Medicaid-covered cost sharing, can be coordinated through one entity, and providers can focus on helping enrollees maintain or improve health outcomes.

Challenges to Enrollment Alignment

Despite significant recent progress, states and plans still face significant challenges in achieving enrollment alignment:

• Differences between Medicaid and Medicare Plan Choice Policies: Differences in how beneficiaries choose plans can result in enrollment in one plan for Medicare, and another for Medicare.
• Differences in Contracting and Procurement Approaches and Schedules: Enrollment alignment or the potential for it varies significantly among states, and is highly dependent on coordination of state Medicaid procurements and timelines with Medicare SNP applications and bid timelines.
• Mismatched Enrollment Parameters: Enrollment parameters established by the state or previously chosen by the plan also affect the ability to align enrollment.  
• Matching Beneficiary Enrollment and Performance Data: It can also be challenging to obtain information necessary to determine to what extent misaligned enrollment is a problem in a state or nationally. This determination may require collecting additional information from states.

Challenges to integration and data collection may occur even when members are enrolled for both programs under the same plan sponsor. Many D-SNPs are operated by plan sponsors who operate multiple Plan Benefit Packages (PBPs). Features designed or data collected for CMS Medicare purposes at the contract level may not align with the data and reporting needs of state Medicaid agencies because they include populations outside of their Medicaid enrollees, precluding efficient collection of data for both purposes and making plan performance for dually eligible members difficult to evaluate. 

How We Can Make Progress

There are a number of existing tools that states and plans can use to work together toward increasing aligned enrollments.

• Requirements to Offer a Corresponding D-SNP: More states are beginning to require that Medicaid MCO plan sponsors chosen for MMLTSS programs also sponsor a corresponding D-SNP in the same service area. 
• Early Request For Informationand Procurement Coordination: States can plan ahead for differences in procurement schedules by issuing a Medicaid RFI or RFP outlining basic Medicaid and MIPPA requirements for such D-SNPs in time for the CMS D-SNP application process (18-24 months ahead of a planned enrollment date.) To make this work, the Medicaid RFP should also include a Medicaid implementation timeline that gives bidders enough time to get a companion D-SNP in place by the time it is required for purposes of the Medicaid program
• Default Enrollment: New Medicare rules allow “default enrollment” of new Medicare-Medicaid beneficiaries for only those D-SNPs operated under the same parent company of their Medicaid MCO. This replaces a previous “seamless enrollment” rule provision suspended by CMS that had been available to all MA plans.
• Utilizing the Existing Infrastructure: When there is already an existing infrastructure of Medicaid MCOs and D-SNPs, states can prioritize choosing qualified Medicaid MLTSS plan sponsors that have significant existing D-SNP enrollment. This will minimize disruption and maximize enrollment alignment by giving extra points for participating D-SNPs with significant enrollments.
• C-SNPs and I-SNPs: Integrated enrollment pathways for Medicare-Medicaid beneficiaries in these plans have not yet been developed. However, some of these plans serve large numbers of Medicare-Medicaid beneficiaries under the scope of their current CMS agreements, and pathways for further integration for beneficiaries in these plans should be considered.

These problems and solutions stem from policies and decisions that have evolved over many years. It may take considerable time to resolve them and to find additional ways to align enrollment.  Recognizing that many states and plans are at different levels of integration, these tools are meant to enable incremental steps along the integration continuum. In the meantime, there are several recommendations that CMS could follow, including: 

• Work with states to develop ongoing automated file comparisons or other mechanisms for determining and reporting the number of Medicare-Medicaid beneficiaries enrolled in unrelated plans for Medicare and Medicaid.
• Develop additional pathways to integration to enable states and plans to address situations where beneficiaries are enrolled in unrelated plans. This might include expansion of Medicare passive enrollment policies to allow auto-assignment with opt-out protections for Medicare-Medicaid beneficiaries.
• Consider providing additional incentives for states (such as grants) to assist them with resources and staffing needed to assess and address enrollment misalignment in their programs.
• Examine how recent Special Enrollment Period changes affect beneficiaries’ ability to access enrollment in integrated programs and consider modifications as needed. 

Editor’s note: This blog is based on a full policy paper published by the SNP Alliance. The full paper can be found here.