Improving care integration for Medicare-Medicaid dual eligible beneficiaries is one of the many initiatives embedded in the Affordable Care Act (ACA). The health reform law created the Medicare-Medicaid Coordination Office at the Centers for Medicare and Medicaid Services (CMS), and provided funds for state demonstrations to integrate care for dual eligibles, several of which are now in implementation.  For states taking that route, an issue brief from the Integrated Care Resource Center and Mathematica Policy Research is an excellent resource to help them sort out the complex, overlapping benefit and payment structures of Medicare and Medicaid.

Care for Dual Eligibles is Complex, Expensive:

Dual eligibles tend to be less healthy and more expensive to cover than other populations in Medicare and Medicaid. Taken as a group, the nation’s roughly 10 million dual eligibles account for roughly 40 percent of state Medicaid spending and over 30 percent of federal Medicare spending – a total of more than $350 billion in 2013. Dual eligibles are more likely to be disabled than other Medicare beneficiaries, and are more likely to have chronic conditions. All of those factors make better care coordination for dual eligibles a valuable goal.

So far, 15 states have received CMS grants to design care integration models. Most of the state demonstrations involve the use of integrated health plans that will compete to provide most or all Medicaid and Medicare services for the state’s full-benefit dual eligibles. Other models include managed fee-for-service with shared savings. Browse the state integrated care design summaries here for details about what each state intends to do.

See these previous blog posts related to care integration for dual eligibles:

Primer on Medicare-Medicaid Interaction for Dual Eligibles:

Integrated care programs will have to grapple with overlapping Medicaid and Medicare payment policies, eligibility, and benefits. To help navigate that landscape, Mathematica Policy Research wrote an excellent primer for states trying to integrate care for dual eligibles.

Here is an overview of what the brief covers:

1.  Eligibility and Enrollment of Dual Eligibles:

Medicaid eligibility varies significantly by states, but the federal government sets minimum requirements for states to cover certain populations, such as low-income children, pregnant women, and disabled adults. Medicare is available to adults older than 65 years and adults younger than 65 years with certain disabilities and chronic diseases.

As with all Medicare beneficiaries, dual eligibles can choose to enroll in fee-for-service Medicare or in private Medicare Advantage health plans. Within Medicare Advantage are Special Needs Plans for Dual Eligibles (D-SNP), which are designed to coordinate care for dual eligibles. D-SNPs will play an important role in several state integrated care demonstrations.

2.  Benefits and Payment for Dual Eligibles:

Basically, Medicare is the primary payor for most services – such as physician and hospital care – and Medicaid pays for Medicare cost sharing (Part A deductible and coinsurance; Part B deductible, premium, and copayments; and Part D premium, deductible, copayments, and doughnut hole costs), long term services and supports (LTSS), and enhanced behavioral health.

The picture quickly becomes much more complicated than that, so the Mathematica brief provides excellent tables to describe how Medicare and Medicaid benefits overlap for dual eligibles.

The full brief also has detailed information on Medicare and Medicare Advantage rate setting, which differ from Medicaid rate settingRead it here.