How Medicare Advantage Special Needs Plans Can Help in Integrating Care to Improve Outcomes
States are increasingly looking to Medicare Advantage dual-eligible special needs plans as a partner in better integrating benefits and improving care for individuals who are eligible for both Medicare and Medicaid benefits (also known as “dual eligibles”). A new paper from Anthem’s Public Policy Institute examines the value of these plans for states and individuals, especially in improving care delivery and health outcomes.
States have long struggled with ways to better integrate benefits and improve care for dual eligibles, a costly and complex population to serve. Not only are these individuals by definition low income, they also tend to have significant health issues. More than twice as many report being in poor health (19 percent compared to 7 percent of non-dual beneficiaries)[i], 41 percent have at least one mental health diagnosis, and 60 percent have multiple chronic conditions.[ii] In part because of these significant health needs, they also represent a disproportionate share of Medicare and Medicaid spending relative to their share of enrollment in each program.[iii]
Dual-eligible special needs plans are a type of Medicare Advantage plan that tailor their benefits specifically to the needs of dual-eligible enrollees. These plans are required to contract with state Medicaid programs to ensure a minimal level of coordination across Medicare and Medicaid programs. Beyond this basic contracting, these plans can also be a good partner for states that are seeking to increase integration of benefits because they offer states an existing, flexible framework with a relatively small initial commitment of resources.
Drawing from interviews with current and former state Medicaid program staff in states that have used dual-eligible special needs plans to increase care integration, as well as policy experts in this area, this paper describes the benefits these plans offer and highlights key takeaways for successful partnerships to advance states’ integration efforts.
Key findings from the paper include:
- Dual-eligible special needs plans can improve beneficiary experiences. These plans can often improve navigation of benefits by offering a more user-friendly benefit structure, allowing individuals to access a broader, yet targeted, set of benefits and services more seamlessly.
- Dual-eligible special needs plans can drive care improvements for enrollees. Plans are able to offer care coordination and can leverage their care management infrastructure and tools to provide meaningful coordination of care for enrollees. Plan-based care coordinators can identify and meet beneficiary needs, authorize services, and act flexibly and quickly when new needs are identified.
- Dual-eligible special needs plans offer simplifications for providers. In more integrated models, providers work with a single entity that is responsible for all coverage determinations and reimbursement, which also helps streamline administrative processes. Providers may also find it helpful to their own care management efforts to have access to the care coordination services that plans offer members.
- Dual-eligible special needs plans provide states with a pathway to better integrate long-term services and supports. As states and plans gain experience with increasing levels of integration, additional Medicaid benefits can be folded into contracts over time.
Finally, the paper finds that states that have been testing and building on special needs plans as a vehicle for integration are seeing positive results for their beneficiaries. The paper highlights findings from recent studies that have shown that implementing these plans has led to lower rates of hospitalization and emergency department use among special needs plans enrollees compared to dual eligible beneficiaries in Medicare fee-for-service.[iv] These findings demonstrate the potential of special needs plans to help advance integration in a manner that can really improve care for dual eligible individuals.
The full report is available for download here.
[i] Medicare Payment Advisory Commission. (2016). A Databook: Health Care Spending and the Medicare Program: Section 4 Dual-Eligible Beneficiaries. Retrieved from http://www.medpac.gov/docs/default-source/data-book/june-2016-data-book-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0 (accessed January 27, 2017).
[ii] Centers for Medicare & Medicaid Services, Medicare-Medicaid Coordination Office. (2016). Fact Sheet: People Enrolled in Medicare and Medicaid. Retrieved from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf (accessed December 13, 2016).
[iii] Medicare Payment Advisory Commission. (2016). June 2016 Report to the Congress, Chapter 9. Retrieved from http://www.medpac.gov/docs/default-source/reports/chapter-9-issues-affecting-dual-eligible-beneficiaries-cms-s-financial-alignment-demonstration-and-t.pdf?sfvrsn=0
[iv] Arizona Health Care Cost Containment System, Individuals Covered by Both Medicare and Medicaid (Duals). Retrieved from https://www.azahcccs.gov/AHCCCS/Initiatives/CareCoordination/duals.html (accessed August 30, 2016).