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Enhancing Medicare-Medicaid Integration: Bringing Elements of the Financial Alignment Initiative into Dual-Eligible Special Needs Plans


Individuals dually eligible for Medicare and Medicaid typically must navigate a fragmented and sometime conflicting set of program requirements and processes. The Centers for Medicare & Medicaid Services (CMS), Congress, and states have developed numerous ”integrated” programs to address this system complexity, with the Financial Alignment Initiative (FAI), authorized through the Center for Medicare and Medicaid Innovation (CMMI), promoting the greatest amount of integration. However, the FAI currently is available in only 11 states, while other, lesser-integrated programs are available almost nationwide. This limits access to integrated programs to a small subset of the 12 million dually eligible individuals.


With support from Arnold Ventures, ATI Advisory identified provisions in the FAI that CMS and/or Congress could extend to dual-eligible special needs plans (D-SNPs) through rulemaking and legislation, or that states might consider implementing in D-SNPs through current authority. We reviewed FAI contract provisions along with Medicare Advantage and D-SNP guidance, regulation, and statute, and spoke with current and former state officials with experience implementing and administering an FAI program.


Many of the integration provisions available through the FAI are possible through D-SNPs, but states often do not realize the extent of the D-SNP authority. Further, the CMS Medicare-Medicaid Coordination Office (MMCO) has broad authority to promote integration but has minimally used this authority outside the FAI. This results in a substantial portion of dual eligible individuals lacking access to meaningfully integrated programs.

  • MMCO should clarify to states how to accomplish FAI provisions using D-SNP contract authority and could require some of these provisions in D-SNP programs;
  • Congress should clarify its intent with authority provided to MMCO through the Bipartisan Budget Act of 2018, and MMCO should explore this authority to promote stronger integration in the D-SNP program; and,
  • MMCO should determine whether elements of the FAI meet CMMI spending and quality criteria required to expand provisions into the D-SNP program.

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