Authors: Allison Rizer (ATI Advisory), Cleo Kordomenos (ATI Advisory), Amy Abdnor (Arnold Ventures), and Arielle Mir (Arnold Ventures)
Date of Publication: June 28, 2022
In recent years, policymakers have set their sights on making care and coverage more coordinated for the low-income older adults and people with disabilities who are enrolled in both Medicare and Medicaid. Integrating Medicare and Medicaid for this “dual-eligible” population can make it easier for individuals to navigate a complex system and create financial incentives for providers to work together. Despite this promise, only half of dual-eligible individuals have access to a meaningfully integrated coverage program.
To date, most federal efforts have used Medicare authorities to expand access to programs that integrate care for dual-eligible individuals, such as requirements on Medicare plans to coordinate with Medicaid funded services. However, the resulting Medicaid-Medicare coordination is dictated by states—a Medicaid agency must put the conditions into place that allow for integration. Despite this, little has been done in the recent past through the federal government’s authority of the Medicaid program to align the Medicaid program with the Medicare program. This is a missed opportunity.
In May 2022, ATI released a Policy Roadmap for CMS and the Center for Medicaid and CHIP Services (CMCS) to consider. This Roadmap outlines a bold vision for ways the Administration could use existing authority in the Medicaid program to further coordination and integration between Medicaid and Medicare.
We believe CMCS can improve the care experience for every dual-eligible individual in this country by focusing on two sets of authorities: (1) Medicaid managed care and (2) general and home and community-based services (HCBS) program approvals.
- Require Medicaid Managed Care Programs Serving Dual-Eligible Individuals to Integrate with Medicare. States with Medicaid managed care for dual-eligible individuals are well-positioned to integrate their Medicaid programs with Medicare. They have an existing health plan infrastructure, and the majority of dual-eligible enrollment in Medicaid managed care is with organizations that have D-SNP experience.  Despite this, only 20 states include any integration in their Medicaid managed care design, yet about 30 states have “comprehensive” managed care serving this population. CMS could change this by creating federal requirements that Medicaid managed care programs must have an aligned D-SNP. When held accountable for delivering the full range of Medicare and Medicaid benefits, managed care plans can reduce the duplication and fragmentation individuals currently experience, by creating the right financial incentives to deliver person-centered, efficient care.
- Promote Coordination with Medicare Through General Medicaid and HCBS Program Approvals. Through its authority to approve HCBS waivers and general Medicaid programs, CMS can create a foundation for integrated experiences in all states and for all dual-eligible individuals. Regardless of state program design, states submit requests to CMS for approval in the form of waiver requests and State Plan Amendments. CMS also uses federal regulations to establish core requirements across all Medicaid programs. CMS should include and consider a state’s coordination and integration with Medicare for dual-eligible individuals in program requirements. For example, Medicaid program stakeholder engagement processes should incorporate the unique needs and preferences of dual-eligible individuals and HCBS waiver reporting should include the impact of program efforts on the health and welfare of dual-eligible individuals (see the Policy Roadmap and Compendium below for a full list of opportunities).
Implementing the recommendations outlined here, would be, as they say, “easier said than done.” The CMS offices that typically approve state submissions are resource-constrained and work under challenging timelines in the best of circumstances. However, with support from agency leadership, proactive communication with states about the benefits of Medicare coordination, and technical support to state leaders, progress is possible. The Medicare-Medicaid Coordination Office within CMS has played an important role in promoting integration in other aspects of program design and could play a similar consultative role here, as well.
As outlined in CMS’ 2022 Strategic Framework, integrating Medicare, Medicaid, and the Marketplaces is a key priority for the agency. Using the Medicaid authorities outlined here, CMS could make meaningful progress toward that goal that every dual-eligible individual have access to an integrated coverage option.
Technical Resource: Crosswalk between Medicare-Medicaid integration opportunities in Medicaid and the specific regulations that could be amended to promote greater integration.