Making Sense of Medicare-Medicaid Integration Models

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AUTHOR – Allison Rizer

Most of us agree: there is value in Medicare-Medicaid integration. But how well do you understand the programs that aim to accomplish integration? I presented on this topic to a group of providers recently and someone bravely mentioned he had no idea what the MMP program was. A day later I was talking to a former colleague in this space who mentioned she struggled to understand the differences between some duals’ programs.

Part of the understanding gap is on us in the industry—we get comfortable with acronyms and lingo and assume the rest of the world is too. I’m certainly culpable (all acronyms used in this blog are spelled out in a guidebook we hyperlink to below). But much of the gap in understanding is because our healthcare system is complex. And it’s excruciatingly complex when you have to navigate two large and disparate systems: Medicare and Medicaid. If I’ve done my math right, there are at least 43 combinations of Medicare and Medicaid coverage nationwide that a dual eligible might experience,[1] and this doesn’t include nuances like whether enrollment is with the same or different organizations for Medicare and Medicaid coverage:

There’s an alphabet soup to describe some of these 43 combinations – for example HIDE SNP and FIDE SNP in addition to the acronyms already shown in the graphic above (I provided an overview of HIDE SNP and FIDE SNP in a separate blog post). But to my former colleague’s question about the differences between the approaches, and in particular, which approach was best, it’s not a simple answer. New innovations mean there’s no longer a clear continuum where it’s obvious that one program is more integrated (or better) than another. Each of these 43(+) combinations has its strengths and limitations, and different stakeholders each have their own perspectives. But there are some objective aspects of each program that should inform these perspectives, and states and other stakeholders should consider these objective aspects as they continue to implement and refine programs for dual eligibles.

We’ve developed a guidebook that describes these strengths and limitations for select program approaches:

  • Coordinated (Standard) D-SNP
  • Capitated D-SNP
  • Medicaid Managed Care Contract aligned with a DSNP
  • Capitated MMP
  • PACE

Download our full guidebook here. In addition to strengths and limitations, the guidebook includes program descriptions and other nuances to consider as you engage in decision making (or even just conversations) related to Medicare-Medicaid integration.

[1] This assumes an individual is eligible for each of the programs, e.g., a nursing facility level of care need required for an I-SNP or PACE.

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