All dual-eligibles are low-income people. Most are people 65 or older with severe chronic physical or cognitive conditions, but some are younger people who are seriously disabled. Dual-eligibles' care costs totaled an estimated $319.5 billion in 2011. The healthcare and other support services they receive often are fragmented and uncoordinated because dual-eligibles tend to fall through the cracks of the two very different public programs.
“We are excited to announce this new partnership with New York, which will help us work towards the goal of better care for Medicare-Medicaid enrollees,” said CMS Administrator Marilyn Tavenner in a written release. “We look forward to working with the state to provide these beneficiaries with more coordinated, person-centered care.”
Dual-eligibles are many of the nation's sickest and most vulnerable adults. While making up only 15% of Medicaid and 18% of Medicare enrollees, they account for 39% of Medicaid and 31% of Medicare expenditures.
The CMS Financial Alignment Initiative has come under fire by critics for setting unrealistic start times given its scope, which had some demonstrations scheduled to begin as early as this year and others by the beginning of next year. Patient advocacy groups are concerned that these highly vulnerable beneficiaries are being rushed into programs that aren't prepared to serve them adequately.
States can either opt to participate in one of two models set out by the CMS. Under the capitated model, a three-way contract is formed between the CMS, the state and a private health plan charged with managing care for dual-eligibles. States opting to participate under the alternative managed fee-for-service model enter an agreement with the CMS where the state is eligible to garner a share of any federal savings by designing programs that improve quality and reduce costs for both Medicare and Medicaid.
So far six states—California, Illinois, Massachusetts, New York, Ohio and Virginia—have received approval for their dual-eligible proposals under the capitated model. Only Washington state has been approved for an agreement under a fee-for-service model.
“We are delighted to partner with CMS to offer access to more coordinated care to Medicare-Medicaid beneficiaries with long-term care needs,” New York State Health Commissioner Dr. Nirav Shah said in a written release. “Providing customized services that address each individual's medical, behavioral and social needs is critical to improving the health and well-being of this population.”
Under New York's demonstration, all participating health plans will be Medicaid managed long-term-care plans that are modified to include Medicare services.
According to Mark Kissinger, director of the division of long-term care for the New York State Department of Health, as many as 25 health plans are currently being considered to take part in the initiative, although the number that receive final approval will be smaller.
“We had a long negotiation with CMS on this deal, and we did push (the start date) back a couple of months,” Kissinger said. “But it really is part of our whole (Medicaid Redesign Team) strategy, which is care management for all.”
In a written response to news of the announcement, Medicare Rights Center President Joe Baker said that while he was heartened by his organization's initial review of the New York agreement, more analysis of the plan was needed.
The memorandum of understanding “will require a more thorough review, particularly with regard to enrollment protocol, rate-setting and reimbursement methodology, and protections related to care coordination and compliance with the Americans with Disabilities Act and other laws,” Baker wrote. “It is also important that (the New York State Department of Health) develops and effectively disseminates quality metrics that account for the specifics of the dually eligible population and enable consumers to make educated plan choices.”