In all, 26 states applied to participate in the CMS Financial Alignment Initiative, a provision the Patient Protection and Affordable Care Act to integrate Medicaid and Medicare benefits for dual-eligibles. But 15 states indicated this summer that they were either delaying launch of the plans or withdrawing from the program. The main reason states gave for delaying the launch or dropping out was the rate-setting process for establishing payments to plans.
The national goal is to better coordinate care for dual-eligibles, who are among the nation's sickest and most vulnerable adults. Their care costs totaled an estimated $319.5 billion in 2011.
Many dual-eligibles under age 65 have multiple chronic health conditions, including mental health and substance abuse issues, or physical or developmental disabilities. Some duals are homeless. Often, the healthcare and other support services duals receive are fragmented and uncoordinated because they fall through the cracks of the two public programs.
Of the more than 90,000 people Massachusetts is targeting in this category, 13% decided to opt out as of Nov. 1, according to the Massachusetts Health and Human Services department. In that same period, 3,786 people signed up.
Advocates say that reasons for opting out include a person's preferred physician not being in one of the offered plans. They have the ability to change their minds about being a part of the program.
Despite the opt-outs and small enrollment so far, the state “is where we need to be to get started,” said Robin Callahan, Massachusetts deputy Medicaid director for policy and programs.
Massachusetts has more experience in integrating care for dual-eligibles than most other states. Blue Cross and Blue Shield of Massachusetts, Boston Medical Center HealthNet Plan, Commonwealth Care Alliance, Fallon Total Care, Neighborhood Health Plan and Network Health were expected to offer plans for dual-eligibles.
But by June, Blue Cross and Blue Shield, Boston Medical Center and Neighborhood Health Plan had dropped out. In a written statement, the Blues said it came down to “programmatic and funding requirements” of the program. The other two insurers haven't issued any public comment.
Callahan said the departures came down to the plans either being unable or unwilling to develop the appropriate infrastructure to offer One Care plans and serve dual-eligible members. But she expressed confidence that the remaining plans have the ability to offer high-quality services for a population that has complex needs, often including the need for long-term services and supports.
The state originally planned its One Care program to serve its more than 110,000 dual-eligibles. But it had to reduce its goal to about 90,000 after the three health plans dropped out.
If one of the three remaining plans wants to expand into one of the uncovered areas, they will have the ability to do so, Callahan said.
It's understandable that some plans would get cold feet because dual-eligibles are a “heavy lift” for any managed-care plan, said Scott Plumb, a senior vice president of the Massachusetts Senior Care Association, a group representing nursing homes, assisted-living facilities and residential care facilities.
He said one concern for health plans is that One Care has passive enrollment, meaning that dual-eligibles are automatically signed up if they don't explicitly opt out. That increases the chances that the plans will have to serve people who don't want to participate and haven't committed to managing their own health.
