New York state's experiment to better coordinate care for low-income and disabled residents who are dually eligible for Medicaid and Medicare is losing hundreds of enrolled beneficiaries.
As many as 124,000 were eligible for New York's initiative, called the Fully Integrated Duals Advantage, when it launched Jan. 1 of this year.
But as of Sept. 1, only 7,280 had enrolled.
The goal of the demonstration is to coordinate care for dual-eligible beneficiaries, who often have trouble navigating the separate Medicare and Medicaid programs and their multiple doctors and other providers. That drives up the cost of their care and leads to poorer outcomes.
In New York state alone, dually eligible patients collectively cost $36 billion across the two programs, according to a 2012 United Hospital Fund report.
These beneficiaries are low-income people, some under 65, often with physical, cognitive or behavioral disabilities. In the past, they generally have been exempted from mandatory Medicaid managed-care programs because of their special needs and vulnerable status. Under a dozen state demonstrations, beneficiaries generally can choose whether to opt in to the program.
As of Sept. 1, 57,375 in New York had opted out, according to state data.
And while the ability to opt out appears to be a problem for the demonstrations nationwide, community stakeholders have noticed a troubling trend in New York that doesn't appear to be happening elsewhere.
“FIDA enrollment has actually decreased,” according to the website of Leading Age New York, which represents nursing homes, senior housing and adult care facilities in the state.
Between August and September, nearly 400 dropped out of the Fully Integrated Duals Advantage program.
Neither state officials or stakeholders could definitively say why enrollees were dropping out. But it's perplexing because proponents of the duals demonstrations say once a person is enrolled in the programs, they are pleased with their care.
“Enrollees are happy that they are able to access services more easily than before," said Krystal Scott, New York state policy director at the Medicare Rights Center, "They also enjoy the fact that they have a team of providers helping them reach their healthcare goals, access care and live at home in their community.”
Under Fully Integrated Duals Advantage, individuals have access to Medicare home health services including intermittent skilled nursing care, and physical therapy. They also get Medicaid offerings like nursing services, home health aide services, medical supplies, equipment and appliances, physical therapy, occupational therapy, speech pathology and audiology services.
Unlike other duals demonstrations, which target all duals under 64 in certain areas of a state, FIDA participants must either require community-based long-term care services for more than 120 days or be eligible for but not already receiving facility-based or community-based long-term support and services.
Eligible participants reside in Kings, Nassau, New York, Queens and Richmond counties. The state had hoped to expand the program into Suffolk and Westchester counties, but state officials said they've lacked adequate networks.
Plans that had initially wanted to be a part of FIDA are having a change of heart. The state revealed that UnitedHealthcare, ArchCare Community Life, Integra MLTC, and Montefiore MLTC, have all decided to not participate in the demonstration after initially expressing interest.
Leslie Moran, a senior vice president with the New York Health Plan Association said low enrollment appears to be scaring off insurers.
Montefiore said it withdrew after it determined, “We could better serve this patient population through our existing care programs,” a spokeswoman said.
The other plans did not return requests for comment.
The state itself has been inconsistent about its commitment to the program. This summer, the CMS sent a letter to all 12 states giving them the option to extend their demonstrations an additional two years. The agency conceded that it would need more time to evaluate if the demonstrations were indeed working.
New York's demonstration is set to end Dec. 31, 2017. The state's Medicaid director sent a letter (PDF) to the CMS expressing interest in continuing the demonstration.
“The extension will also allow additional time to develop the FIDA demonstration into a mature and established product that in the future can be available to New Yorker's statewide,” the letter read.
However, during a webinar earlier this month, state officials indicated that the letter was simply an option in case they wanted to continue. This month, state health officials planned to meet with stakeholder groups to consider whether to extend the program, and what changes, if any, they would want to put in place as part of an extension.
Advocates hope the demonstration will continue. “It's too early to pronounce victory or defeat,” said the Medicare Rights Center's Scott.
The New York Department of Health did not return multiple requests for comment.
