That population's coverage cost about $319.5 billion in 2011, or 35% of total spending by Medicare and Medicaid, according to the Kaiser Family Foundation. Many in this population have severe chronic conditions and physical or behavioral disabilities.
The CMS hired research firm RTI International to perform an independent analysis of the state demonstrations aimed at better aligning the coverage and services of American who are so-called dual-eligibles. The audit would help find ways to cut costs.
RTI's initial report (PDF) was completed in October 2015 but was published on the CMS' website just last week.
The report was posted days after the U.S. Government Accountability Office criticized the CMS for not having a consistent way to review the progress of the demonstrations that began under the Affordable Care Act. The data from the 12 state programs aren't comparable.
Some states were surprised by how much it would cost to modify their IT systems simply to implement the demonstration. The report didn't specify how much states were spending. Another issue is conflicting Medicare and Medicaid policies regarding eligibility criteria and enrollment.
To get people into the demonstrations states largely rely on passive enrollment, which involves randomly assigning beneficiaries to a plan if they don't select one and don't opt out. However, there were challenges on this front as well.
Despite efforts to accommodate plan capacity such as enrolling a limited number of people at one time, demonstration plans needed to handle the influx of many enrollees at one time. Another issue was that plan “staff spent an inordinate amount of time trying to locate enrollees in order to complete initial health assessments and introduce enrollees to the benefits of the demonstration,” the report says.
But “addressing the nuts and bolts of aligning the Medicare and Medicaid program policies, procedures and systems has been more time-consuming than they expected,” the report says.
The evaluation focuses on seven demonstrations that were up and running as of May 1, 2014, in California, Illinois, Massachusetts, Minnesota, Ohio, Virginia and Washington state. The demonstrations streamlined services by, for example, allowing beneficiaries to use one card to obtain all needed services, instead of presenting two.
RTI's work is far from over. The firm is contracted to produce three annual reports for each demonstration that's launched, and an annual report on all states with dual demos. These reports will contain greater detail about the demonstrations and their experiences, and they will be posted on the CMS website.