States participating in demonstrations aimed at lowering costs and improving care for residents dually eligible for Medicaid and Medicare have a new tool to enroll a historically elusive population.
Simpler outreach materials will boil down the complexities of coverage offered by demonstrations, which contract with private managed-care plans to coordinate Medicare and Medicaid benefits and spending for dual-eligible beneficiaries. The voluntary program could be helpful and satisfying for patients since many duals have severe chronic conditions and physical or behavioral disabilities and many plans offer a full range of care, including long-term care.
But patient advocacy groups say the materials are too technical and confusing, leading to a high opt-out rate.
In the 10 states with a capitated duals demonstration, only 361,000 individuals have enrolled as of May, according to Health Management Associates, a Washington-based consulting and research firm. That figure is only 27% of the 1.3 million beneficiaries eligible to participate in those states.
States with a capitated demo receive a fix payment combining Medicaid and Medicare, minus agreed-upon savings. These plans are paid a risk-adjusted capitated rate.
The demonstration were created because even though dual-eligible beneficiaries make up only 13% of the population enrolled in both programs, they account for 40% of total Medicaid spending and 27% of total Medicare spending. Experts say the lack of coordination results in poor quality care and unnecessarily high costs.
The changes to the materials came from suggestions made by dual-eligibles participating in the demonstration in three states.
Close to the top of the documents is now the most important information, such as actions the member needs to take to enroll, how to file a complaint about the program, which providers and drugs are covered and simpler language about covered benefits. States can use these materials to attract patients starting next year.
Some advocates think it will help enrollment.
“Improved health plan materials will result in less confusion, meaning consumers will be more likely to stay in demonstrations and successfully use their coverage when they do,” said Leonardo Cuello, director of health policy for the National Health Law Program.
Others aren't sure.
“The high opt-out rates are not just a matter of beneficiary confusion and poor notices,” said Amber Cutler, a senior staff attorney for Justice in Aging, an advocacy group. “Data has demonstrated that beneficiaries most often opted out because they did not want to make a change and feared losing access to their provider.”
A University of California-Berkeley School of Public Health phone survey of 2,100 dually eligible Californians supported this belief. Of those surveyed, 47% cited a desire to keep their doctor as their reason for opting out.
