CMS asks Congress to help improve care for dual eligibles

The CMS has submitted a series of legislative ideas to Congress they say would better coordinate care for people eligible for both Medicare and Medicaid. These beneficiaries tend to be sicker and more expensive to manage.

The first idea is to make permanent a demonstration on retroactive Medicare Part D coverage for low-income beneficiaries.

Currently, low-income beneficiaries are assigned at random to a qualifying Part D plan, which is reimbursed based on the standard Part D prospective payment, regardless of how many services were used during this period. The demo, which ends next year, pays plans a rate closer to actual costs incurred. The CMS claims the pilot has both saved money and not imposed any burden on duals.

The next idea is to ease cost and simplify the message in marketing materials created by state and federal officials regarding dual eligible special needs plan (D-SNP).

The agency also wants the authority to streamline how dual health plans appeal denied claims.

Finally, the agency wants to limit the ability to change plans via special enrollments. Currently, the CMS is required to maintain a special enrollment period for full-benefit dually eligible beneficiaries. This recommendation would narrow situations in which a dual could switch plans beginning in 2019.

"Efficient use of the Part D special enrollment for dual eligible beneficiaries reduces aggressive marketing targeted to low-income beneficiaries, improves incentives to make investments in and provide care coordination for high-cost, often vulnerable beneficiaries," the CMS said. It also "reduces the administrative burden on health plans from beneficiary fluctuations between plans numerous times throughout the year."

Dually eligible beneficiaries made up 20% of the Medicare program and 15% of the Medicaid program in 2012. However, they accounted for 34% of Medicare expenditures and 33% of the Medicaid spending that year, the last available data, according to the CMS.

"A lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for Medicare-Medicaid enrollees and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs and to enrollees," CMS said in a report submitted June 18 to Congress.

Together these beneficiaries cost states and the federal government $306 billion in 2012. Duals tend to have fragmented care experiences, leading to higher use of health services.

By 2016, there were 11.7 million dually enrolled in Medicare and Medicaid, according to the agency.

Health plans praised the requests overall. "Work now to be done is in advancing integration," said Dr. Cheryl Phillips, president and CEO of the SNP Alliance, a trade organization. "Each of these represents needed incremental steps in that forward direction."

The changes would make it easier for insurance companies to coordinate care for duals, said Kristine Grow, spokeswoman for America's Health Insurance Plans. "By integrating their care and support, we are better equipped to care for the whole person, make short-term investments to improve their long-term health, and optimize every dollar spent on their care," she added.

Advocates were mixed in their opinions. They supported the goal of better integration but said the ideas must be implemented carefully. For instance, integrated marketing materials must be at a low reading level as many duals suffer cognitive impairments, said Leena Sharma, senior policy analyst at Community Catalyst's Center for Consumer Engagement in Health Innovation.

There has been criticism that some dual enrollee mailing materials sent out in the past were too difficult to understand.

Georgia Burke, an attorney with the nonprofit Justice in Aging was concerned about limiting special enrollment opportunities for duals. The CMS already is planning to pursue a related rule and those efforts should be studied before they are codified into law Burke said.