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New Report: Guaranteeing Integrated Care for Dual Eligible Individuals

Washington, DC – In 2019, 12.3 million individuals in the U.S. qualified for Medicare and Medicaid. Approximately 88% of these “dual eligible” individuals, who have higher than average health care needs and therefore greater costs, navigated these programs separately.

The current system makes it extremely difficult for health care providers to deliver patient-centered care and is challenging for beneficiaries and their families to navigate care. In states that contract with managed care plans to deliver Medicaid services, some of which may “carve out” certain benefits, a dual eligible individual must navigate not only separate programs but also multiple Medicaid plans.

“Medicare-Medicaid beneficiaries should not be expected to navigate multiple plans and programs to access care,” said Katherine Hayes, BPC director of health policy. “And yet, in at least 14 states plus D.C., these dual eligible individuals are forced to do just that.”

To address these ongoing issues facing dual eligible individuals, the Bipartisan Policy Center this morning released a new report, Guaranteeing Integrated Care for Dual Eligible Individuals, with recommendations for Congress and states to better integrate care for over 12 million individuals. They include:

  • Establish a framework for the integration of Medicare and Medicaid services for dual eligible individuals. To ensure that full-benefit dual eligible individuals have access to fully integrated care models, BPC recommends that the HHS secretary establish a full integration standard of coverage and care for dual eligible beneficiaries. The HHS secretary should also provide access to fully integrated services for all dual eligible beneficiaries in partnership with states. Additional funding and regulatory authority should also be given to the Medicare-Medicaid Coordination Office to establish and oversee full integration in all programs serving dual eligible individuals.
  • Improve enrollment and eligibility. Enrollment in full integration models should be limited to full-benefit dual eligible individuals. Auto-enrollment into the state-implemented or federal fallback integration models should be allowed, with a beneficiary opt-out available in the case of Medicare-covered services. Congress should also permit and encourage states to implement 12 months of continuous Medicaid eligibility for dual eligible individuals.
  • Provide incentives for state-administered integrated care programs. Congress should define and develop full integration models for states that choose to integrate care, while providing financial and technical assistance to support state implementation. The HHS secretary should also be given the authority to develop a guaranteed shared savings program for full integration models.
  • Federal fallback. While BPC believes states should lead in the integration of Medicare and Medicaid services, we understand that all states may not fully integrate care. Therefore, along with incentives to create or improve state-led integration, the HHS secretary should also have authority to implement a federally-administered integration model—or “fallback” program—should states choose not to integrate care.
  • Improve beneficiary experience. To have a seamless experience for beneficiaries, BPC recommends collaboration between CMS, the Administration for Community Living, and states to implement model standards for outreach and education. Resources and technical assistance to states should be provided, and Congress should encourage states to prioritize partnerships with community-based organizations and local governments.

“Integration of Medicare and Medicaid services for dual eligible beneficiaries is long overdue,” Hayes continued. “Fully integrated programs have the potential to improve the quality of care and lower the total cost of care for the dual eligible population. The recommendations in this report ensure beneficiary choice and offer states the resources and assistance needed to implement integrated programs.”

This report is a follow-up to BPC’s July 2020 report urging full integration of care for Medicare-Medicaid beneficiaries.

Guaranteeing Integrated Care for Dual Eligible Individuals was produced by Bipartisan Policy Center staff in collaboration with senior advisors and experts, including Sheila Burke, Jim Capretta, and Chris Jennings, and with support from Arnold Ventures. Experts Henry Claypool and Sara Rosenbaum also contributed to the report.

Download the full report