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A Pathway to Full Integration of Care for Medicare-Medicaid Beneficiaries

BPC has worked for a number of years to improve integration of services for those who are eligible for Medicare and Medicaid. In continuing that work over the past year, BPC conducted research, hosted roundtable discussions, and interviewed key stakeholders to better understand the barriers to integration of these programs and the challenges faced by those who must navigate them. BPC also commissioned a study (see Appendix I) to better understand the challenges and successes of federal and state demonstrations to align these programs.

The primary goals in recommending alignment are to improve beneficiary experience, outcomes, and well-being. Given the lack of coordination in the current system, BPC believes there is also potential for savings over the long term, primarily in the form of reduced hospitalizations, hospital readmissions, emergency department visits, and post-acute care. However, before those savings can be achieved, there will need to be up-front investments to provide resources to states and to the office within CMS that administers the program, to develop infrastructure where it is currently lacking. Finally, this proposal would guarantee a simplified and seamless integrated care option by a certain date.

Efforts to better integrate care should recognize the heterogeneity of the dual eligible population, and the importance of a transition to integrated care for distinct populations. Dual eligible individuals should have comprehensive information about the benefits and drawbacks of enrolling in a fully integrated care model. There should be ample time for community-based education to help beneficiaries understand their enrollment options and the benefits available to them before they are enrolled in integrated care programs. Also, while these models should deliver a less complex and costly care experience, beneficiaries should be given the opportunity to opt-out of them at any time.

BPC’s recommendations are designed to create strong incentives to states to integrate care. The report identifies three care models from which states can choose to achieve full integration:

  1. improved Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs) that reflect lessons learned from the Financial Alignment Initiative (FAI) demonstration’s Medicare-Medicaid Plans (MMPs)
  2. the Programs of All-Inclusive Care for the Elderly (PACE)
  3. a flexible model negotiated between the secretary of the U.S. Department of Health and Human Services (HHS) and a state, building off the managed fee-for-service model used by the State of Washington

Each model must cover all Medicare and Medicaid benefits and meet all integration requirements identified in this report. These recommendations are intended to build on best practices of the past 40 years in integrating care for full-benefit dual eligible individuals.

These recommendations provide significant incentives to states in the form of planning grants, technical assistance, and guaranteed shared savings, if integration of services reduces costs over time. They also include provisions to help dual eligible individuals better understand the benefits and trade-offs of receiving care through a fully integrated plan, by providing federal resources for consumer education, and by recommending closer coordination between the Centers for Medicare & Medicaid Services (CMS) and the Administration for Community Living (ACL).

To guarantee an integration option for all populations of dual eligible individuals in every state by a date certain, these recommendations include the framework for a federal fallback program to operate in states that choose not to integrate care. Under this approach, the secretary of HHS would contract with improved FIDE SNPs, which would be based on best practices from the FAI demonstration’s Medicare-Medicaid plans. PACE would also continue to be available as an option.

Over the last decade, stakeholders—including state and federal policymakers, consumer advocates, health plans, and providers—have worked to improve the complex challenges associated with improving care for those who rely on Medicare and Medicaid to address their health and long-term care needs. BPC is one of a small but growing group of organizations and agencies seeking to accelerate integration of care for dual eligible individuals. BPC does not hold a monopoly on good ideas and recognizes there are many paths forward. BPC welcomes the opportunity to work with policymakers and other organizations to identify viable solutions to improve care and lower costs for a vulnerable and high-cost population.

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I. Framework for the Integration of Medicare and Medicaid Services for Dual Eligible Individuals

To ensure that all full-benefit dual eligible individuals have access to fully integrated care models by a date certain, Congress should:

A. Define “full integration” for programs serving dual eligible individuals.

  1. Fully aligned financing, with a single entity responsible for Medicare and Medicaid funding in all counties/regions of a state
  2. A single set of benefits, including medical benefits, behavioral health, and long-term services and supports
  3. A single point of access, which requires a single plan or sponsor offering the full range of benefits with one enrollment period, one set of member materials, one enrollment and identification process, one point of access for all benefits, one point of contact for benefit decisions, and a single grievance and appeals process
  4. A process that makes sure beneficiaries are informed of and understand their options and rights within an integrated program, and provides sufficient time to make decisions regarding enrollment, with strong safeguards to protect beneficiaries
  5. Health plan access to claims and encounter data for new enrollees to identify high-risk enrollees and provide prompt assessments, including a standard functional assessment tool, a single primary care provider, and an interdisciplinary care team to develop an individualized person-centered care plan that is designed to meet the unique needs of high-risk enrollees; the care plan should include primary, specialty, acute and post-acute care, and pharmacy services. The care plan should be updated as needed to address beneficiaries needs as they change over time and across care settings
  6. Provider access to integrated information systems and care transitions, to be able to identify high-risk enrollees, to assure timely individual assessments, and to provide smooth care transitions without disruptions in services
  7. A single and streamlined set of measures across the two programs, including a set of quality measures and performance evaluations developed for complex populations, to be used for quality improvement and to serve as a basis for quality reporting to help beneficiary decision-making

B. Require states to provide access to fully integrated Medicare and Medicaid services for all dual eligible individuals. Provide resources and technical assistance to states to implement full integration of services. A federal fallback would go into effect in states that do not integrate services.

C. Provide the Medicare-Medicaid Coordination Office with direct funding and full regulatory authority for all programs serving dual eligible individuals—including integrated care models implemented by states and the federal fallback program. This would require increased staffing and resources.

D. Provide general waiver authority to the secretary of HHS to align administrative differences between the Medicare and Medicaid programs, excluding issues related to eligibility, benefits, access to care, Medicare freedom-of-choice protections, or beneficiary due process rights.

E. Direct the secretary of HHS to adopt best practices from the Financial Alignment Initiative demonstration and apply them to Fully Integrated Dual Eligible Special Needs Plans.
The secretary should convene a working group to identify best practices where they have yet to be identified. The group should be composed of state agency officials, representatives of consumer organizations, private health insurance plans, consumer advocacy and other experts to develop uniform standards in the following areas:

  • Care management standards for integrated clinical health services, behavioral health, and LTSS
  • Network adequacy standards appropriate for dual eligible individuals
  • Standard materials for marketing, plan notices, and other member materials
  • A single open enrollment period process
  • A process for joint oversight of plans by CMS and states

II. Enrollment and Eligibility

To ensure all full-benefit dual eligible individuals are able to enroll in fully integrated plans, Congress should:

A. Limit enrollment in fully integrated models to full-benefit dual eligible individuals.

B. Allow auto-enrollment into state-implemented, fully integrated care models with a beneficiary opt-out available at any time. Auto-enrollment with beneficiary opt-out should be the default in the federal fallback program.

C. Permit and encourage states to implement 12-month, continuous Medicaid eligibility for dual eligible individuals.

III. State-Administered Integration of Care

To encourage states to integrate Medicare and Medicaid for dual eligible individuals, Congress should:

A. Define and develop fully integrated models for states that choose to integrate care. States would choose from three models meeting the definition of “full integration”” defined above: (1) improved FIDE SNP, (2) PACE, and (3) a flexible model negotiated between the secretary and a state, building off the model used by the State of Washington.

B. Provide financial and technical assistance to states that fully integrate care. For those states that notify the secretary of the intent to integrate care as outlined above, the secretary should make available to states adequate resources to develop, implement, and sustain a process for integration of services. States should also receive technical assistance at a level similar to assistance made available as part of demonstrations, building on and expanding the existing Integrated Care Resource Center to help advise individual states.

C. Provide the secretary of HHS with authority to develop a guaranteed shared savings program for integrated care.

IV. Federal Fallback Program for States that Do Not Integrate Care

A federal fallback program is critical to a well-functioning program of Medicare and Medicaid integration. The following section provides a general framework for the fallback, if states are not able or willing to implement an integrated solution. BPC plans to fully explore the critical details of the federal fallback— including eligibility, benefits, consumer protections, reimbursement, contracts and procurement, and numerous other details—as a next step to improve care for dual eligible individuals.

To ensure all dual eligible individuals have access to fully integrated care models, Congress should:

A. Create a federal fallback to be implemented in states that decide not to implement an integrated program. The federal fallback program could include one or more of the integration models developed for state implementation. PACE organizations would be considered an integrated option; however, the existing state and federal oversight structure would continue.

  1. Eligibility – Options could include SSI eligibility, state-specific eligibility levels as of the date of enactment or some hybrid.
  2. Services – All Medicare and Medicaid-covered benefits offered by an improved FIDE SNP should be offered as a single benefit package that includes medical services, behavioral health services, and long-term services and supports (LTSS). LTSS benefits would be available to eligible individuals meeting the Health Insurance Portability and Accountability Act of 1996 standard of a deficit of two or more activities of daily living (ADLs) or a need for supervision as a result of cognitive impairment.
  3. Delivery System – The primary delivery system for the federal fallback should be through a risk-based model, similar to the FIDE SNP. PACE would also qualify as an integrated care model.
  4. Financing – Financing for the federal fallback would be existing state and federal spending for dual eligible individuals. This would be similar to the recoupment, or “clawback,” of funding authorized under Medicare Part D.

B. Provide authority for the secretary to require Medicare Advantage carriers to offer one fully integrated plan in each service area in which they offer coverage. States could also request that the secretary exercise this authority as part of state-based integration efforts. This requirement is necessary to ensure an integrated coverage option is available in service areas that otherwise might not have a plan offering.

V. Improving Beneficiary Experience

To ensure beneficiaries have a seamless experience in integrated care models,
Congress should:

A. Direct the secretary of HHS to require collaboration between CMS, the Administration for Community Living, and states to implement model standards for outreach and education, and increase funding to the State Health Insurance Assistance Program to expand and improve information and counseling available for dual eligible individuals.

B. Provide resources and technical assistance to states for consumer, provider, and plan engagement and education, and encourage states to prioritize partnerships with community-based organizations and local governments.

C. Direct the secretary to improve and expand training for insurance brokers to include a training module on fully integrated plans.

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