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An Updated Policy Roadmap: Caring for Those with Complex Needs

Beginning in 2013, four of BPC’s health leaders—former Senate Majority Leaders Tom Daschle and Bill Frist, former Health and Human Services Secretary and Gov. Tommy Thompson, and former Congressional Budget Office Director Alice Rivlin—began working on bipartisan policy solutions to improve care and financing for those with complex health care needs. Since then, BPC has issued more than a dozen reports with recommendations addressing complex care, some of which have been enacted into law or incorporated into regulations or other agency guidance. For example, the Bipartisan Budget Act of 2018 included policies that BPC has long recommended, such as permanently authorizing dual-eligible special needs plans (D-SNPs); establishing new integration standards for D-SNPs; unifying grievances and appeals procedures for certain D-SNPs, and allowing Medicare Advantage plans to provide Special Supplemental Benefits for the Chronically Ill (SSBCI) that address social needs for select Medicare beneficiaries. Today, about 3 million dual-eligible beneficiaries are enrolled in D-SNPs, and the number of plans offering SSBCI stood at 947 (15.1%) in 2021.

Despite this progress, policymakers should take additional action if both equity in access to care and quality of service are to continue advancing in public
and private insurance programs. In Medicaid, the use of multiple home and community-based services (HCBS) waivers or a combination of waivers and state plan amendments (SPAs) creates an enormously complex system for states to manage and beneficiaries to navigate. Additionally, confusion surrounding Medicaid buy-in programs for working individuals with disabilities, as well as the lack of federal guidance, is a barrier to state adoption of those programs, which are often critical to allowing individuals with disabilities to live independently and work.

Because Medicare does not cover comprehensive long-term services and supports (LTSS), individuals with functional limitations who do not qualify for Medicaid must pay out-of-pocket for LTSS, often until they spend down their savings to qualify for Medicaid, and many also rely on unpaid caregivers to deliver LTSS. For those enrolled in Medicare fee-for-service, either by choice or because Medicare Advantage plans offering SSBCI are not available, policymakers could improve equity by making similar evidence-based, nonmedical benefits available to individuals with chronic conditions who are served in risk-based or care management models. Public- and private-sector reforms that address these and other challenges discussed in this report would help remove barriers to quality, person-centered care for individuals with complex health care needs.

This report draws on recommendations from 12 previous reports to lay out a roadmap of policy solutions that Congress and federal agencies should still consider. Some of the recommendations here are reflected in pending legislation, described in the Policy Landscape section below, although the outlook for those measures was uncertain at the time BPC drafted this report. To the extent that any of these recommendations become law, BPC hopes the Biden administration will work closely with states and stakeholders to implement the policies effectively and expeditiously.

This report presents the recommendations in two parts. Part I focuses on proposals that improve health and long-term services and supports for low-income individuals through the Medicaid program. Part II includes recommendations to provide support for middle- and higher-income individuals who may also face catastrophic long-term care costs, often causing them to exhaust their financial resources until they must rely on Medicaid. While Congress passed legislation to expand Medicaid home and community-based services (HCBS) through enhanced funding for states in the American Rescue Plan Act, we hope this report will be useful to policymakers as they seek additional ways to improve care for those with complex needs.

To keep this report at a manageable length, we have included basic background information and policy rationales. Where we believe additional information would be useful, we have provided links to previous reports.

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Recommendations Part I – Improving Medicaid Coverage for Those with Complex Needs

  • A. Simplifying and Streamlining Medicaid HCBS Authorities

    • Congress should establish a new, consolidated SPA, combining existing state plan options and waivers. Current enrollees should be grandfathered to prevent a disruption in services.
    • The Centers for Medicare & Medicaid Services (CMS) should clarify that under 1915(i) SPAs, states are permitted to phase in benefits, but they must provide coverage statewide when the SPA is fully implemented.
    • CMS should provide comprehensive technical assistance to states as they transition to the new, consolidated HCBS state plan authority.
    • Congress should direct the secretary of HHS to collect data and issue an annual report on disparities in access to HCBS and make recommendations to Congress to address inequities.
  • B. Integrating Medicare and Medicaid Services for Dual Eligible Beneficiaries

    1. Congress should establish a framework for integrating Medicare and Medicaid services for dual eligible individuals.

    • a. Congress should create a “full integration” standard of coverage and care for dual-eligible beneficiaries.
    • b. Congress should require the HHS secretary, in partnership with states, to provide access to fully integrated Medicare and Medicaid services for all dual eligible individuals, like the approach taken under the Financial Alignment Initiative (FAI) demonstration. The secretary would make integrated care available under a federal fallback program in states that decide not to integrate.
    • c. Congress should provide the Medicare-Medicaid Coordination Office with funding and regulatory authority to establish and oversee full integration in all programs serving dual eligible individuals, including integrated care models implemented by states and the federal fallback program.
    • d. Congress should provide 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, and beneficiary due process rights.
    • e. Congress should direct the HHS secretary to adopt best practices from the Financial Alignment Initiative demonstration and apply them to Fully Integrated Dual Eligible Special Needs Plans. The secretary should also convene a working group to identify best practices where they have yet to be identified.

    2. Congress should improve enrollment and eligibility.

    • a. Congress should limit enrollment in fully integrated models to full-benefit dual eligible individuals. The secretary of HHS should also consider limiting beneficiary enrollment to fully integrated Medicare Advantage (MA) plans, if such an approach does not limit access to supplemental benefits or adequate access to providers.
    • b. Congress should allow auto-enrollment in state-implemented or federal fallback integration models with a beneficiary opt-out available at any time in the case of Medicare-covered services.
    • c. Congress should permit and encourage states to implement 12-month, continuous Medicaid eligibility for dual eligible individuals; it should also encourage states to reduce administrative burdens on beneficiaries.

    3. Congress should provide incentives for state-administered integrated care programs.

    • a. Congress should define and develop full integration models for states that choose to integrate care.
    • b. Congress should provide financial and technical assistance to states,through HHS, to support state implementation of full integration in states that notify the secretary of their intention to integrate care. This support should include funding to plan, develop, and implement these models.
    • c. Congress should provide the secretary of HHS with authority to develop a guaranteed shared savings program for full integration models.

    4. Congress should establish a federal fallback program.

    • a. Congress should direct the HHS secretary to fully integrate Medicare and Medicaid services for full-benefit dual eligible individuals. The federal government should recoup payments for enrolled individuals that would have otherwise been made to the state, like the approach taken in Medicare Part D for prescription drugs.
    • b. Congress should permit state participation in all aspects of policy development for integration programs.
    • c. To ensure options for beneficiaries in all counties, Congress should direct the secretary of HHS to require MA plans to offer at least one fully integrated plan in each service area in which they offer coverage.

    5. Congress should improve the beneficiary experience.

    • a. Congress should direct the HHS secretary to require collaboration between CMS, the Administration for Community Living, and states to implement model standards for outreach and education. It should also increase funding to the State Health Insurance Assistance Program so it can expand and improve information and counseling for dual eligible individuals.
    • b. Congress should provide resources and technical assistance to states for consumer, provider, and plan engagement and education, and should encourage states to prioritize partnerships with community-based organizations and local governments.
    • c. The HHS secretary should use their authority to improve and expand training for insurance brokers by including a training module on fully integrated models.
  • C. Addressing Barriers to Medicaid Buy-In Programs for Workers with Disabilities

    1. The administration should issue an executive order that clarifies and simplifies the current Medicaid Buy-In programs for workers with disabilities.

    • a. The administration should direct CMS to issue agency guidance identifying the full range of authority available to states to design, improve, and expand Medicaid Buy-In (MBI) programs for workers with disabilities.
    • b. The administration should instruct CMS to change the name “Medicaid Buy-In” to “Medicaid for Workers with Disabilities.”

    2. HHS/CMS should issue regulations on Medicaid Buy-In programs.

    • a. HHS/CMS should issue a Notice of Proposed Rulemaking (NPRM) to give CMS the opportunity to address topics not addressed through informal guidance.

    3. Congress should consolidate Medicaid Buy-In authorities.

    • a. Congress should update, consolidate, and streamline existing authorities into a single state option.
    • b. Congress should reauthorize TWWIIA-funded Medicaid Infrastructure Grants and appropriate funding to help states develop programs and study best practices in other states that have successfully promoted MBI options.

Recommendations Part II – Options to Improve LTSS for Individuals Not Qualifying for Medicaid

  • A. Establishing an HCBS Buy-In Through Integrated Models of Care

    1. Congress should allow Medicare beneficiaries who are ineligible for Medicaid to purchase LTSS coverage through fully integrated care models, including improved FIDE-SNPs, PACE, or other models approved by the secretary of HHS.

  • B. Improving Chronic Care

    1. Congress should expand non-medical benefits in Medicare fee-for-service.

      • a. Congress should give the HHS secretary authority to identify and authorize coverage of and payment for evidence-based, non-medical benefits for patients with chronic conditions under the following conditions:
        • Peer-reviewed evidence demonstrates that the benefit improves or maintains health or function for a specific subset of patients with certain chronic conditions and/or functional limitations.
        • The CMS Office of the Actuary certifies that coverage of the defined benefit for the defined population results in no net increase in Medicare spending.
        • The chronic condition is being managed by an ACO, a comprehensive primary care model, through Chronic Care Management (CCM), or through other payment or delivery models that include a care management component.
      • b. In establishing eligibility for non-medical services, the HHS secretary will need to make coverage decisions based on both chronic conditions and functional status. To facilitate this, Congress should direct the secretary to develop a uniform functional assessment tool and define the conditions under which providers would perform the assessment.
      • c. Congress should direct the secretary to establish criteria for organizations that would be eligible to provide non-medical services identified by the secretary in traditional Medicaid fee-for-service (FFS). The secretary should also establish monitoring programs to minimize fraud, waste, and abuse.
      • d. For any new evidence-based benefits for the chronically ill, the HHS secretary should make available to Medicare providers a list of suppliers in the geographic area in which they provide services.
      • e. Congress should direct the secretary to examine potential modifications to the risk-adjustment model to ensure more accurate predictions of medical expenses for Medicare beneficiaries with functional limitations. The secretary should consider the appropriateness of developing a tool that can determine eligibility and assess risk.

    2. Congress should improve the chronic care management benefit.

    • a. Congress should eliminate the beneficiary co-pay for CCM services covered under Medicare for calendar years 2024, 2025, and 2026, because
      the benefit covers provider-to-provider communications outside an office visit and are not obvious to the beneficiary.
    • b. Congress should expand the list of qualified health providers who can bill for CCM services to include licensed clinical social workers working within the scope of practice in such a way as to maximize cost-effective care and minimize program costs.
    • c. Congress should direct the HHS secretary to eliminate beneficiary co-payments for advance-care planning for calendar years 2024, 2025, and 2026.

    3. The HHS secretary should improve the availability of non-medical health-related services and supports in the home and community.

    • a. The HHS secretary should direct CMS and the Administration for Community Living to develop a model contract that could be used to facilitate referrals, coordination, and reimbursement for non-medical, health-related services.
  • C. Creating a Caregiver Tax Credit

    1. Congress should establish a refundable tax credit to help caregivers with out-of-pocket costs for paid LTSS-related care.

  • D. Improving the Availability and Affordability of Private Long-Term Care Insurance

    1. Congress should standardize and simplify private long-term care insurance to achieve an appropriate balance between coverage and affordability, by making “retirement long-term care insurance” (LTCI) available.

    2. Congress should incentivize employers to offer retirement LTCI and to auto-enroll certain employees (age 45 and older with minimum retirement savings), with an opt-out similar to many employer-sponsored retirement savings accounts.

    3. Congress should permit early penalty-free withdrawal from retirement savings accounts to cover retirement LTCI premiums.

    4. Congress should ask the National Association of Insurance Commissioners (NAIC) to modify model laws and regulations to accommodate products that convert from life insurance to long-term care insurance.

  • E. Strengthen Public Education on Long-Term Care

    1. The Financial Literacy and Education Commission and partnering federal agencies should coordinate to strengthen educational resources on LTC and incorporate LTC planning into retirement education topics

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