On August 1, 2024, I will have a blog on what is happening with Special Needs Plans (SNPs) and Medicare-Medicaid integration policy. Coincidentally, the Kaiser Family Foundation (KFF) issued a comprehensive analysis on the status of dual eligible healthcare. As such I decided to publish this short bonus blog today as a good primer for some of the issues we will be talking about in the SNP blog tomorrow.
The KFF analysis of dual eligible care in Medicare and Medicaid is quite exhaustive. For those not as familiar with KFF, it is the premier healthcare policy think tank in America. I strongly recommend you review the whole briefer. I have posted the briefer link at the end of this blog. I also posted below what I think is one of the most relevant graphics in the briefer as well. I also posted a separate 2023 KFF briefer on characteristics of dual eligibles as well.
What are dual eligibles?
Dual eligibles are individuals who qualify and enroll in both the Medicare and Medicaid programs. A dual eligible would have primary coverage in Medicare due to age (65 or older) or being classified as disabled (under 65). The dual would be eligible for Medicaid as secondary coverage principally due to low income.
You can qualify as a partial or full dual in the Medicaid program. Depending on income, Medicaid will cover Medicare premiums only or Medicare premiums and cost-sharing. In addition, depending on income, a dual may receive full Medicaid benefits and services (those services not covered by Medicare). It is also important to remember that dual eligibles often have access to Medicaid chronic long-term care (LTC) benefits. Medicaid is primary for chronic LTC. Remember that nursing home and similar care is covered by Medicare for short-term stays and by Medicaid for chronic or long-term stays.
The KFF findings
Key findings by KFF on the status of dual eligible healthcare in the United States:
- About 94% of full-benefit dual eligibles received their Medicare and Medicaid benefits through separate Medicare and Medicaid plans or programs.
- 28% of duals were in traditional Medicare and Medicaid fee-for-service (FFS).
- 24% were in Medicare Advantage (MA) and Medicaid managed care.
- 24% were in traditional Medicare and Medicaid managed care.
- 19% in MA and Medicaid fee-for-service.
- Just 6% are what would be defined as truly integrated care. KFF says that would be the more-recent Medicare-Medicaid Plan (MMP) pilots and the decades-old Program of All-Inclusive Care for the Elderly (PACE) programs (a great deal of focus here is on LTC). These are truly single plans funded by both government programs and covering all care (always LTC needs for PACE and LTC for MMPs in some states).
How states approach dual eligible care can be very different:
- In 18 states and D.C., more than half of all duals were in traditional Medicare and Medicaid fee-for-service.
- In 4 states, more than half of all duals were in MA and Medicaid managed care.
About 28% of duals received their Medicare benefits through a MA Dual Eligible Special Needs Plan (D-SNP). How integrated the Medicaid benefit is with the D-SNP can vary and generally depends on how sophisticated healthcare policy is in a state. Minimally, federal law calls for a “coordinated D-SNP” to rather lightly coordinate care with a Medicaid program or managed care plan.
More progressive states require tighter “integrated SNPs,” which go quite far down the road or close to full integration. These are either Fully Integrated Dual Eligible (FIDE) Plans or Highly Integrated Dual Eligible (HIDE) plans. These FIDEs and HIDEs have small enrollment now but are beginning to emerge and grow due to regulatory efforts of the Centers for Medicare and Medicaid Services (CMS) and Medicaid agencies in some states. They admittedly do not go all the way of the MMPs (which are being phased out by 2026 in favor of FIDEs and HIDEs) or the PACE programs. This is so because services are not provided by a single plan or entity, not all services needed by an enrollee are furnished, or there are separate contracts with Medicare and Medicaid. For a description of FIDEs and HIDEs, go to the bottom of the blog.
Conclusion
The message here is that healthcare for dual eligibles is extremely fragmented. Almost 30% of duals are not in managed care plans at all. Over 40% of duals are in either Medicare or Medicaid managed care, but in a FFS program for the rest of their care. Almost 25% are in managed care plans for both of the programs, but they are not truly integrated plans. This is a big problem as dual eligibles are medically complex and usually have major social determinant barriers. As such, they consume a disproportionate share of healthcare. They are 17% of Medicare and 14% of Medicaid enrollment, but consume 33% of traditional Medicare and 32% of Medicaid spending.
In tomorrow’s blog I will discuss how CMS is working with agencies to improve the integration of the Medicare and Medicaid programs. As KFF notes, too, there are several proposals in Congress that favor even tighter integration of the two programs, including having all dual eligibles enroll in a single plan or a brand new government program. Other proposals would increase funding to help duals navigate the systems.
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FIDEs and HIDEs described
FIDE — A Fully Integrated Dual Eligible (FIDE) SNP plan provides Medicare and essentially all Medicaid covered services through a single managed care organization. The same organization that offers the FIDE SNP must also offer any Medicaid benefits or services through a Medicaid managed care organization contract. Contracting remains separate for Medicare and Medicaid. Some services still may be provided by the Medicaid FFS program or by a different Medicaid managed care plan (e.g., behavioral health could be carved out by the state Medicaid agency). The FIDE SNP must also meet all the requirements of a coordinated SNP.
In 2025, FIDE SNPs may only enroll full-benefit dual-eligible individuals if they are enrolled in both the FIDE SNP and the Medicaid plan sponsored by the same organization. Further, long-term services and supports and all Medicaid benefits must be covered. FIDE-SNPs that have exclusively aligned enrollment (EAE) between Medicare and Medicaid are called “Applicable Integrated Plans” (AIPs). EAE is a requirement as of 2025 as well.
HIDE — A Highly Integrated Dual Eligible (HIDE) SNP plan provides Medicare and most Medicaid covered services through a single managed care organization or have Medicaid services provided by a Medicaid managed care plan operating in the same counties as the D-SNP (controlled by the same Medicare plan sponsor). HIDE SNPs include coverage of long-term services and supports or behavioral health or both. The HIDE SNP must also meet all the requirements of a coordinated SNP. HIDEs can also have EAE but are not required to be aligned.
KFF briefers
https://www.kff.org/medicare/issue-brief/a-profile-of-medicare-medicaid-enrollees-dual-eligibles/
#medicare #medicaid #dualeligibles #medicareadvantage #medicaid #managedcare #specialneedsplans #snps
— Marc S. Ryan
