The document summarizes Illinois' Medicare-Medicaid Alignment Initiative to integrate care and financing for dual eligible beneficiaries (9 million Americans enrolled in both Medicare and Medicaid). It aims to improve quality of care while lowering costs by 1-5% annually through care coordination and capitated managed care plans. Key aspects include voluntary enrollment of 135,825 beneficiaries in capitated financial models, unified processes, and testing through the Center for Medicare and Medicaid Innovation's financial alignment demonstrations in six states.
2. Medicare
Provides health insurance
to older adults and certain
people with disabilities
Federal program funded by
two trust funds
Covers acute care services
Does not cover long term
services and supports
(LTSS)
Medicaid
Provides coverage to
people with low-incomes
Joint federal and state
program funded by both
Covers both acute and long
term services and supports
(LTSS)
Medicare and Medicaid Programs
Differ in Funding and Scope of
Services
4. Dual Eligible Beneficiaries Have
Complex Health and LTSS Needs
70.10%
9.20%
14.90%
4.70% 1.10%
US Medicaid Expenditures
on Duals $120.5 Billion
Age 65+
5.9
million
Age <65
3.4
million
Total
Dual
Eligibles:
9 million
US Medicaid Duals
Population
5. Dual Eligible Beneficiaries
Disproportionately Impact Medicaid and
Medicare Spending
US Medicaid Enrollment
Children
28.8 million
49.5%
Adults
14.6 million
25.2%
Other Aged
& Disabled
5.8 million
10%
Dual Eligibles
9 million
15.3%
US Medicaid
Spending
Non-
Duals
61%
Duals
39%
6. Affordable Care Act Created Two Offices
to Address Care and Cost Issues for
Duals
US Department of
Health and Human
Services (HHS)
Centers for Medicare and
Medicaid Services (CMS)
Coordination
Office
Innovation
Center
8. The Center for Medicare and
Medicaid Innovation
The Innovation Center has demonstration
authority to…
• Testing new payment and service delivery models
that fully integrate care for Dual Eligible
Beneficiaries
• Evaluate results of demonstrations and advancing
best practices
• Engaging a broad range of stakeholders to
develop additional demonstrations for testing
9. Financial Alignment and Integrated
Care Demonstrations Are
Beginning
• Six states approved
(June 2013)
• 1 million
beneficiaries
nationwide
• MA focusing on non-
elderly disabled
• WA targeting high-
cost/high-risk
beneficiaries
• CA, IL, OH and VA
focusing on elderly
and disabled
communities
10. Illinois Medicare-Medicaid Alignment
Initiative - Design
• 135,825 beneficiaries
anticipated to participate
• Capitated financial model
• Initiative will last three years
• Voluntaryenrollment beginning
January 2014 (for 6 months)*
• Benefits will include nearly all
Medicare and Medicaid
services
• Unified administration
process
• Improve care coordination
• Integrate financing
11. Illinois Medicare- Medicaid Alignment
Initiative - Goals
• Provide savings
– 1% in first year, 3% in second year; and 5% in
third year
– Managed Care with capitated payment
– Increased care coordination
– Use of HCBS over institutional care
• Improve care
– Decreased emergency room visits
– Reduced hospitalizations
12. Illinois Medicare-Medicaid Alignment
Initiative – Questions
CMS
Illinois Dept.
of
Healthcare
and Family
Services
Managed
Care
Organization
• Specifics to be spelled
out in three-way contracts
between the entities:
– How will beneficiaries be
notified?
– How will plans and
providers meet the needs
of beneficiaries?
– What counseling
assistance will be provided
and by whom?
– What will the sources of
program savings be?
– What grievance and
appeals process will be
available?
13. Prepared by:
Bruce J. Lederman, JD
b: chicagonow.com/aging-in-
chicago/
t: @aginginchicago
Notas do Editor
Medicare-Medicaid Alignment Initiative PlansThank you for joining this brief overview of the Illinois Medicare-Medicaid Alignment Initiative. My name is Bruce Lederman and in this presentation I will review how the health care delivery system for dual eligible beneficiaries in Illinois is being redesigned to become one that is more person-centered with a focus on improved health outcomes while reducing costs growth. With the voluntary enrollment period beginning on January 1, 2014, I believe that you will be hearing more about this demonstration in the coming months. So let’s get started.
Medicare is the federal program that provides health insurance to older adults and certain people with disabilities. It is paid for by two Federal trust funds and covers physician visits, medication costs and hospital and post-acute services. It does not provide for long term services and supports (or LTSS as it is called).Medicaid is a joint federal and state program and it provides health care coverage to people with low incomes who also fall into certain categories such as children, pregnant women, older adults or the disabled. It also pays for long term services and supports. Because Medicaid is funded by a combination of federal and state dollars, eligibility requirements and Medicaid benefits vary among the 50 states.
There are a number of individuals who are beneficiaries of both programs. They are technically referred to a Dual Eligible Beneficiaries and often the shorthand “Duals” is used. There are a variety of reasons why someone would qualify for both programs, but in general either an individual was qualified for Medicaid and became additionally eligible for Medicare once they reached age 65 or at some point after reaching age 65, the individual became eligible for the Medicaid enrollment due to change in their financial resources.Information from Kaiser Health News 2012 Information
The majority of the 9 million Duals are over the age of 65 and are among the sickest individuals covered by either the Medicare or Medicaid programs. These are people with complex health and long term care needs who have their acute medical care expenses paid for by Medicare, while Medicaid covers their premiums and other expenses and for those fully eligible duals who meet asset and income thresholds their long term services and supports needs are also paid for by Medicaid.In it’s annual report to Congress the Medicare Advisory Payment Commission noted that because the Medicare and Medicaid programs have different regulatory and reimbursement schemes, current coverage and payment policies for duals incentivizes cost shifting and hinders efforts to improve quality and coordination of care. In 2010 there were approximately 338,000 Duals in Illinois and Illinois Medicaid expenditures for this population mirrors the national Medicaid data shown on the slide. Source, Urban Institute 2010
On the national level Duals comprise 15% of those enrolled Medicaid enrollment, but are responsible for 39% of spending for that program. Similarly this disparity also in the Medicare program where Duals only constitute 16% of Medicare enrollment, but are responsible for 25% of Medicare spending. Half of the Medicare Duals are in fair or poor health, and that is more than twice the rate of other Medicare beneficiaries.As a group, Duals are more likely to have mental health needs, more likely to have less than a high school education and are more than twice as likely to be a member of a minority population. Here is something to consider, Duals are seven times more likely to be a long term care resident than non Dual Medicare beneficiaries.
So in response, the legislation creating the ACA included the creation of two new federal offices to explore how to improve access and delivery to care and control growth in spending: the Federal Coordinated Health Care Office (Coordination or Duals Office) and the Center for Medicare and Medicaid Innovation (also known as the Innovation Center). with Medicare and Medicaid expenditures as % of GDP expected to double in the next 25 years,
The coordination office seeks to improve the alignment of care between the two programs to improve quality and lower the cost of care to dually eligible beneficiaries by funding state Demonstrations.It is projected that in the next 25 years, Medicare and Medicaid expenditures will double as a percentage of GDP. The hope is that the demonstrations funded by the Coordination office, will produce interventions to impact this trend.
While the folks at the Coordination Office are keeping busy aligning the Medicare and Medicaid programs, the Innovation Center is busy developing new payment and service delivery models and is currently funding 28 states to implement strategies for payment reform.
One of the Innovation Center’s new payment and service delivery models that fully integrate care for Dual Eligible Beneficiaries is the, cleverly named, financial alignment and integrated demonstration. Six states are approved and this demonstration will last for 3 years and enrollment will eventually grow to two million nationally. CA, IL, OH, VA and MA will test a capitated payment model of reimbursement and WA will test a FFS model.In Illinois there are 1.9 million Medicare beneficiaries (2010) and 338,582 Duals (or 19% of all Medicare beneficiaries).In Illinois there were 2.8 million enrolled in Medicaid (2010) Duals are 25% of the Medicaid Spending
Voluntary enrollment in the Illinois initiative is scheduled to begin on January 1 and some consider this an ambitious goal and have suggested that Illinois should follow the recent example of California, which decided to delay enrollment in its own Alignment initiative for four months.The goals of this demonstration mirror those of others around the country: One To unify the administration process so dual will seamlessly be able to enroll and disenroll in both programs with a single appeal process.Two. To improve care coordination between the two programs to avoid unmet needs and underutilization of community based services and Three – integrate financing to facilitate care coordination.
There are many questions as to the source of these savings…Illinois currently has one of the highest rates of potentially avoidable hospital admissions nationally and;Illinois has one of the highest proportions of spending on institutional services compared to HCBS.
How much money can really be saved?Will managed care organizations be able to fully coordinate the complex needs of this challenging population?Will community-based organizations be able to participate fully in their traditional role as care providers?There are among the many questions that community-based providers of LTSS and elder advocates have for the Illinois Department of Healthcare and Family Services.
