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Summary:
This report discusses efforts to improve the delivery of health and long-term care services for individuals who are dually enrolled in Medicaid and Medicare (i.e., dual eligibles), which generally includes the elderly and some individuals with disabilities. Dual eligibles are more likely than other Medicare beneficiaries to be in fair or poor health, cognitively and/or functionally impaired, and have more chronic ailments and conditions. The Medicaid and Medicare programs that provide services to dual eligibles are administered by different units of government, guided by different laws and regulations, and cover a different set of services for these individuals. These differences can lead to fragmentation and inefficiencies. Some federal and state policymakers have tried to address these challenges and develop a coordinated and/or integrated approach to delivering Medicare and Medicaid services through managed care. The Program of All-inclusive Care for the Elderly (PACE), as well as state programs in Arizona, Massachusetts, Minnesota, New York, Texas, and Wisconsin, are examples of the types of managed care programs discussed in this report. Recently, the Medicare Modernization Act (P.L. 107-193) established the Medicare Special Needs Plan (SNP) option, which was intended to improve care coordination and service delivery for certain groups of Medicare beneficiaries. Under the SNP option, Medicare managed care plans are allowed to limit enrollment to certain types of beneficiaries such as dual eligibles. SNP plans may choose to better coordinate the care of dual eligibles by contracting with the state Medicaid agency to also provide Medicaid services, but SNP plans are not required to do so. It is too soon to tell the extent to which the new SNP option will actually increase participation in integrated Medicare/Medicaid managed care plans. There are a variety of challenges in developing, enacting, and implementing integrated Medicare and Medicaid programs. The specific circumstances will vary by state, but some of the challenges have included reconciling conflicting operational requirements between Medicaid and Medicare, ensuring sufficient experience of managed care plans with the needs of dual eligibles, and addressing provider and beneficiary resistance to managed care. These and other challenges are discussed in this report. Finally, this report describes policy considerations and legislation that have been introduced in this area during the last several sessions of Congress. This report will be updated to reflect significant policy or programmatic changes at the national level.
