FEBRUARY 24, 2022 Laura M. Keohane Ann Hwang
Editor’s
Note
This article inaugurates the Health Affairs
Forefront major series, Medicare and Medicaid Integration.
The series will feature analysis, proposals, and commentary that will inform
policies on the state and federal levels to advance integrated care for those
dually eligible for Medicare and Medicaid.
This article is written by Laura Keohane and
Ann Hwang, who will author several series articles in response to the latest
developments in policy and research affecting the dual eligible population.
Other authors will contribute to the series as well.
The series is produced with the support
of Arnold Ventures. Included articles are
reviewed and edited by Health Affairs Forefront staff; the
opinions expressed are those of the authors.
The series will run through August 30,
2022; submissions are accepted on a
rolling basis.
On January 12, 2022, the Centers for Medicare
and Medicaid Services (CMS) released the Contract Year 2023 Medicare
Advantage and Part D proposed rule. These rules contain a number of
provisions that will affect coverage for the approximately 4 million
dual-eligible beneficiaries who receive their Medicare services through
dual-eligible special needs plans (D-SNPs) or Medicare-Medicaid Plans (MMPs).
This article focuses on provisions of importance to the dual-eligible
population and efforts to foster better integration of Medicare and Medicaid
benefits through managed care plans.
Addressing the lack of coordination between
Medicare and Medicaid benefits is expected to improve quality of care for
dual-eligible beneficiaries, who struggle to navigate between these two
programs, and reduce overall spending on services. The limited evidence available
about managed care integration efforts is not conclusive about whether these
initiatives meet those aims. These proposed regulations signal CMS' continued
commitment to these strategies but raise questions about whether states will
opt to engage in the substantial effort required to oversee integrated managed
care plans.
Dual-Eligible Special
Needs Plans (D-SNPs) As The Path Forward For Medicare-Medicaid Plans
Over the past decade, two large-scale
strategies for aligning Medicare and Medicaid benefits through managed care
plans for dual-eligible beneficiaries have emerged. The first approach,
launched as part of the Financial Alignment Initiative
(FAI) demonstration project authorized in the Affordable Care
Act, created new Medicare-Medicaid Plans (MMPs) that are jointly funded by both
programs to provide combined benefits. These plans have substantial oversight
by the federal government and participating states.
The second strategy took an existing type of
Medicare Advantage plan that exclusively enroll dual-eligible
beneficiaries—dual-eligible special needs plans (D-SNPs)—and gradually expanded
the degree of Medicaid coordination available in these Medicare plans. D-SNPs,
which enroll approximately 3.3 million
dual-eligible beneficiaries, can range from having minimal to
extensive Medicaid benefit integration. Under the most integrated D-SNP
options, state Medicaid programs contract with insurers that offer both
Medicaid managed care benefits and Medicare D-SNPs, thereby giving
dual-eligible beneficiaries the opportunity to enroll in two separate plans
operated by the same insurer.
The FAI demonstration concludes in December
2022 in California and is still a demonstration project for the remaining
states, raising questions about future coverage for the 400,000 MMP members.
CMS indicates in these new proposed regulations that it views conversion to
integrated D-SNPs as the future off-ramp for MMPs, and the proposed regulations
take several steps to implement MMP features in D-SNP plans. MMPs have more
oversight and integration requirements than D-SNPs but also have more
flexibility in how some benefits are administered than D-SNPs, since MMPs
operate as part of a demonstration project. The regulations bridge some of
those differences between D-SNPs and MMPs and nudge D-SNPs closer to the more
integrated model established in MMPs.
What’s Not In The
Regulations: Incentives For States To Expand Or Launch Integrated Benefits
Before discussing the details of what the
regulations cover, let’s start with an important spoiler alert about what the
regulations do not include: meaningful incentives for more states to offer
integrated benefits. When the FAI demonstration launched, many states expressed
interest, but only 13 participated. Even though more states have adopted integrated
D-SNPs than MMPs, most states still have no large-scale participation in
integrated benefits among dual-eligible beneficiaries. Like the rest of the
Medicare population, Medicare managed care participation
is common among dual-eligible beneficiaries: Forty percent of
dual-eligible beneficiaries with full Medicaid are enrolled in Medicare
Advantage. However, only 55 percent of these beneficiaries are in a D-SNP, and
MedPAC estimated that only 18 percent of
D-SNP members have significant integration with Medicaid
benefits. According to the latest Medicaid scorecard from
CMS, only 18 states have more than 10 percent of dual-eligible beneficiaries in
an integrated care program. Most states would have to take significant action
to pursue a D-SNP integration strategy since this approach relies on alignment
with Medicaid managed care, and only half of states offer
long term services and supports through Medicaid managed care plans.
State Medicaid programs have limited bandwidth
to oversee Medicare plans for dual-eligible beneficiaries, and it is difficult
to argue states should prioritize this role when there is not a clear funding
source for this work—either to launch new programs or to support ongoing work.
The proposed regulations do not establish a mechanism for states to financially
benefit from Medicare-side savings in D-SNPs, a fundamental issue with that
model that would most likely require legislation to address. The FAI
demonstration did establish a shared savings mechanism between states and
Medicare for MMPs, which meant states could still financially benefit even if
the savings was achieved by reducing the use of Medicare-covered services like
hospitalizations. The FAI also included demonstrations that did not require
managed care, and there has not yet been a successor program for these
approaches after the FAI ends.
What’s In The
Regulations: Measures To Improve Experiences For Dual-Eligible Beneficiaries In
Medicare Advantage
The most straightforward proposed changes
require two basic improvements for all D-SNPs regardless of their level of
integration with Medicaid. Based on successful consumer advisory panels
implemented in MMPs, all D-SNPs will now be required to convene an advisory
group of dual-eligible plan members to weigh in on issues like benefit design,
members’ experiences, and plan communications. As part of health risk
assessments that D-SNPs are already required to administer, all plans will also
have to start screening for housing and food instability with a consistent set
of questions. The screening requirement complements related efforts by CMS to
consider incorporating social risk factors into performance measurement, described
in the recently released Advance Notice of Methodological
Changes for Calendar Year 2023 Medicare Advantage Capitation Rates and Part C
and Part D Payment Policies.
Another noteworthy provision in the proposed
regulations seeks to address potentially confusing or misleading activities of
third-party marketing organizations across the entire Medicare Advantage
program, a measure that may be particularly valuable to dual-eligible
beneficiaries who currently face an overwhelming amount of choice and
marketing. CMS points out that
dual-eligible individuals in Los Angeles have over eighty-five choices for
Medicare managed care coverage for 2022, including seventy Medicare Advantage
plans, nine D-SNPs, two Fully Integrated D-SNPs (FIDEs), and five MMPs.
Improving the quality of information available about plan selection may help
dual-eligible beneficiaries decide between traditional Medicare and different
types of Medicare Advantage coverage to find an option that fits their needs.
Raising The Bar For
Integration In Integrated D-SNPs
D-SNPs can range from offering a minimal level
of integration with Medicaid benefits to offering coverage that is closely
aligned with Medicaid coverage. CMS designates D-SNPs that meet certain
requirements for integration as Fully Integrated or Highly Integrated D-SNPs
(FIDEs and HIDEs). These plans are operated by insurers that also provide
Medicaid managed care benefits. Such plans are already required to take certain
integration steps that are not available in all D-SNPs, like offering
beneficiaries with aligned coverage a unified appeals process for Medicare and
Medicaid benefits.
The proposed regulations require a higher
degree of integration with Medicaid benefits from these plans to retain their
designation as FIDEs and HIDEs. To address concerns that a dual-eligible
beneficiary may be enrolled in a FIDE and still have Medicaid coverage from a
separate insurer, the proposed regulations would require FIDEs to only enroll
dual-eligible beneficiaries with the same insurer for Medicaid managed care and
to provide Medicare and Medicaid plan offerings in the same geographic service
areas. The proposed regulations also require FIDEs to provide Medicaid
capitated coverage of cost-sharing instead of arrangements where state Medicaid
programs process cost-sharing claims separately. CMS clarifies and introduces
new limits on what type of LTSS, behavioral health, and other Medicaid benefits
can be carved out of Medicaid managed care coverage for insurers operating
FIDEs and HIDEs. CMS notes that many FIDEs and HIDEs already meet most of the
proposed standards.
Options For States To
Exercise Additional Oversight Of D-SNPs
CMS also proposes to give states new, optional
oversight requirements for D-SNPs. These options provide a way for states with
existing MMPs to transition those plans to FIDE or HIDE D-SNPs while retaining
some of the oversight authority that is unique to the MMP program. One
challenge with monitoring D-SNPs is that a D-SNP is often operated as part of a
larger Medicare Advantage contract that includes multiple plans, including
non-specialized plans that are open to all Medicare beneficiaries, not just
dual-eligible beneficiaries. CMS would allow states to require that D-SNPs be
operated as part of Medicare Advantage contracts that only contain D-SNPs and
exclude other types of plans. Since many Medicare Advantage performance
measures are reported at the contract level, this step would provide greater
transparency about how D-SNPs perform on indicators like medical loss ratios and Medicare Advantage star ratings.
This power would also facilitate the creation of integrated Medicare and
Medicaid member materials for information like what providers are in network,
another measure that was successfully piloted in the MMPs.
Reducing Medicaid
Spending By Recalculating How Maximum Out-Of-Pocket Limits Are Applied
The measure with the most significant
financial consequences for D-SNPs and states is a proposal that affects all
Medicare Advantage plans, D-SNP or otherwise. Since 2011, Medicare Advantage
plan coverage must include an out-of-pocket (OOP) limit that applies to
services covered under Part A and B benefits. Many dual-eligible beneficiaries
qualify for Medicaid coverage of Medicare cost-sharing. Under current
regulations, a plan can choose to only count cost-sharing paid directly by the
beneficiary toward the OOP limit, not cost-sharing paid by Medicaid. Even if a
state Medicaid program has paid enough cost-sharing to reach the OOP limit for
a dual-eligible member, a Medicare Advantage plan can continue to charge
cost-sharing. In contrast, if a member without Medicaid paid enough
cost-sharing to reach the OOP limit, a Medicare Advantage plan would cover all
subsequent services in full without any cost-sharing. Because of this
difference in how cost-sharing is counted towards the OOP limit, a Medicare
Advantage plan may offer more comprehensive coverage to beneficiaries without
Medicaid who reach the OOP limit than dual-eligible beneficiaries with the same
spending levels.
The proposed regulation requires plans to
calculate whether a beneficiary has reached the OOP limit in the same way for
Medicare-only and dual-eligible beneficiaries: based on the cost-sharing
requirements of the plan, not on whether those amounts are paid directly by beneficiaries
or not. This measure will be cost-saving for state Medicaid programs,
especially for states that opt to pay full Medicare cost-sharing amounts to
providers. Providers could also see modest increases in payments for high-cost
dual-eligible Medicare Advantage members since the plan will be responsible for
payment in full for members who exceed the OOP limit; state Medicaid programs
can opt to not pay providers the full Medicare cost-sharing amount for
dual-eligible beneficiaries under “lesser-of” policies that cap cost-sharing
payments at Medicaid payment rates, which are often lower than Medicare. Since
D-SNPs exclusively enroll dual-eligible beneficiaries, this change will have
the largest financial impact on D-SNPs and could reduce the amount of funds
that D-SNPs
have available to spend on supplemental benefits like dental coverage or
transportation support.
A Better Integrated Care
Model But Limited Reach
For dual-eligible beneficiaries who already
have integrated benefits through D-SNPs or MMPs, these proposed regulations
include several provisions designed to improve members’ experiences in D-SNPs
and to strengthen integration requirements for D-SNPs that have extensive
alignment with Medicaid managed care plans. These changes capture elements from
the MMP that CMS has found to be beneficial and lay the groundwork for the
conversion of MMPs to integrated D-SNPs. However, the regulations raise
important questions about whether states will have sufficient incentive to
advance integrated products, given limited bandwidth and the lack of financial
benefits for states. By raising the bar for integrated products, stricter
regulations create a risk that both states and plans may be less inclined to
enter this market.
Public comments on the proposed regulations
can be submitted until
March 7.
https://www.healthaffairs.org/do/10.1377/forefront.20220218.251565\
No comments:
Post a Comment