Individuals dually eligible for Medicare and Medicaid are among the most vulnerable, highest-need, and highest-cost beneficiaries in the US health care system. One of the most challenging aspects of providing care for this population is that responsibility for administration, oversight, and financing for their services is split between the federal and state governments. With the passage of the Patient Protection and Affordable Care Act (ACA), there are significant new opportunities to integrate these two programs and vastly improve service delivery and financing for duals.

This Profiles of State Innovation roadmap draws from interviews with seven states – Arizona, Hawaii, New Mexico, Oregon, Tennessee, Texas, and Vermont – as well as lessons from additional states to offer guideposts for improved integration of care for dual eligibles. The roadmap details three core decision points to help states determine what direction to choose for designing integrated programs for dual eligibles based on current state strengths and capacities. It also identifies key ACA provisions that support state efforts to enhance care for dual eligibles.

This roadmap is part of a series developed to help Medicaid stakeholders design more effective care delivery models for seniors and people with disabilities, particularly in light of new opportunities under ACA. The recommendations herein are proffered with the acknowledgement that our understanding is evolving and the expectation that the new Federal “Office of the Duals” will provide further guidance in the near term.

Profiles of State Innovation Series

This roadmap is part of CHCS’ Profiles of State Innovation series, made possible through The SCAN Foundation to help Medicaid programs develop high-quality, cost-effective, and consumer-focused approaches for delivering long-term supports and services.