Individuals who are eligible for both Medicare and Medicaid often have complex health and social needs that are difficult to address in a fragmented, uncoordinated system of care. Like a growing number of states, Idaho wanted to serve dually eligible beneficiaries in a more integrated way. In 2014, the state launched a unique integrated care program, the Medicare Medicaid Coordinated Plan (MMCP). Although the state does not have a Medicaid managed long-term services and supports (MLTSS) program, this Dual Eligible Special Needs Plan (D-SNP)-based model provides all Medicare services and most Medicaid services, including long-term services and supports (LTSS). MMCP serves almost 30,000 dually eligible Idahoans and is a useful model for other states. With the support of the West Health Policy Center, the Center for Health Care Strategies looked at MMCP’s structure, highlighting the program’s early successes and lessons for other states.

Impetus for Pursuing an Integrated Care Program

In 2011, Idaho was among a group of states interested in pursuing a capitated model demonstration under the Centers for Medicare & Medicaid Services’ (CMS) Financial Alignment Initiative. However, with only one health plan in the state, it was unable to move forward. At about the same time, Idaho’s legislature mandated that its state Medicaid agency improve service delivery for dually eligible beneficiaries.

After considering its options, the Idaho Department of Health and Welfare (IDHW) decided to use a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) — a type of D-SNP — as a platform to provide a high level of Medicare and Medicaid integration across the state. A FIDE SNP combines all of the services offered by Medicare with a prescription drug plan and all or most of a state’s Medicaid services, including LTSS. Like all other D-SNPs, a FIDE SNP must have a contract with the state Medicaid agency.

Program Overview

Idaho launched MMCP with the goal of creating a program that offered the most seamless and best possible experience for beneficiaries, while also streamlining program administration. MMCP began with one health plan, Blue Cross of Idaho, and added a second plan, Molina, in select counties in 2018. The program is now available in 21 of the state’s 44 counties. Key program elements include:

• Contracting Strategy. Idaho requires any D-SNP that wants to operate in the state to participate in MMCP — it will not offer contracts to D-SNPs outside of this program. In addition, plans must meet thorough program requirements and pass a comprehensive Medicaid readiness review.
• Covered Benefits. MMCP covers Medicare Parts A, B, and D along with almost all Medicaid benefits, including behavioral health and LTSS, as well as supplemental services such as care coordinators, a nurse advice line, gym memberships, and vision coverage. Medical transportation, dental benefits, and developmental disability waiver services are covered, but carved out.
• Eligibility and Enrollment. All full-benefit dually eligible individuals are eligible for MMCP. Enrollment into MMCP is voluntary, and beneficiaries may enroll into either health plan in counties where both are offered.
• Care Coordination. MMCP care coordinators serve as the single point of contact for the enrollee and care team, provide patient education, and support with medication management and care setting transitions.

Key Accomplishments

After overcoming some initial stakeholder resistance, Idaho now has broad support for its integrated care model, and cites accomplishments in several areas, including:

• Rapid Knowledge Acquisition. Historically, Idaho has not used a managed care approach for its Medicaid program. In choosing to start with managed care for dually eligible individuals — a complex population that other states have wholly excluded or enrolled into the program after accumulating years of experience — Idaho had to rapidly acquire new knowledge and skills to develop and oversee contracts with managed care plans.
• Stakeholder Engagement. In addition to IDHW-led town hall meetings and provider-focused educational events, the IDHW bureau chief and health plan partners participated in informational meetings across the state. The robust event schedule and commitment to transparency boosted program credibility with consumers and providers. As a result, providers saw the program’s benefits and encouraged their patients to enroll. This was an important achievement because lack of provider buy-in has been a problem for coordinated care initiatives in several states. IDHW also had to help its own staff overcome hesitations about a managed care-based integration model. Following a transition period during which state and health plan care coordinators conducted in-home visits together, state staff now say that they miss working with their plan colleagues.
• Coordinated Outreach. IDHW spent significant time working with health plans to promote MMCP and develop co-branded messaging. IDHW worked diligently to ensure that both state and plan communication about the program was aligned and delivered consistently. Health plans paid for much of the program’s promotion, but the state remained the program’s public face during implementation. For example, state staff led in-person informational meetings, and state logos were featured on all print resources, which helped to build trust and lend credibility to the program.
• Foundation for MLTSS Program Development. IDHW used what it learned from MMCP to respond to the state legislative mandate to improve Medicaid service delivery. On November 1, 2018, IDHW launched Idaho Medicaid Plus, a mandatory Medicaid MLTSS program for dually eligible beneficiaries who are not enrolled in MMCP. After successful implementation in Twin Falls County with the MMCP plans — Blue Cross of Idaho and Molina — the program will expand to other counties in 2019. The state hopes that Idaho Medicaid Plus enrollees will eventually also enroll in MMCP so that they can receive their Medicare and Medicaid services from the same plan and benefit from improved coordination of care.

Challenges and Lessons

Idaho learned a great deal as it overcame challenges in launching MMCP, and its experiences can offer valuable lessons for other states.

Use Local Care Coordinators

IDHW requires care coordinators to live in the same communities as enrollees so that they understand the environment, service providers, and transportation system. Having Idaho-based program care coordinators has been an important element of building trust among enrollees.

Take-away:  To the extent possible, use locally based care coordinators who have a strong understanding of community resources and culture.

Understand the Medicare Landscape and Its Language

While IDHW staff are well-versed in Medicaid, they had to learn about Medicare. Its terminology, regulations, processes, and timelines were new to them. In the beginning, they relied on their plans for guidance. Now, they have gathered a wider circle of experts and resources to help them recognize and tackle “Medicare issues,” and have often turned to the Medicare-Medicaid Coordination Office at CMS and its technical assistance contractors to answer questions.

Take-away: Develop expertise or identify resources to help decipher the Medicare policy landscape.

Require State-Specific Orientation

Health plans that work across states may prefer to use standardized member materials across multiple markets, which may not capture differences in how states offer Medicaid services. With support from CMS, IDHW negotiated with plans to limit the use of standardized materials and required them to include language in beneficiary materials that is specific to Idaho and its Medicaid program.

Take-away: Ensure that participating health plans have a solid understanding of state Medicaid program elements and policies, and communicate these accurately in their materials.

Expect Data Needs to Evolve

Identifying and collecting meaningful and reliable data for performance metrics is challenging. Due to delays in receiving health plan encounter data, IDHW changed its focused in initial years from tracking program outcomes to monitoring enrollee experience and operational data, such as anecdotal reports of enrollee successes and plan disenrollment rates. Importantly, IDHW found that it needed new data elements to support day-to-day operations and is developing a method to track plan-level appeals data in real-time.

Take-away:  Initial data collection may begin with structural and process measures to help monitor day-to-day operations, with outcome measures and higher-level oversight elements added later.

Idaho’s MMCP: A First-of-Its-Kind Example

CMS’ new proposed rules will likely push states with D-SNPs to require a greater degree of Medicare-Medicaid integration. One way for D-SNPs to meet this higher standard is to become FIDE SNPs, contracting with states to provide LTSS and/or behavioral health benefits. As the first state to develop a FIDE-SNP platform without a Medicaid MLTSS program foundation, Idaho is an example to others of a new way to provide integrated care to dually eligible populations.