For the nearly 13 million people in the U.S. who are eligible for both Medicare and Medicaid, navigating complex, uncoordinated care and services can be frustrating and confusing. Innovator states across the U.S. are stepping up to meet this pressing challenge. Increasingly, states are turning to models that are based on dual-eligible special needs plans (D-SNPs) as a strategy for integrating Medicare and Medicaid services.

D-SNPs are in almost every state and therefore states operating a range of Medicaid delivery systems can use their contracting authority with D-SNPs to advance Medicare integration with their Medicaid programs. For example, some states like Nevada do not enroll dually eligible individuals in Medicaid managed care, yet are in the early stages of implementing a D-SNP-based integrated care program for their dual-eligible population. Other states, such as Washington, carve out some services — like long-term services and supports — from their Medicaid managed care programs, but are still working to align D-SNPs with their Medicaid delivery systems. Following are examples from Nevada and Washington State’s recent efforts that may inform how other states advance integrated care using D-SNPs.

Nevada: Strengthening State Oversight and Enhancing D-SNP Integration

Compared to other states, Nevada has relatively little experience serving their dually eligible population through managed care arrangements. While the state does have a comprehensive Medicaid managed care program, it does not mandate enrollment for dually eligible individuals. It is also relatively new to D-SNP contracting. Nonetheless, Nevada’s Department of Health and Human Services is building a foundation for its D-SNP-based program through activities that include:

  • Conducting an in-depth assessment of the state’s current landscape: Nevada is analyzing the health status and service utilization patterns of its dually eligible population and assessing the state’s contracts with D-SNPs and its procurement process to identify opportunities to improve care coordination for dual-eligible individuals and enhance beneficiary experience.
  • Implementing oversight and contracting strategies: Nevada will use results from the landscape assessment and analyses to inform the development and implementation of additional D-SNP contract care coordination standards. The state will also develop quality metrics, reporting templates, and other mechanisms to support its oversight efforts to ensure D-SNP compliance with contract requirements.

These activities will help Nevada improve dually eligible individuals’ access to and experience of care, as well as promote better care coordination and transitions of care. Whether or not Nevada mandates Medicaid managed care for dual-eligible individuals as a long-term goal, it will have taken important steps toward Medicare-Medicaid integration.

Washington State: Improving Access to Coordinated, Integrated Care for Dual-Eligible Individuals

Washington State is also developing approaches to better coordinate care and improve health outcomes among its dual-eligible population enrolled in D-SNPs; however, the state has more experience serving its dual-eligible population through managed care. Washington enrolls dual-eligible individuals in Medicaid managed care plans that integrate medical and behavioral health services. The state also operates a successful managed fee-for-service model demonstration under the federal Financial Alignment Initiative, which enrolls high-risk, dual-eligible individuals with fee-for-service Medicare into Medicaid health homes. The state is applying lessons from its demonstration and other integration efforts to improve access to coordinated, integrated care for its dual-eligible populations who receive their Medicare coverage through D-SNPs. Activities include:

  • Implementing new D-SNP policies to enhance integration of care and service delivery for dual-eligible individuals. Washington added D-SNP contract requirements to align with state-specific care coordination requirements and incorporate the care coordination approaches used in its Medicaid health home program in the D-SNPs’ Model of Care. The state is also requiring that D-SNPs align provider networks and geographic coverage areas with the Medicaid managed care plans that integrate medical and behavioral health services for dual-eligible populations.
  • Enhancing state data analytics capacity for evaluating effectiveness of programs that serve dual-eligible individuals. Washington is enhancing its data analytic capacity to inform the design of policies to advance integration in its D-SNP program and evaluate their effectiveness. The state is seeking to address health disparities by using enrollment and service data to evaluate quality measures by race and ethnicity.
  • Determining consumer preferences and improving state communication about the value of integrated care. The state is surveying dual-eligible individuals about what they value in terms of care coordination and what would help them make informed decisions about health plan options. The state will use the survey findings to update communication methods and resources, including working with enrollment counselors to enhance their communication with dual-eligible individuals about the value of enrolling in D-SNPs.

Washington’s efforts will ensure that a larger portion of the state’s dually eligible population have access to an integrated Medicare-Medicaid model than is currently served by its Financial Alignment Initiative demonstration.

Opportunity to Increase Access to Fully Integrated D-SNP Models

Nevada and Washington are two examples of states that Arnold Ventures is supporting through the Advancing Medicare & Medicaid Integration initiative. Other states interested in improving care for their dual-eligible populations may face resource gaps that prevent them from moving forward. Advancing Medicare & Medicaid Integration is supporting states to help fill these resource gaps. The initiative aims to help states: (1) increase the availability of models that fully integrate Medicare and Medicaid, especially the fully integrated Dual Eligible Special Needs Plan (FIDE SNP) model; (2) increase enrollment in fully integrated models; and (3) improve the mix of services that dual-eligible individuals receive to achieve better care and outcomes. To learn more, visit the Advancing Medicare & Medicaid Integration website.

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