Individuals dually eligible for Medicare and Medicaid are among the highest-need populations in either program. States integrating care for this high-need population must ensure that individuals’ health and social service support needs are addressed promptly. Stratifying Medicare-Medicaid enrollees by their level of need may help states and health plans in better prioritizing and promptly addressing care management needs to ensure high-quality, timely care.
This brief, made possible through support from The Commonwealth Fund and The SCAN Foundation, describes how three states — California, Ohio, and Virginia — are requiring integrated health plans to stratify Medicare-Medicaid enrollees by their level of need within new capitated financial alignment demonstrations. It details each state’s stratification process, including the data used, risk groups, and assessment time frames. This information can help guide states implementing financial alignment demonstrations, as well as states and health plans integrating care through Dual Eligible Special Needs Plans or managed long-term services and supports programs.