State Medicaid agency staff are experts when it comes to Medicaid, but what happens when state goals expand to integrate Medicare and Medicaid? These two programs cover care and services for more than 12 million people nationally who are dually eligible for both programs, and many states are attempting to bring together Medicare and Medicaid to improve care. However, to align and better coordinate these programs, Medicaid staff need to understand Medicare policy, including how Medicare Advantage dual eligible special needs plans (D-SNPs) operate. So, what resources can states use to build Medicare knowledge and effectively develop integrated models?

To answer this question, the Center for Health Care Strategies (CHCS) spoke with Medicaid officials from two states — Indiana and Maine — that developed Medicare knowledge to successfully guide their planning of integrated models in managed and non-managed care environments. This blog post features insights from conversations with Andrew Bean, Deputy Director, and Steve Counsell, MD, Medical Director, Division of Aging, from the Indiana Family and Social Services Administration (FSSA). It delves into the experiences of Indiana’s Medicaid agency, highlighting what drove their need to build Medicare knowledge, their learning milestones, and the resources they used. The blog post also shares experiences in building Medicare knowledge from Olivia Alford, Director of Delivery System Reform in Maine’s Office of MaineCare Services, who recently participated in CHCS’ Medicare Academy, a multi-state learning opportunity that is helping states build practical Medicare knowledge.

Building Medicare Knowledge to Fully Integrate Care: Lessons from Indiana

This year Indiana is launching Pathways for Aging, a Medicaid managed long-term services and supports (MLTSS) program for individuals age 60 and over. By adding long-term services and supports (LTSS) to the benefits covered by the state’s Medicaid managed care plans, the D-SNPs affiliated with these plans can be designated as fully integrated dual eligible special needs plans (FIDE SNPs). FIDE SNPs are a type of Medicare Advantage plan that offer greater Medicare-Medicaid integration than coordination-only D‑SNPs by providing Medicare and Medicaid covered benefits to enrollees through one legal entity.

In 2019, Indiana was on the road to Medicaid LTSS reform, driven primarily by a need to rebalance the system toward more person-centered, community-based care. This work shined a light on the state’s dually eligible population, which until now, has been enrolled in traditional Medicaid and makes up 90 percent of Indiana’s nursing home residents. As a result, the state Medicaid director at the time fully endorsed and championed Medicare and Medicaid alignment as a key Medicaid LTSS reform strategy.

At the same time, the Centers for Medicare & Medicaid Services (CMS) issued requirements for D-SNPs around sharing information with states on high-risk D-SNP enrollees’ hospital and skilled nursing facility admissions. Adding this new requirement to Indiana’s state Medicaid agency contract (SMAC) with D-SNPs was identified by FSSA staff as a catalyst for adding other SMAC requirements aimed at advancing the state’s integration goals. However, before they began this work, they needed to build their knowledge of Medicare, including the rules that govern the program, how D-SNPs operate, and how to better communicate, coordinate, and collaborate with D-SNPs.

Indiana FSSA developed partnerships with CMS’ Medicare-Medicaid Coordination Office (MMCO), the Integrated Care Resource Center (ICRC), and the National Committee for Quality Assurance (NCQA) to support their continued learning. The state also received grant support from Arnold Ventures’ Advancing Medicare & Medicaid Integration initiative to develop an integration strategy. In addition, several new Indiana FSSA staff are currently participating in CHCS’ Medicare Academy.

Indiana FSSA staff used their growing knowledge of two Medicare policy topics to build their integrated care program: D-SNP plan benefit packages (PBPs) and Model of Care (MOC) requirements:

• Plan Benefit Packages: Medicare Advantage plans, including D-SNPs, can offer one or more PBPs. Different PBPs may enroll different types of Medicare beneficiaries, serve different geographic areas, and offer different benefits to their members. Indiana was particularly focused on D-SNP members eligible for its MLTSS program, which will only enroll individuals age 60 and above. With technical assistance from MMCO and ICRC on how to segment dually eligible populations, FSSA staff created a program design with several different PBPs. These PBPs are tailored to the needs of Indiana’s dually eligible populations and will allow for exclusively aligned enrollment of D-SNP members age 60 and over who will be enrolled in MLTSS plans.
• Model of Care Requirements: The MOC describes the D-SNP’s approach to care coordination. CMS requires all D-SNPs to develop a MOC and have it approved by NCQA. FSSA received technical assistance from NCQA to better understand how MOCs are created, as well as the timeline and process for MOC review and approval. FSSA used this Medicare knowledge to develop SMAC requirements for MOC and D-SNP care coordination to support the state’s LTSS system reform and Medicare-Medicaid integration goals.

Indiana FSSA’s growing knowledge of Medicare policy areas, such as the design of PBPs and development of care coordination requirements, combined with an understanding of how to leverage the SMAC, were critical to helping the state advance its goals toward fully integrated care.

Advancing Integration Without Medicaid Managed Care: Maine’s Experience

Maine is another state working to advance Medicare-Medicaid integration for its dually eligible populations. The state does not include Medicaid managed care plans in its delivery system, which makes integrating care using D-SNPs more challenging.

Despite this barrier, the state is seeking innovative ways to improve coordination of care for dually eligible individuals. Like Indiana, Maine staff identified a need to build their Medicare knowledge to work effectively with D-SNPs to achieve their goals. Staff from both Maine’s Medicaid agency and the Office of Aging and Disability Services have been involved in the state’s efforts to build Medicare capacity, including participating in the first cohort of CHCS’ Medicare Academy.

Through the Medicare Academy, state staff learned more about Medicare Advantage terminology and the contracting calendar that D-SNPs must follow. Understanding how the Medicare Advantage calendar may be different from the state’s timelines has been helpful to Maine’s short- and long-term planning. This has also improved the state’s communication with its D-SNPs, including, for example, supporting D-SNPs’ care coordination efforts.

Without Medicaid managed care plans, the state has sought to identify other entities with which its D-SNPs can partner to coordinate care for dually eligible individuals. Maine’s service coordination agencies provide care coordination for people receiving Medicaid LTSS, including older adults and people with disabilities enrolled in home- and community-based services waiver programs. By requiring D-SNPs to hold Memorandums of Understanding with service coordination agencies, the state has created a vehicle for better coordination of Medicare and Medicaid-covered services.

All these learnings and experiences are reflected in Maine’s SMAC, which is becoming increasingly sophisticated and driving integration forward.

Resources to Build Integrated Care Expertise

Building the knowledge to integrate two programs that were never designed to work together is a monumental task for states seeking better care and outcomes for their dually eligible populations. However, they don’t need to do this work alone. Both Indiana and Maine used external resources from MMCO, ICRC, NCQA, and CHCS’ Medicare Academy to guide staff through foundational and advanced learnings, advance their state Medicare-Medicaid integration goals, and ultimately improve services for dually eligible individuals. These resources are readily available to other states.