The Bipartisan Policy Center recently released two white papers on the importance of integrating the financing and delivery of Medicare and Medicaid services for individuals who are eligible for both programs, also known as “dual-eligible individuals.” The first paper, “Integrating Care for Individuals with both Medicare and Medicaid: An Update,”  [ES1] provides background information on dual-eligible individuals, including population demographics and program eligibility, and an overview of existing models of integration.  The second paper outlines a series of policy options to better integrate Medicare and Medicaid for dual eligible individuals.

While this work began prior to the current outbreak of COVID-19, we recognize that dual-eligible individuals are among those at highest risk for illness or death. Many are living in nursing homes or long-term care facilities and face a higher risk of exposure.  Those who live in the community face similar risks as they undertake necessary activities, such as grocery shopping, or through interactions with friends and family members.

BPC seeks feedback on policy options related to integration of care, but BPC would also like to take this opportunity to identify the needs of states, plans, providers, and consumers in protecting these high-risk individuals from exposure to the virus.  Specifically, BPC seeks input in two areas:  1) the short-term needs of plans, consumers, and providers in protecting dual-eligible individuals from COVID-19; 2) near-term policy options found in the paper “Policy Options for Integrating Care for Individuals with both Medicare and Medicaid.”[ES2] Recognizing the burden placed on consumer organizations, states, health plans and providers, the comment period will run through June 1, 2020.

1. In addition to the recent supplemental appropriations to help combat the virus in nursing homes, what additional resources are needed by states to address the needs of this population, including those who reside in the community?
2. What additional regulatory flexibility is needed by plans and providers to help keep dual-eligible individuals safe?
3. What do dual-eligible enrollees need to address their personal and financial, health and well-being?

1. Congress should further align oversight of programs serving dual-eligible individuals by consolidating regulatory authority for all programs serving dual-eligible individuals into the MMCO.
2. Congress should direct the secretary of HHS to adopt best practices from the Financial Alignment Initiative demonstration and apply them to Fully-Integrated Dual-Eligible Special Needs Plans (FIDE-SNPs). The secretary should convene a working group and implement standards agreed upon by the working group where best practices have yet to be identified to develop uniform standards in the following areas:
   • Care management standards for integrated clinical health services, behavioral health, and LT
   • Network adequacy standards appropriate for dual-eligible individuals
   • Standard materials for marketing, plan notices, and other member materials
   • A single open enrollment period process
   • A process for joint oversight of plans by CMS and states
   • Alignment of Medicare and Medicaid measures, including measures of access to care, beneficiary experience, and appropriateness of financial incentives among plans, providers, states, and the federal government
   • A model outreach and engagement plan to help inform and educate enrollees and providers on the requirements and benefits of fully integrated care models (see enrollee improvement recommendations below)
3. Limit enrollment in integrated models to full-benefit dual-eligible individuals.

To encourage states to fully-integrate care for dual-eligible individuals, Congress should:

1. Provide the secretary of HHS with authority to develop a shared savings program in existing payment and delivery models for dual-eligible individuals.
2. Direct the secretary of HHS to provide technical assistance and resources to states that would like to move forward to integrate Medicare and Medicaid services, building on the existing Integrated Care Resource Center to provide in-person technical assistance teams at states’ request.

1. Direct the secretary of HHS to require collaboration between CMS, ACL, and states to implement model standards for outreach and education and increase funding to the State Health Insurance Assistance Program to help dual-eligible individuals better understand the options available to them in order to make informed choices.
2. Provide resources and technical assistance to states for consumer and provider engagement and education and encourage states to partner with community organizations and local governments.
3. Allow states to implement 12 months of continuous Medicaid eligibility for dual-eligible individuals.

To drive full integration of care for dual-eligible individuals over the long term, Congress should:

1. Require full integration of Medicare and Medicaid Services within five years. Direct the secretary of HHS to consolidate and designate specific payment and delivery models designed to integrate care for dual-eligible individuals. In designating models of care, Congress should draw from models that have been successfully implemented in states that participated in the FAI, or other successful programs implemented by states. 
2. Require all MA carriers to offer one FIDE-SNP in each service area in which they offer coverage to provide choice and continuity of care.
3. Allow states that wish to be responsible for fully integrating care for dual-eligible individuals to notify the secretary of their intent to implement one or more of the payment and delivery models outlined above, and present a plan on how they intend to signal to current and future dual-eligible individuals that they will enter into a coordinated plan.
4. Direct the secretary of HHS to directly contract with plans and provider care models in states that choose not to fully integrate care and require contributions from those states to financially support programs similar to the “claw-back” implemented in Medicare Part D. In developing this federal “fallback” program, the secretary should determine models to be used, establish eligibility standards, benefits, and determine which Medicaid eligibility groups should be included. Eligible individuals should be auto-enrolled using the same requirements established under the FAI, and individuals should be able to opt-out. Require MA plans to offer one FIDE-SNP option in each service area in which they offer coverage.