Dual Eligibles

Dual Eligibles

Individuals who are eligible for both Medicare and Medicaid (“dual eligibles”) are among the most chronically ill individuals enrolled in these programs, and they account for a disproportionately high share of program expenditures. The following ACA provisions are aimed at improving health care quality, reducing costs, and expanding access to care for dual eligibles: 

  • Establishment of the Medicare-Medicaid Coordination Office (also called the Federal Coordinated Health Care Office or the Coordination Office) to develop new approaches to covering and financing care for dual eligibles. The Coordination Office is charged with improving coordination between the federal and state governments in order to reduce inefficiencies, program conflicts and cost-shifting between Medicare and Medicaid, while improving quality and ensuring access to care.
  • Authorization for 5-year Medicaid waivers involving dual eligibles to with a possible 5-year extension, at the Secretary’s discretion.  
  • Waiver of all cost-sharing under Part D plans for certain full-benefit dual eligibles who would be institutionalized but for the provision of home and community-based care.  
  • Increased quality requirements for Medicare Advantage Special Needs Plans that exclusively serve dual eligibles. 

To date, CMS and the Coordination Office have implemented the following initiatives in furtherance of their efforts to coordinate care for dual eligibles: 

  • State Demonstrations to Integrate Care for Dual Eligible Individuals. In April of 2011, the Coordination Office selected 15 states to design demonstration projects that would test new integrated care models for dual eligibles. Each of the 15 states would receive up to $1 million to support the design of integrated programs. The states are in different stages of development, and CMS will work with states to implement the plans that hold the most promise.
  • Financial Alignment Initiative. The Coordination Office will test two models for states to better align the financing of Medicare and Medicaid, and to integrate primary, acute, behavioral health and long term services and supports for dual eligibles. The first is a capitated model, through which a state, CMS and a health plan enter into a three-way contract.  The health plan will receive a prospective blended payment to provide comprehensive, coordinated care. The second is a managed fee-for-service model, through which a state and CMS enter into an agreement. The state would share in savings resulting from programs designed to improve quality and reduce costs for both programs. The Coordination Office has issued guidance outlining the requirements of each model. The 15 states that received design contracts under the State Demonstration to Integrate Care for Dual Eligible Individuals may use their planning contract to support the development of a proposal in connection with this initiative.

    In the spring of 2012, 26 states submitted proposals to participate, and the Coordination Office hosted public comment periods for each state proposal. To date, CMS has determined that eleven states (Colorado, Illinois, Massachusetts, Michigan, New York, Ohio, South Carolina, Texas, Virginia, and Washington) have met the standards and conditions for the demonstration.  CMS entered into Memoranda of Understanding with each of these three states to establish the parameters of the initiative.
  • Alignment Initiative. The goal of this initiative is to more effectively integrate the Medicare and Medicaid programs and to facilitate a national conversation with stakeholders to identify opportunities for alignment.  On May 16, 2011, CMS issued a Request for Information seeking comments on opportunities to prevent cost-shifting between Medicare and Medicaid and to improve access to care for dual eligibles.
  • Medicare Data for Dual Eligibles for States.  On May 11, 2011, the Coordination Office made a process available through which state Medicaid agencies may request timely Medicare Parts A, B, and D data for dual eligibles to support care coordination. This information is now available via the State Data Resource Center.

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. On March 15, 2012, CMS announced that it would make available $128 million over four years for its Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents.  The Coordination Office, in collaboration with the Center for Medicare and Medicaid Innovation, are partnering with eligible, independent, non-nursing facility organizations to implement evidence-based interventions to reduce avoidable hospitalizations for dual eligibles living in nursing homes.  In September of 2012, seven organizations were selected for participation in this initiative.