Medicare and Medicaid: Implementing State Demonstrations for Dual Eligibles Has Proven Challenging: HEHS-00-94.

MEDICARE; MEDICAID; HEALTH insurance; MEDICAL care; HEALTH policy

"Dual eligibles" refers to low-income Medicare beneficiaries who also qualify for full Medicaid benefits. These eligibles often receive benefits from two sets of providers, and an estimated 97 percent of dual eligibles receive their benefits under Medicare's fee-for-service option. Some states are considering making one managed care plan responsible for the delivery of all covered services. Two states (Minnesota and Wisconsin) are enrolling dual eligibles into an integrated care program and two more (New York and Massachusetts) plan to do so in 2001. States are emphasizing service delivery in beneficiaries' homes and targeting different segments of the dual-eligible population compared with PACE, which enrolls only people who are at risk of nursing home placement. Finding the overall challenges of integration too great, Florida and Texas are developing projects integrating Medicaid acute- and long-term care services only. Colorado is pursuing a program that avoids the use of waivers. Difficulty in reaching agreement on an appropriate Medicare payment methodology for integrated care programs was an important factor that delayed the approval of state waiver applications. Payment rates should adequately compensate health plans for differences in frailty among dual eligibles while meeting OMB's requirement that Medicare demonstrations not increase federal Medicare expenditures. [ABSTRACT FROM AUTHOR]

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