Dual Eligibles

New Studies Tout Benefits of High Duals Integration, Pinpoint Shortcomings

As CMS applies pressure on health plans and states to enhance coordination for dually eligible Medicare-Medicaid enrollees and as congressional lawmakers urge momentum for the Delivering Unified Access to Lifesaving Services (DUALS) Act, the path to integrated care remains a challenge in many states. And two recent studies show that beneficial outcomes, even for enrollees in Dual Eligible Special Needs Plans (D-SNPs), are not guaranteed.

In separate analyses looking at the New York and Virginia markets, researchers discovered a wide range of improvement areas that, even among highly integrated D-SNPs (HIDE-SNPs) and fully integrated D-SNPs (FIDE-SNPs), could capitalize on the potential of the D-SNP approach. The study covering the Virginia market, published last month in JAMA Health Forum, analyzed the impact of exclusively aligned enrollment (EAE), which the study authors describe as “the highest level of D-SNP integration.” This occurs when the parent organization’s D-SNP (a type of Medicare Advantage plan) is limited to individuals who are also enrolled in that organization’s Medicaid managed care organization.

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VNS Health Pursues ‘Near Duals’ MA Growth in NYC and Beyond

Medicare Advantage membership growth during both the 2024 Annual Election Period (AEP) and the Open Enrollment Period (OEP) was largely driven by major insurers (namely, CVS Health Corp.’s Aetna) and some of the insurtechs, according to a recent AIS Health analysis. But many of the regional and provider-led insurers that performed well during the AEP also continued their growth through the OEP. One such plan is VNS Health, which has long catered to underserved New Yorkers with complex needs and recently relaunched MA plans designed for Medicare-Medicaid dual eligibles and “near duals.”

As part of an annual series on the growth stories of AEP/OEP “winners,” AIS Health, a division of MMIT, spoke with leaders at VNS Health about their successful reentry into MA.

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With Focus on Future, MA Plan Innovations Hold Promise for Aging in Place

Outside of serving seniors through a Special Needs Plan geared toward institutional/institutional equivalent enrollees, Medicare Advantage plans are not fundamentally designed to support seniors’ long-term care needs. But with their inherent focus on care coordination and recent innovations in nonmedical benefits that can support aging in place, MA plans are uniquely positioned to address gaps in the continuum between Medicare and Medicaid, which is the primary payer of long-term services and supports (LTSS).

Speaking during a prerecorded session of the upcoming Virtual Fifth National Medicare Advantage Summit, panelists agreed that while nonmedical benefits were initially perceived as marketing tools to differentiate plans from their competitors, there is great potential for them to serve enrollees in the long term. Participants in the panel discussion, “The Opportunity for Medicare Advantage Plans to Address Long-Term Care Needs,” which will be livestreamed and archived on July 10, discussed a variety of benefit innovations and the mounting evidence around their impact to costs, outcomes and quality of life.

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CMS Dangles ‘Wild and Crazy’ Opening for Special Needs Plans

After interest among long-term care providers and Medicare Advantage insurers to partner on Institutional Special Needs Plans plateaued during the COVID-19 pandemic, a somewhat ambiguous provision in a recent CMS final rule has the potential to significantly increase the I-SNP market. By expanding the definition of qualifying facilities that serve institutionalized members, SNP experts say it could reduce current barriers to enrollment and garner interest from assisted living facilities (ALFs), which have largely been shut out of the I-SNP opportunity.

I-SNPs, which were permanently authorized in the Bipartisan Budget Act of 2018, currently restrict enrollment to MA-eligible individuals who meet the definitions of “institutionalized” (i.e., they continuously reside for 90 days or longer in one of several types of long-term care facilities or are expected to need the level of services provided in such a facility) or “institutionalized-equivalent,” meaning they reside in an ALF and get the same level of care they’d receive in a qualifying long-term care facility. Such facilities that currently qualify (as defined by Medicaid or Medicare statute) are skilled nursing facilities, nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric hospitals, rehabilitation hospitals or units, long-term care facilities and “swing-bed” (e.g., critical access) hospitals.

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News Briefs: SCAN Wins Lawsuit Over 2024 Star Ratings Calculations

SCAN Health Plan won a legal challenge to CMS’s calculation of the 2024 Star Ratings that could have major implications for quality bonus payment (QBP) outlays and 2025 cut point generation. According to a June 3 memorandum opinion filed in the U.S. District Court for the District of Columbia, Judge Carl Nichols agreed with the not-for-profit Medicare Advantage insurer that CMS “failed to follow its own regulation,” which resulted in SCAN receiving an incorrect Star Rating. In a lawsuit filed against HHS in December, SCAN argued that CMS was “arbitrary and capricious” when it applied new guardrails (i.e., restricting the movement of cut points by no more than 5% in either direction) to hypothetical cut points for the previous year rather than actual cut points, yet did not amend its regulations to reflect that decision. Nichols agreed that the “best and most natural reading” of CMS’s so-called Guardrail Rule was that it referred to actual cut points in both the initial year and the following year, and he granted the plaintiff’s motion for summary judgment. SCAN, which serves roughly 277,000 MA enrollees in five states, had a 4.5 Star Rating for six consecutive years until 2024, when it received a 3.5 Star Rating, costing it nearly $250 million in lost quality bonus payments. Elevance Health, Inc. in December filed a similar lawsuit; the insurer in March disclosed that CMS “updated” its original ratings, which will lead to an additional $190 million in revenue for plan year 2025. MA insurers Hometown Health Plan and Zing Health also have similar suits pending, reported Modern Healthcare.

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SFHP Leverages Local Connections, In-House Capabilities to Launch D-SNP

To prepare for new integrated care requirements for dual eligible Californians, San Francisco Health Plan (SFHP) and other Medi-Cal plans are in throes of setting up a Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) in their service area, if they haven’t done so already. During the 15th Annual Medicare Market Innovations Forum, held April 8-9 in Orlando, Florida, SFHP’s Diane Sargent discussed the daunting task of building a D-SNP and the tremendous potential to improve care delivery for up to 47,000 dual eligible beneficiaries in the plan’s service area.

As part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, the state’s Dept. of Health Care Services (DHCS) is implementing new policies to promote integrated care for duals that build on the Coordinated Care Initiative (CCI), the state’s financial alignment demonstration with CMS that included Medicare Medi-Cal Plans (MMPs) serving duals. Under the first phase of CalAIM, which kicked off in January 2023, DHCS launched D-SNPs in the seven CCI counites. Under an exclusively aligned enrollment (EAE) model, duals access their Medicare and Medi-Cal coverage via the same managed care plan. Managed care plans in non-CCI counties that wish to continue serving dual eligibles must launch EAE D-SNPs no later than Jan. 1, 2026.

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News Briefs: Habitat Health Launches PACE Program in California With Kaiser Permanente

With support from Kaiser Permanente and investment firm Town Hall Ventures, Habitat Health has established a new Program of All-Inclusive Care for the Elderly (PACE) provider. Offering comprehensive care to adults who wish to live independently in their homes and communities, Habitat Health will serve aging and low-income adults in California in partnership with Kaiser and eventually expand to other states with local care partners. Habitat Health plans to begin serving PACE-eligible individuals in Los Angeles and Sacramento in 2025 and will serve as payer for all participants’ Medicare and Medicaid services. The new PACE provider will “benefit from Kaiser Permanente’s expertise in creating efficient systems and developing innovative technology to integrate complex care, and from Town Hall Ventures’ experience building successful care delivery companies that support underserved communities,” stated a March 27 press release from all three entities. Town Hall Ventures, whose leadership includes former CMS Acting Administrator and White House adviser Andy Slavitt, was founded in 2018 and has invested in or participated in the launch of 35 health care companies, including Cityblock Health, Landmark Health, Signify Health and VillageMD.

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AHIP Panelists: Improving Aging in Place Requires Cross-Stakeholder Support

When it comes to aging in place, seniors in the U.S. have a hodgepodge of programs and services available to them, and health plans can be a connector to and integrator of those services in their respective markets. Speakers at AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 to 14 in Baltimore, agreed that health plans can also play a valuable role in driving innovations across the Medicare and Medicaid programs, such as providing emergency and acute care in the home, supporting family caregivers, and advocating for policy solutions.

Before CMS in 2020 introduced the Hospital Without Walls program enabling health systems to provide acute hospital care in the home, integrated insurer-provider Kaiser Permanente (KP) launched the Advanced Care at Home (ACAH) model. One of several KP initiatives that support aging in place, ACAH leverages expert care teams and technology to provide 24/7 physician-led acute care and coordinate patients’ recovery in the familiar setting of the home. Eligible patients are identified in urgent care, emergency and/or inpatient settings but must also meet certain social and clinical criteria, explained Rachna Pandya, regional strategic implementation leader of Medicare operations and strategy, during the session, “Best Practices to Support Aging in Place.”

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Senators Hope to Build Momentum on New Duals Integration Bill

After circulating a discussion draft in the first half of 2023, Sen. Bill Cassidy, M.D. (R-La.) on March 14 released his long-awaited bipartisan bill aimed at improving coverage for Medicare-Medicaid dual eligibles. The Delivering Unified Access to Lifesaving Services Act of 2024 calls for comprehensive changes to the way states and plans currently deliver care to dual eligibles, who often have multiple chronic conditions and account for a disproportionate share of spending.

The bill was introduced by Cassidy and his cosponsors, Sens. Tom Carper (D-Del.), John Cornyn (R-Texas), Mark Warner (D-Va.), Tim Scott (R-S.C.) and Bob Menendez (D-N.J). It would, among other things, require all states to establish an “integrated health plan” for duals — either building off their own or existing options — and require managed care organizations to develop and update comprehensive care plans that include a designated care coordinator for each beneficiary. The legislation also includes “passive enrollment” of qualifying dual eligibles into such plans and continuity of care requirements. The legislation also seeks to expand access to Programs of All-Inclusive Care for the Elderly (PACE) to individuals aged 55 and older.

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As Health Equity Measurement Begins, MA Plans Must Use Precision to Close Gaps

Starting with the 2027 Star Ratings, CMS will begin rewarding Medicare Advantage plans for their efforts to assess social risk factors and address disparities in certain quality measures with the new Health Equity Index (HEI). Not all plans will qualify and only a third of top-performing plans will be rewarded, but the time is now for plans to look at how they are doing on the claims-based measures that will be impacted and how they are performing for members with one of the qualifying factors (i.e., eligible for Medicare and Medicaid, disability and/or the Part D low-income subsidy).

During a recent panel moderated by AIS Health, a division of MMIT, speakers at the 7th Annual Medicare Advantage Leadership Innovations forum discussed best practices for assessing members’ social needs and how plans can use data to address them and move the needle forward on health equity.

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