Because of their two-fold distress, disability and indigence, many loved ones with serious mental illness receive health insurance from both Medicare and Medicaid. They belong to a cohort of about 8 million other Americans who are “dual eligibles”.
While coverage of both Medicare and Medicaid may seem comprehensive, in reality this arrangement poses many challenges for its beneficiaries. The two systems are different in many respects. Coordination of the two is cumbersome and expensive. Dual eligibles tend to have more complicated, chronic, and costly health problems. While dual eligibles account for 18% of Medicaid beneficiaries and 16% of Medicare beneficiaries, they account for 46% of Medicaid expenditures and 25% of Medicare expenditures (CHCS, 2009).
As they battle their harsh budget realities, state governments across the nation are working to reform their Medicaid programs. A significant part of this effort is to change the way dual eligibles interface with Medicaid. Rather than an uncoordinated and random fee-for-service relationship of duals with providers, states now seek to consolidate care for duals into coordinated managed care organizations (MCOs), specifically into health maintenance organizations (HMOs).
At this writing (December 2011), the State of New Jersey is negotiating with the Centers for Medicare and Medicaid a comprehensive waiver that in part will induce such a result. Dual eligibles would be enrolled in HMOs and covered by so-called Medicare Advantage Special Needs Plans (SNPs) that would coordinate through one entity all the services provided to the recipient and payment from Medicare and Medicaid to the providers. It is a dramatic undertaking that portends some of the changes proposed by the Affordable Care Act of 2010.
With such significant changes ahead for the health care delivery system for dual eligibles with psychiatric disabilities, PsychOdyssey Academy launches this new course with the intent to prepare its students better to understand the context in which this change is occurring.
CHCS [Center for Health Care Strategies, Inc.](2009). Supporting integrated care for dual eligibles. Retrieved on January 1, 2012 from www.chcs.org.
This 50-page publication from the Henry J. Kaiser Foundation in 2010 offers a thorough introduction to this important program for loved ones with severe mental illness. It provides an overview of Medicaid, the nation’s largest health coverage program, which covers nearly 60 million low-income individuals, including children and families, people with disabilities and seniors who are also covered by Medicare. It also explains how Medicaid will change and expand under health reform.
The Center for Medicaid and CHIP Services (CMCS) is one of six Centers
within the Centers for Medicare & Medicaid Services, an agency of
the U.S. Department of Health and Human Services (HHS). CMCS serves as
the focal point for all national program policies and operations related
to Medicaid and the Children’s Health Insurance Program (CHIP). Medicaid’s website, www.medicaid.gov, provides a broad array of information
Medicaid was originally enacted in 1965 to enable states, at their option, to furnish medical assistance, as well as rehabilitative and other services, for certain families and aged, blind, and disabled individuals whose income and resources are insufficient to meet the costs of medically necessary services. The program has evolved over time, and, today, Medicaid serves as the nation’s primary health insurance program for low‐income and high‐need individuals. Under the Affordable Care Act (ACA), Medicaid will expand in 2014 to become the base of coverage for the low‐income population. This brief from the Kaiser Foundation presents an overview of the current Medicaid program framework, with a focus on eligibility, benefits and cost sharing, care delivery and provider payment, long-term services and supports, and dual eligibles.
Nearly 9 million Medicaid beneficiaries are “dual eligibles”, who are low-income seniors and younger persons with disabilities enrolled in both the Medicare and Medicaid programs. Many with severe mental illness are dual eligibles. According to this brief from the Kaiser Foundation, dual eligibles are among the sickest and poorest individuals covered by either the Medicaid or Medicare programs. They must navigate both Medicare and Medicaid to access services, and rely on Medicaid to pay Medicare premiums and cost-sharing and to cover critical benefits Medicare does not cover, such as longterm care. Because dual eligibles have significant medical needs and a much higher per capita cost than other beneficiaries, they are of great interest to both Medicare and Medicaid policymakers and to the state and federal governments that fund and manage the programs.
In the current health care system, far too many dual eligible beneficiaries receive uncoordinated fee-for service medical and long-term care. In spite of recent efforts to create vehicles for integrating care through Special Needs Plans (SNPs), more than 80 percent of dual eligible remain in fee-for-service systems that keep them in treatment silos. And although the Centers for Medicare and Medicaid Services (CMS) has encouraged the integration of care via SNPs, state Medicaid agencies have struggled to create meaningful arrangements with these plans. Based on its experiences in the field, this resource paper by the Center for Health Care Strategies provides the rationale for integrating care for duals, reasons why integration has not taken hold thus far, and current and emerging vehicles for integration.
Most Medicaid beneficiaries nationally are enrolled in some form of managed care, and, with current budget pressure and health reform on the horizon, states are expected to increase their reliance on managed care to deliver services in their Medicaid programs. A 50-state survey, conducted by the Kaiser Commission on Medicaid and the Uninsured and Health Management Associates, provides a comprehensive look at state Medicaid managed care programs, documenting their diversity, examining how states monitor access and quality, and exploring emerging efforts to improve care, including managed long-term care and initiatives targeted toward dual eligibles. The survey was released September 13, 2011, at a public briefing at the Kaiser Foundation’s Washington, D.C., office.
To watch a very helpful webinar (90 minutes) about Managed Medicaid Care Programs with Kaiser experts and Medicaid directors from NY, NC, and TX, click here.
This primer from the Kaiser Foundation explains Medicare spending trends, how the program is financed, and factors contributing to the growth in Medicare spending as Congress and the Administration start to focus on the nation’s budget deficit. Medicare being the “other half” of a dual eligible’s health insurance, families navigating mental illness will benefit from a deeper understanding of Medicare as well as Medicaid.
Here is a live case of a state seeking to implement the kinds of reforms mentioned in the other readings. The State of New Jersey has approached the Centers for Medicare and Medicaid Services to approve a waiver to its Medicaid contract with the Federal government that will change the health care insurance process for many Jerseyans with psychiatric disabilities. A significant part of the waiver is the proposed reform of the State’s handling of Medicaid benefits for its dual eligibles, who are to be assigned to managed care organizations (MCOs) that will better co-ordinate their care. (There are currently 23,000 duals already voluntarily enrolled in MCOs, while 117,000 now in a fee-for-service arrangement will be converted to MCOs in October 2011.)