Dual Eligible Demonstrations – What States Are Moving Ahead?

Executive Briefing | by | October 23, 2015


Athena Mandros
Athena Mandros

In 2012, the Centers for Medicare and Medicaid Services (CMS) began approving state dual eligible demonstration projects, with the first demonstration launching in July 2013 (see Where Are The Dual Eligible Demonstration Projects?). Last summer, CMS announced that states with dual eligible demonstrations would have the opportunity to extend the demonstrations for two years citing concerns with state budgetary cycles and lack of evaluation data. Given the extension, where are states with their dual demonstration?

There are currently 13 states with dual demonstration programs in place: Nine states with capitated demonstrations – California, Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, Texas, and Virginia; Two states with fee-for-service demonstrations – Colorado and Washington; and one state (Minnesota) with a unique arrangement. As of June 2015, there were over 350,000 dual eligibles enrolled in the capitated demonstrations – a large increase from January 2014 when there were only 9,800 dual eligibles enrolled (see Medicare & Medicaid Financial Alignment Initiative ).

For the CMS extension of the demonstration, states were required to submit a non-binding letter of intent by September 2015 (see Financial Alignment Extension Opportunity Memorandum). Of the thirteen states with dual demonstration, twelve expressed interest in extending the demonstration for two years. Virginia was the only state not to submit a letter to extend their program. In September, Virginia released a plan to include the dual eligible population in its new managed long-term services and supports program once the demonstration ended in December 2017 (see Virginia To Launch Mandatory Medicaid Managed Long-Term Services & Supports After Duals Demonstration Ends In 2017).

Two other states, California and Texas, submitted letters of intent to participate in the two-year extension, but with caveats. California stated “While we are hereby stating our interest in considering an extension of this demonstration, we cannot make any commitment at this time” (see California Letter Of Intent To Extend Financial Alignment Initiative Scheduled End Date). Texas included a bulleted list of concerns that need to be addressed before they consider extending their demonstration. Concerns included only being able to passively enroll dual eligibles in the demonstration once per calendar year, and lack of data sharing from CMS to complete financial reconciliation (see Texas Letter Of Intent To Extend Financial Alignment Initiative Scheduled End Date).

One other state, New York, remains committed to extending their Fully Integrated Duals Advantage (FIDA) program, but has indicated they plan to make changes to the program. Thus far, enrollment in the program has been low – approximately 7,000 members of the estimated almost 124,000 estimated to be eligible for participation. And most of the 7,000 enrollees were already enrolled in managed care for their long-term services and supports meaning the state failed to move dual eligibles in fee-for-service (the most expensive) delivery system to the program. In order to increase enrollment, New York has suggested making interdisciplinary care teams (IDT) optional and allowing beneficiary care to be coordinated by care managers instead. Both providers and enrollees have expressed problems with the model. The state is also suggesting bonus incentive pools for members and providers who continue to use the IDT model. In addition, New York has suggested including additional home-and-community based services in the program to incentivize dual eligible enrollment (see Building for the Future: Managed Long Term Care Programs In New York).

In sum, the future of the dual eligible demonstration is still iffy. States were required to submit letters of intent, but those letters were non-binding. In the future, I expect we will see dual eligible demonstrations incorporated or absorbed by Medicaid managed long-term services and supports programs or other state Medicaid managed care programs that focus on consumers with complex conditions more generally. As states continue to decide the fate of their dual eligible demonstrations, we will be sure to keep you informed.


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