Featured in Health Business Daily, Dec. 12, 2017

Calif., NY Duals Demos Struggle With Enrollment, Despite Changes

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care. Subscribe today!

By Jane Anderson
September 7, 2017Volume 23Issue 17

California and New York both have struggled with enrollment in their Financial Alignment Initiative (FAI) demonstrations, but for different reasons that could shed some light on what has worked — and what hasn’t — in the multi-state CMS-backed duals demos. California’s program suffered in large part because physicians opposed it and helped their patients opt out, stakeholders say. In New York, the problem was a combination of factors, such as the inclusion of a large group of health plans that didn’t have experience in the Medicare managed care space, others suggest.

Designed to better coordinate Medicare and Medicaid benefits through three-way contracts with CMS, states and managed care organizations, the first of 11 capitated demos began rolling out in 2013, with the last ones slated to end in late 2019. California, which began enrolling in April 2014, by far has the biggest program — with about 29% of total FAI enrollment — but its membership is still just 117,000 of an estimated 456,000 eligible beneficiaries. Meanwhile, out of an estimated 170,000 eligible beneficiaries in New York, the state has enrolled only 5,164 individuals in its long-term care focused Fully Integrated Duals Advantage (FIDA) program and its demo serving individuals with intellectual and developmental disabilities.

Both California and New York say they are taking steps to stabilize enrollment and refine enrollment processes, and new data from AIS Health’s DUAL Medicare-Medicaid Dual Eligibles Database support this. California had 117,192 people enrolled in the program as of July 2017, down about 15% from its peak in early 2015 but up slightly from 114,024 in January. Meanwhile, enrollment in New York’s is just around half of its peak in October 2015 and down by less than 5% from 5,421 a year ago.

After a rocky few years marked by strong provider pushback, California “is going reasonably well,” observes James Verdier, senior fellow with Mathematica Policy Research, which has provided technical assistance to CMS and more than 25 states on integrating Medicare and Medicaid. “They got a lot of up-front resistance from providers who preferred being in fee-for-service, and they would persuade enrollees and patients that fee-for-service was a better deal.”

Lisa Rubino, Molina Healthcare, Inc. senior vice president, Medicare, says that Molina had a higher opt-out rate in California at the beginning of the program than it did in Texas, Michigan or Ohio, three of the five other states in which it’s participating (it’s also in Illinois and South Carolina). “There were a lot of providers in California who were resisting the program and who helped people to opt out,” she tells AIS Health.

Medicare Advantage News

DHCS Is Fine With Streamlined Enrollment

In fact, California’s statewide opt-out rate has remained high at about 50% over the course of the demonstration. The state ended passive enrollment in most counties in 2015 and last year implemented streamlined enrollment, which provides a simpler method for beneficiaries to sign up for the Cal MediConnect (CMC) product associated with their Medi-Cal managed long-term services and supports (LTSS) health plan (MAN 9/1/16, p. 1). That process, which cuts out the extra step of requiring beneficiaries to contact the state enrollment broker to complete their CMC enrollment, is limited to members who are actively enrolled in an MCO’s Medicaid plan and who also meet all the requirements for the CMC plan.

The California Department of Health Care Services (DHCS) says it has no plans to expand streamlined enrollment at this time and that it has “seen a modest increase in enrollment since pursuing the voluntary enrollment strategy.” There are currently 11 health plans in CMC, and that number will remain the same for 2018, the state says.

Rubino says Molina’s CMC plan loses about 1% of members per month, and streamlined enrollment “is somewhat replacing that.” The majority of people disenroll because they lose Medicaid coverage, she says, adding that Molina is “working with the state to turn passive enrollment back on, or to do a mailer for us to individuals who would have been passively enrolled.”

Provider and especially member education is key to boosting enrollment, Rubino says. “Dual eligibles like to sit across the kitchen table and understand their options,” she says, adding that strong written materials are needed to bolster passive enrollment programs.

In the California program, “some of the communications and outreach to beneficiaries and providers in the early stages weren’t as clear as they could have been,” Verdier says, while noting that other states also had some communications problems.

According to DHCS, “An analysis showed that some populations were more likely to opt out, for example some beneficiaries who speak languages other than English as well as those with LTSS needs, and DHCS has targeted outreach and education to those populations. As the enrollment rate in Cal MediConnect has stabilized, so has the disenrollment rate.”

L.A. Care Health Plan CEO John Baackes tells AIS Health that the initial communication from the state to passively enrolled dual-eligibles “was rather confusing,” and that prompted providers and advocates to support duals in not enrolling and opting out. “The state did not partner with the physician community prior to the implementation, which resulted in a disconnect between physicians and the demo,” he says.

Also, “although the state imposed a moratorium on any dual-eligible special needs plans (D-SNPs) being approved while the demo was in place, the health plans developed Medicare and Medicaid look-alike plans to avert the rule, which allowed health plans to continue to enroll dual-eligibles into their new Medi/Medi look-alike products while skirting the demo,” Baackes says. Like Molina, L.A. Care continues to push for passive enrollment.

California has decided to stay in the program even though a state analysis found it wasn’t saving money and has restructured one component — the in-home supportive services funding — to make it budget-neutral (MAN 1/26/17, p. 7). California’s 2017-18 budget extends the Cal MediConnect program, continues mandatory enrollment of dual eligibles and continues to integrate LTSS.

Despite its earlier problems with communications and opt-out rates, California generally has performed well on the monitoring aspects of the program, holding focus groups, performing surveys and just generally providing “lots of opportunities for feedback from everyone involved,” Verdier says.

In addition, DHCS says, recent evaluation data shows high satisfaction and low hospitalization rates among CMC members, and “many CMC plans have created unique programs to facilitate successful transitions of members to lower levels of care who may not have otherwise been able to leave institutional care.”

In New York, meanwhile, a total of 18 health plans have participated in the state’s FIDA program, but only two — Healthfirst Health Plan, Inc. and VNS Choice — have had more than 1,000 enrollees at any point. VNS Choice had 1,533 FIDA enrollees in August, while Healthfirst had 965.

“New York is very much an outlier,” says Verdier. “It goes back to the original program design.” The state allowed multiple Medicaid partially capitated managed long-term care plans to join FIDA, “none with any real experience” in Medicare managed care, he says. “The basic health care building blocks were missing a lot of experience.”

New York has about 70,000 people enrolled in D-SNPs in the same geographic area, along with another 70,000 people enrolled in Medicare Advantage, Verdier says. “Plans by and large were not able to make the case to enrollees and potential enrollees that the dual demo was a good option for them, and so they didn’t get and retain as many enrollees. They also didn’t do as much passive enrollment as other states.”

NY Launched Major Marketing Effort

In an effort to boost program enrollment, New York last year embarked on a multi-month marketing campaign geared toward providers and eligible beneficiaries (MAN 9/15/16, p. 5). The program largely focused on increasing providers’ awareness of FIDA, and included ads placed in medical journals, on professional sites and in bus shelters and phone booths near hospitals and health care facilities, the New York state Dept. of Health (DOH) says. In addition, all FIDA plans “are permitted and encouraged to market the program,” DOH tells AIS Health.

Enrollment has recently stabilized, says DOH, and disenrollments have decreased. In addition, the state in March added Suffolk and Westchester counties to the program, which has helped boost enrollment. New York plans to stay in the program through 2019, and the state says it is “currently in the process of holding a series of meetings with a variety of stakeholders to gather their input and design the future of integrated care products.”

For both California and New York, more robust physician engagement earlier in the stakeholder process could have helped to ensure physician and beneficiary participation, acknowledges CMS. “In California, more outreach to providers serving ethnic communities and to stakeholders supporting nursing facility residents may have increased early enrollment as well,” a spokesperson tells AIS Health.

Overall, the FAI has shown how challenging it can be to integrate Medicare and Medicaid managed care programs, observes Verdier. “There’s a whole bunch of stuff in Medicaid that looks like the same thing in Medicare, but once you get beyond that high level it’s really, really difficult,” he says.

He adds that care coordination has been key to success in these demo models. “The whole system for dual eligibles is just rife with silos. Most of the people who are dual eligibles don’t even have high school degrees. To my mind, the must crucial person is the care manager at the health plan. You’ve got to do everything you possibly can to break down the silos.”


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