New AHIP Proposal to Improve Care for Dually Eligible Beneficiaries

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AHIP proposal on dual eligibles improve care and reduce health care costs for seniors and people with disabilities.

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As Congress looks at ways to reduce the deficit, health plans are urging policymakers to empower states to better integrate health care coverage for beneficiaries eligible for both Medicare and Medicaid. Giving states a variety of options to increase care coordination for “dual-eligibles” is the focus of a new proposal released today by America’s Health Insurance Plans (AHIP). Recent studies suggest that these activities can improve care and reduce health care costs for seniors and people with disabilities.

Dually eligible beneficiaries are among the nation’s most vulnerable populations. They have a higher prevalence of multiple chronic conditions and correspondingly complex health care needs. Although they comprise only 15 percent of all Medicaid beneficiaries, dual eligibles account for nearly 40 percent of all Medicaid expenditures. Using projections from the Congressional Budget Office, federal spending on dual eligibles will total nearly $3.7 trillion over the next decade.

A recent report by Kenneth E. Thorpe, Ph.D., highlights the significant cost savings and care improvement that can be achieved by utilizing health plans’ programs to coordinate care for dually eligible beneficiaries, including initiatives to reduce preventable hospital readmissions and improve medication adherence. According to this report, “expanded reliance on health plans and other coordinated care approaches for dually eligible beneficiaries can achieve significant savings while improving quality of care.”

“Health plans have pioneered care coordination and quality improvement programs that are improving health outcomes, helping patients avoid unnecessary hospital admissions and readmissions, and allowing beneficiaries to stay in their home and delay or avoid a stay in a nursing home,” said AHIP President and CEO Karen Ignagni.

The new AHIP proposal outlines a menu of options for integrating Medicare and Medicaid benefits for dually eligible beneficiaries that can improve both the quality and cost-effectiveness of care they receive.

States currently take a variety of approaches to serving dual eligibles. Some states currently rely on Medicare and Medicaid fee-for-service programs, while others utilize a combination of health plans and fee-for-service programs to serve dual eligibles. Other states are prepared for full integration of Medicare and Medicaid benefits through health plan programs and the care coordination and quality improvement initiatives these plans provide. The AHIP proposal recognizes this diversity of approaches and, therefore, outlines three options for states to move towards seamless coverage for dually eligible beneficiaries.

The proposal also identifies key building blocks that states at all of these stages can use to make progress toward increased care coordination and program integration, including: early stakeholder engagement, enhanced data sharing, streamlined enrollment processes, consistent network adequacy requirements, uniform quality measurement and reporting requirements, an integrated appeals process, and coordinated program administration with clearly defined roles for the federal government and states to avoid duplication.

To read the full proposal, visit AHIP Coverage.

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