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DOH Outlines Plans for Medicaid-Medicare Managed Care

The Department of Health (DOH) shared its plans for expanding enrollment in integrated Medicaid-Medicare managed care products in a meeting with managed care plans last week. Noting that over 300,000 beneficiaries eligible for both Medicare and Medicaid ("dual eligibles") are enrolled in both Medicare and Medicaid on a fee-for-service (FFS) basis, the Department has decided to move forward with default enrollment in Medicare Advantage plans for mainstream Medicaid managed care beneficiaries who turn 65 or become disabled. Under default enrollment, mainstream managed care beneficiaries who become eligible for Medicare would be enrolled in the companion Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) of their mainstream plan and in the plan's Medicaid Advantage plan. If the beneficiary requires long term care, he or she would be enrolled in the companion D-SNP and Medicaid Advantage Plus (MAP) plan. Beneficiaries could opt out of default enrollment and choose another D-SNP, MAP plan, or Program of All-Inclusive Care for the Elderly (PACE) or could choose to enroll in FFS ("original") Medicare and enroll in a partially-capitated managed long term care (MLTC) plan if they require long term care. The slides from the meeting describe various scenarios and timelines. Only integrated plans that have a 3-star Medicare Advantage rating and receive Centers for Medicare and Medicaid Services (CMS) approval of their default enrollment application would qualify to participate in default enrollment.

Default enrollment presents competitive challenges for managed care plans sponsored by long term care providers. These plans typically specialize in Medicare and Medicaid long term care products and do not offer a mainstream product. As a result, they do not have an affiliated mainstream product that would feed their other products through default enrollment. LeadingAge NY is working with the Department to identify potential opportunities for long term care provider-sponsored plans in a market that allows default enrollment.

The Department also mentioned its intention to strengthen integration within the MAP product through integrated marketing, grievance and appeal, and enrollment procedures and integration of behavioral health benefits and Health and Recovery Plans (HARPs). In addition, it is working on improving the eligibility and enrollment procedures for Medicaid beneficiaries new to Medicare.

The Fully Integrated Duals Advantage (FIDA) program will wind down by the end of the year, with approximately 2,700 members to be passively enrolled in the companion MAP products offered by their FIDA plans or in Medicare FFS and the associated MLTCs of the FIDA plans. Beneficiaries will have the ability to choose a different plan or a PACE program. Guidance will be released in the next few weeks identifying the FIDA-MAP plans that satisfy the three-part test necessary to passively enroll FIDA beneficiaries.

Stakeholders are encouraged to submit questions and comments to DOH here.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124