Coordinated Care Management

May 18, 2011

HHS Working with States to Easily Integrate Between Medicare and Medicaid

The U.S. Department of Health and Human Services (HHS) announced today it will work with states to save money and better coordinate care for the nine million Americans enrolled in both Medicare and Medicaid, helping those enrolled in both to find an easier way to integrate care between the two programs.

In addition, HHS also announced a new process that provides faster state access to Medicare data to support care coordination, Access to Medicare.

The new initiatives will be led by the new Federal Coordinated Health Care Office (the Medicare-Medicaid Coordination Office), which was created by the Affordable Care Act, to help make the two programs work together more effectively to improve patient care and lower costs.

The new organization, the Medicare-Medicaid Coordination Office, today launched the Alignment Initiative, an effort to more effectively integrate benefits under the two programs. Currently, low-income seniors and people with disabilities must navigate two separate programs: Medicare for coverage of basic acute health care services and drugs, and Medicaid for coverage of supplemental benefits such as long-term care supports and services. Medicaid also provides help with Medicare premiums and cost-sharing for those who need additional assistance.

A lack of alignment between the programs can lead to fragmented or episodic care for people with both Medicare and Medicaid coverage, which can reduce quality and raise costs. For example, Medicaid and Medicare have different coverage standards for those accessing durable medical equipment in the community. This can lead to fragmented care and coverage gaps that could result in patients losing access to the treatments and equipment that help them live at home or in the community.

Navigating the two programs can be both complicated and burdensome for beneficiaries and their families and caregivers, say experts. Medicaid costs are largely driven by the complex medical needs of low-income seniors and people with disabilities who are eligible for both Medicare and Medicaid.

Medicare and Medicaid spend $300 billion each year to care for people enrolled in both programs, according to HHS statistics. Better coordinated care for this vulnerable population could yield savings and improve care and coverage in Medicaid.

Currently, 60 percent of Medicare-Medicaid enrollees, “dual eligibles,” have multiple chronic conditions and 43 percent have at least one mental or cognitive impairment, according to HHS. While only 15-percent of Medicaid enrollees are also Medicare beneficiaries, Medicare-Medicaid enrollees represented 39 percent of Medicaid spending in 2007, the last year for which there are statistics.

Medicaid spent about $120 billion on this group – about twice as much as Medicaid spent on the 29 million children it covered. The Medicaid spending per Medicare-Medicaid enrollee was $15,459 in 2007, over six times higher than the comparable cost of a non-disabled adult Medicaid-only enrollee ($2,541), according to HHS.

Even temporary coverage gaps can be disruptive if patients no longer have coverage for wheelchairs or other expensive medical care. The Medicare-Medicaid Coordination Office is seeking input and ideas about how to align in six areas: care coordination, fee-for-service benefits, prescription drugs, cost sharing, enrollment, and appeals. Better alignment in these areas can reduce costs by improving health outcomes and making care coordination more efficient.

The new Access to Medicare data is a tool for states seeking to coordinate care, improve quality, and control costs for their highest cost beneficiaries. For example, a state that wants to expand its long term care and behavioral health care management program to serve low income seniors and people with disabilities needs data on their Medicare-covered hospital, physician, and prescription drug use. With Medicare data, states can identify high-risk and high-cost individuals, determine their primary health risks, and provide comprehensive individual client profiles to its care management contractor to tailor interventions.

The announcement of the new policy on state Medicare data for enrollees in Medicare and Medicaid will be published in a Center for Medicaid, CHIP and Survey & Certification (CMCS) Informational Bulletin today. The Bulletin is available at:

Deborah DiSesa Hirsch is an award-winning health and technology writer who has worked for newspapers, magazines and IBM in her 20-year career. To read more of her articles, please visit her columnist page.
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