Dual Eligible Beneficiaries: One Year In
By Barry Zimmer on March 5th, 2015 in Medicaid
There’s been a lot of confusion associated with the Centers for Medicare and Medicaid Services’ decision to bring together both 
programs for the benefit of dual eligible beneficiaries. Unfortunately, after one year, much of that confusion continues in Ohio. This week, we take a look at the dual eligible beneficiaries aspect, as well as a few more of the highlights, to better understand what – if any – purpose it can realistically serve.
Part of the frustration has to do with the verbiage of the rules and understanding various terms, such as “dual eligible beneficiaries”, “financial alignment demonstrations” and “capitated demonstration health plan”.
The Program
While Congress has worked on bringing Medicaid and Medicare together to better improve the healthcare options for many elderly and disabled Americans, the program’s only been in place one year. The vehicles for delivering this combined healthcare are referred to as “financial alignment demonstrations”.
Financial Alignment Demonstrations: CMS created two testing pilots to gauge which would be better for those approved for dual eligibility. The demonstrations are designed and put into place for three years in those states that are part of the collective CMS effort. They will test a number of changes in how healthcare is delivered while also changing the payment systems and financing options for the states, insurance providers and CMS. Because the current delivery models aren’t efficient, specifically lacking in across the board coordination, the goal is to eliminate what CMS says is a “disproportionate share” of funding. These demonstrations seek to remedy that problem.
Ohio’s Dual Eligible Beneficiaries:
Dual Eligible Beneficiaries: Those who receive both Medicare and Medicaid are dual eligible beneficiaries. Between those who are young and who have significant disabilities, as well as the elderly population, there are more than 9 million dual eligible beneficiaries. Of those 9 million, 7 million are considered full duals, meaning they receive the benefits of both programs. Partial duals account for the remaining 2 million and they receive assistance from Medicaid to help cover their Medicare premiums and other out of pocket expenses.
Capitated Demonstration Health Plan The capitated model is simply the agreement between the Centers for Medicare & Medicaid Services (CMS), Ohio (or any of the other states that are participating), and a health plan that enters into a three way contract to provide comprehensive care in a more coordinated fashion. Each state, including Ohio, was required to submit a readiness review that showed it was in compliance with the guidelines. As part of that review, the beneficiary’s care, including assessment processes, care coordination, provider network development and maintenance and the training protocol, had to be submitted and approved.
MyCare Ohio
Ohio’s plan, known as MyCare Ohio, is currently feeling the stress of transition. The dual eligible program is operating in 29 counties and covers close to 100,000 Ohioans. The biggest problem is delays in payments and the state says it’s due to the way claims are being submitted. It’s believed once those snags are smoothed out, the transition should see fewer delays or hiccups.
If you’d like to learn more about Medicare or Medicaid coverage, or dual eligible coverage, we invite you to contact our offices to discuss your options.