Opportunities From The Financial Alignment Initiative To Increase Integrated Care For Dually Eligible Beneficiaries

This blog was originally published by the Health Affairs Forefront.

Since the Financial Alignment Initiative (FAI) capitated model launched in 2013, a goal of the program has been to better align the financing of Medicare and Medicaid, in part through a three-way contract between the Centers for Medicare & Medicaid Services (CMS), the state, and the Medicare-Medicaid Managed Care Plan (MMP). As the Medicare Advantage CY 2023 Final Rule stated, CMS intends to work with states to transition the FAI capitated demonstrations to integrated Dual-Eligible Special Needs Plans (D-SNPs) by 2025.

The landscape of care for the dually eligible has shifted since the launch of FAI with the increased presence of D-SNPs, and part of the legacy of FAI includes the following D-SNP requirements that stem from the model, as discussed in the Medicare Advantage CY 2023 Final Rule: enrollee advisory committees, simplified grievance and appeals processes, and requiring social determinants of health (SDOH) items in their Health Risk Assessments (HRAs). Here we highlight four additional learnings from FAI that are not required in the Medicare Advantage CY 2023 Final Rule but that may be considered by D-SNPs to better meet enrollee needs, insomuch as implementing is deemed to be feasible.

Strengthening Care Coordination To Improve Outcomes

Care coordination is the central mechanism for integrating care, and FAI leverages an HRA to identify unmet medical, long-term services and supports (LTSS), and behavioral health needs. Care coordinators use this information to identify potentially beneficial services, refer eligible beneficiaries to services, and attempt to address needs related to SDOH.

Optimal care coordination includes developing effective relationships and working with enrollees to develop and implement person-centered care plans. Engagement with care coordinators is associated with beneficiary satisfaction and positive outcomes; for example, it helps beneficiaries learn to better manage their chronic conditions, which in turn improves beneficiary quality of life and may reduce hospitalizations and emergency department use. MMPs take different approaches to care coordination, including how they staff and train care coordinators, and whether HRAs are conducted in person or by mail. 

Despite this opportunity to leverage care coordination to improve outcomes, variability in care coordination approaches and in the extent to which care coordinators directly engage with beneficiaries might, in part, account for a lack of utilization and cost impacts. The CY2023 rule specifies HRA requirements, but D-SNPs should consider additional evidence-based care coordination practices and establish standardized reporting on care coordination activities.  Data that is identifiable and linkable and that includes assessment completion date, assessment type (e.g. in person or by mail), creation of an individualized care plan, dates and types of contact by care coordinators with enrollees, and dates and types of provision of non-traditional goods and services (e.g. care plan options) allow for monitoring and evaluating care coordination at the plan level.

Ensuring Enrollment Continuity To Achieve Continuous Care

The impacts stemming from improved care coordination—access to medical, behavioral health, and LTSS—take time. Therefore, enrollment continuity (i.e., continued enrollment without sudden loss of eligibility and disenrollment) is critical for managed care plans to follow and connect enrollees to resources for needed medical, behavioral health, LTSS and other health-related services. Barriers to achieving enrollment continuity include enrollees opting out of their plan and the loss of Medicaid eligibility. Although FAI allows special enrollment periods, most states do not make use of this option due to the technical challenges or the expense involved in revising their systems. With the multi-year phase out of FAI for the transition from MMPs to D-SNPs, states may have time to work through the technical challenges and/or to revise systems to implement the special enrollment period if it remains an option in the future.  

While dually eligible beneficiaries are thought to sustain Medicaid coverage due to relatively stable income and assets, they may lose coverage due to failure to comply with administrative requirements for recertification. According to a study by Feng et al, as many as 30 percent of dually eligible beneficiaries lost eligibility for a month or more in their first year of enrollment, and 21 percent sustained this loss for three months or longer. Loss in eligibility can lead to interrupted coverage and by extension, interrupt access to necessary health care services.

MMPs took two approaches to address or prevent interruptions in Medicaid coverage. In one approach, care coordinators in some MMPs tracked upcoming redetermination dates and worked with enrollees to submit their paperwork on time. The other approach was to continue to provide services when the loss of Medicaid eligibility was assumed to be temporary and would be retroactively reinstated. D-SNPs could invest in similar strategies to minimize service interruptions and thereby support continuity of care.

Leveraging Payer Coordination To Promote Care Integration

FAI capitated models leverage three-way contracts between CMS, the state, and the managed care plan. Administration of the three-way contracts is monitored by the Contract Management Team (CMT), a team that includes representatives from the State Medicaid agency, the Medicare and Medicaid groups in the CMS Regional Offices, and the Medicare-Medicaid Coordination Office (MMCO) State lead. Regular meetings between these parties help to facilitate coordination, promote integrated care for dually eligible beneficiaries, and provide joint plan oversight. Even without joint plan oversight as in the FAI 3-way contracts, having a mechanism for state-CMS collaboration that draws on the CMT experience, such as the Minnesota’s Demonstration Management Team (DMT), would benefit states working to promote integrated care for dually eligible beneficiaries. This communication avenue can help states to better understand their own authorities and fill a gap in states’ understanding of Medicare regulations.  

Using Aligned Enrollment To Optimize Care Coordination

Aligned enrollment refers to a situation where a beneficiary is enrolled in a Medicare Advantage plan and a Medicaid managed care plan administered by the same parent company. For those beneficiaries who are both eligible for managed LTSS (MLTSS) and participate in MMPs or Fully Integrated Dual Eligible (FIDE) SNPs, aligned enrollment between the two service lines has been demonstrated to reduce beneficiary confusion and increase enrollment in integrated care. Aligned enrollment could similarly reduce confusion for D-SNP beneficiaries.

Applying The Learnings From FAI

The landscape of care provision for dually eligible beneficiaries has changed substantially since FAI was launched in 2013. Plans and CMS continue to look for opportunities to improve care and decrease costs. Given these learnings from FAI, we encourage plans to consider and incorporate the learnings we highlight here as feasible and appropriate. Doing so may help to minimize burden and confusion of dually eligible beneficiaries, increase the opportunity for plans to impact outcomes, optimize care coordination, and increase states’ understanding of Medicare managed care regulations.