Case Studies of Managed Care Arrangements for Dually Eligible Beneficiaries
While The Centers for Medicare and Medicaid Services (CMS) and individual States consider managed care an important vehicle for improving health care delivery and controlling expenditures, health plans contracting with Medicare or with individual State Medicaid Programs face many challenges. These challenges are particularly complex when health plans enroll beneficiaries—known as dually eligible—who are covered by both Medicare and Medicaid. In order to examine managed care arrangements for dual eligible beneficiaries, CMS contracted with RTI, Inc. (500-95-0048) to conduct case studies with 11 M+C Organizations and Medicaid managed care organizations, and four focus groups of plan enrollees were held to obtain beneficiary information and experiences. The market areas studied in 2000 were Los Angeles, Portland ME, Philadelphia and Miami. The central goals of this report are to: (1) describe the existing variation in Medicare and Medicaid managed care combinations in which dually eligible beneficiaries are enrolled; (2) identify problems that managed care organizations (MCOs), beneficiaries, and providers encounter when dually eligible beneficiaries are enrolled in MCOs; and (3) discuss the implications of these findings. The focus of this report is on managed care arrangements under existing authority, not special managed care demonstrations or programs that specifically target dually eligible beneficiaries. Before addressing these goals, we provide background information on Medicare/Medicaid dual eligibility and managed care enrollment available for these beneficiaries.