From coverage to care: addressing the issue of churn.

In any given year, a significant number of individuals will move between Medicaid and qualified health plans (QHP). Known as "churn," this movement could disrupt continuity of health care services, even when no gap in insurance coverage exists. The number of people who churn in any given year is significant, and they often are significant utilizers of health care services. They could experience disruption in care in several ways: (1) changing carrier; (2) changing provider because of network differences; (3) a disruption in ongoing services, even when the benefit is covered in both programs (e.g., surgery that has been authorized but not yet performed; ongoing prescription medications for chronic illness; or some but not all therapy or counseling sessions have been completed); and (4) the loss of coverage for a service that is not a covered benefit in the new program. Many strategies are available to states to reduce the disruption caused by churn. The specific option, intervention, and set of policies in a given state will depend on its context. Policy makers would benefit from an examination and discussion of these issues.

Medicare Advantage Special Needs Plans for dual eligibles: a primer.

The Special Needs Plan (SNP), a new type of Medicare Advantage plan created by the Medicare Modernization Act of 2003 (MMA), targets one of three special-needs populations--including beneficiaries who qualify both for Medicare and Medicaid benefits ("dual eligibles"), the focus of this issue brief. It identifies the key issues that underlie one of the MMA's central goals for dual eligible SNPs--"the potential to offer the full array of Medicare and Medicaid benefits, and supplemental benefits, through a single plan"--and it outlines their progress thus far. The brief observes that true coordination between SNPs and Medicaid programs, despite some state and federal initiatives, has largely failed to occur, and it discusses some of the reasons why. Consequently, the brief offers recommendations for improving dual-eligible SNPs' prospects and extending their lives (legal authorization for SNPs is scheduled to expire at year-end 2008).

Coordinating care for dual eligibles: options for linking state Medicaid programs with Medicare Advantage Special Needs Plans.

Medicare Advantage Special Needs Plans (SNPs) for dual eligibles--individuals who qualify both for Medicare and Medicaid benefits--have the potential to coordinate Medicare benefits with state-administered Medicaid benefits. States that aim to develop such programs may choose from among three potential models: 1) a Medicaid program in which the beneficiary voluntarily enrolls in a single managed care organization (MCO) that delivers both Medicaid and Medicare services; 2) a program in which the beneficiary is required to enroll in a Medicaid MCO but retains freedom of choice regarding whether to enroll in a capitated Medicare plan; and 3) an administrative services organization approach,in which Medicaid retains a vendor to coordinate Medicaid services with the SNPsoperating in the state. The authors also provide guidance on contractual issues important to state Medicaid agencies, and they discuss environmental factors that influence the choice of models and the program's prospects for success.

Impact of the Medicare prescription drug benefit on home- and community-based services waiver programs.

"Dual eligibles" is the term for the 6.4 million low-income, elderly, and disabled Americans who are enrolled in both Medicare and Medicaid. With home-and community-based services waivers allowed under Section 1915(c) of the Social Security Act, many of these individuals are able to live in a home or community setting, thereby avoiding institutionalization. Surveying Maryland's 3,180 dual eligibles who are enrolled in home-and community-based waiver programs, the author finds that the end-of-2005 transfer of prescription drug coverage from Medicaid to Medicare under the Medicare Modernization Act of 2003 could put these beneficiaries in jeopardy. Maryland's experience is likely to be typical of what other states will face. The author recommends a number of federal policy remedies, among them allowing 90-day prescriptions, using open or shared formularies, and lengthening the enrollment period.