Medicaid Managed Care - U.S. Senate Special Committee on Aging

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Coordinating services is complicated for dual eligibles who are covered by two
payers (<strong>Medicaid</strong> and Medicare) and receive both acute and long term care.
Coordination varies by the type of systems dually eligible beneficiaries may enter.
While Medicare and <strong>Medicaid</strong> each seek to promote continuity and coordination,
states experience difficulties coordinating services for dual eligibles. The difficulties
vary with the type of managed care arrangement. There are multiple arrangements
involving <strong>Medicaid</strong> and Medicare, as illustrated by the following table.
<strong>Managed</strong> <strong>Care</strong> A For Dually Eligible Beneficiaries'9
Arrangement Examples Implications
Enroll in same plan for Arizona, Permits maximum coordination of care for
Medicare and <strong>Medicaid</strong> Oregon, health services.
health services Minnesota PMAP
Enroll in same plan for Arizona, Permits maximum coordination of care for
Medicare and <strong>Medicaid</strong> Minnesota MSHO health and long term care services.
health and long term care
services
Enroll in <strong>Medicaid</strong> plan; Arizona, Considerable coordination at the provider
Medicare fee-for-service; no Oregon, rather then HMO level since network
out-of-network cost sharing Minnesota PMAP physicians can follow Medicare fee-forservice
guidelines.
Enroll in Medicare HMO Arizona, Because of the 30 day Medicare lock-in,
with <strong>Medicaid</strong> fee-for- California, members will use providers within the
service Oregon HMO network for most health services.
Enroll in different HMOs for Arizona Conflicts occur with overlapping benefits
<strong>Medicaid</strong> and Medicare and assignment of two physicians.
Enroll in <strong>Medicaid</strong> plan with California, Opportunity to coordinate care is limited to
Medicare fee-for-service; no Tennessee <strong>Medicaid</strong> only benefits since members can use
limits on out-of-network use any provider for Medicare.
The complexity of coordination varies with the type of arrangement. Plans
providing both Medicare and <strong>Medicaid</strong> services have a broader scope of authority
19 It is important to note that Minnesota has two managed care programs that serve the
elderly. The Prepaid Medical Assistance Program (PMAP) is a mandatory program for the elderly and
TANF populations and has operated since 1985. It does not include nursing facility or home and
community based waiver services. Dual eligibles are locked into the network for 12 months for all services,
except the enrollee may go out-of-network for Medicare services if the enrollee is willing to pay the
Medicare co-pays. The Minnesota Senior Health Options (MSHO) is a voluntary alternative to the PMAP
for dual eligible beneficiaries. This program provides both <strong>Medicaid</strong> and Medicare services. Enrollees may
disenroll from the plan or program on a monthly basis but are locked into the plan's network for that month
for all services-neither <strong>Medicaid</strong> nor Medicare will pay for any portion of services obtained outside the
plan's network.
The National Academy for State Health Policy* C 8/97
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