CMS rule proposed for 2025 offers big upsides for dually eligible individuals: Analysis

CMS recently proposed new rules detailing how it wants to cover individuals who qualify for both Medicare and Medicaid. The authors of a new analysis cheer on the suggested changes, stating the updated governance will—if finalized and adopted for target year 2025—not only integrate coverage for underserved populations but also clamp down on the “games” that Medicare Advantage plans have been known to “play.”

Private suppliers of these plans sometimes enroll individuals only in Medicare Advantage products, the authors explain. In so doing, plan administrators miss chances to integrate Medicaid programs on behalf of many underserved patients, they point out.

The authors are Michael Monson and Sarah Barth of the Michigan-based nonprofit Altarum, which conducts research related to economically vulnerable and publicly insured populations. Monson is the firm’s president and CEO, Barth its executive director for Medicare-Medicaid services for states.

Health Affairs Forefront published their commentary online Feb. 23.

In voicing support for CMS’s plans, Monson and Barth reference the agency’s initial rule draft for 2023 and its updated rule draft for 2025. Taken together, the two documents represent a “large step forward to ensure that dually eligible individuals can receive integrated care and services,” they write.

Monson and Barth are especially eager for the arrival of two components in the pending rule for 2025:

1. Enhanced guardrails for agent and broker compensation would deter biased enrollment support.

For dually eligible individuals, paid brokers and agents are “deeply problematic,” Monson and Barth maintain. “These brokers and agents have financial incentives to continually move individuals from plan to plan. Because dually eligible individuals are entitled to special election periods (and other individuals are not), they are targeted by these brokers—especially outside of the annual election period.” More:

The proposed rule would normalize and limit payment across the Medicare Advantage landscape, thereby minimizing some of the incentives for brokers/agents to seek out dually eligible individuals and encourage them to switch.

2. Care integration would improve for dually eligible managed care enrollees who receive Medicare and Medicaid services from the same organization.

In states that use Medicaid managed care organizations to deliver Medicaid benefits, patients often end up with separate—and non-coordinated—plans for each. “When a full benefit dually eligible individual is receiving their Medicare benefits from one Medicare Advantage plan and their Medicaid benefits from a different company’s Medicaid managed care organization, there is virtually no chance that they will receive an integrated experience,” Monson and Barth write. More:

While being in the same plan for Medicare and Medicaid benefits cannot guarantee an integrated experience, it at least creates the necessary conditions for it to occur. Furthermore, the benefits from exclusively aligned enrollment (for example, single ID card, unified appeals and grievances, and so forth) are completely abrogated when individuals are in different plans (or non-integrated plans offered by the same parent company).

There’s more for the likes of Altarum to appreciate in the proposed 2025 rule, the authors show, and one of its best points in their view is its intended automatic implementation, which promises to save state government employees from adding new tasks to their workloads.

“We know that such care integration has the potential to improve the quality of life of these [dually eligible] individuals,” Monson and Barth conclude. “Further limiting the ‘gaming’ that Medicare Advantage plans play will limit confusion for individuals and create more conditions for integrated care across the two programs. Furthermore, the ability of states to receive more timely, critical information will enable them to hold their health plans more accountable and to drive integration.”

The journal has posted the commentary in full for free.