Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Medicare Special Needs Plans

10/29/2010

Because such a high proportion of individuals who need long-term services are dually eligible for Medicaid and Medicare, some states offering MLTC have contracted with Medicare Special Needs Plans to create integrated programs for dually eligible persons. Special Needs Plans are authorized under the Medicare Advantage managed care program. Unlike regular Medicare Advantage plans, Special Needs Plans may limit enrollment to one of three authorized groups: dually eligible persons, beneficiaries requiring institutional level of care, or beneficiaries with specified chronic conditions.20

A state uses the appropriate Medicaid authorities to craft a managed Medicaid program and contracts with a Special Needs Plan, which has a separate contract with CMS to deliver Medicare managed care services. The two are combined at the plan level to create an integrated Medicaid and Medicare program for dually eligible persons. Because no authority exists for mandatory Medicare enrollment, integrated plans must be voluntary. See Table 8-7 for an example of contracting with Special Needs Plans to create integrated Medicare-Medicaid programs.

As noted above, §1934, which authorizes PACE programs, is the other authority that may be used to offer integrated Medicare-Medicaid programs.

TABLE 8-7. Minnesota Senior Health Options
Start Date 1997
Target Group Older persons (65+) who are dually eligible for Medicaid and Medicare, whether or not they have long-term care needs. Enrollment is voluntary.
Service Area Nearly statewide
Scope of Medicaid Capitation All Medicaid services, including primary and acute health care, HCBS, and up to 180 days of institutional long-term care services. Behavioral services are also included. (Medicare services are fully capitated in a separate payment to Minnesota Senior Health Options from the Medicare program.)
Authorities Section1915(a) authority and §1915(c) waiver. When this program began in 1997, it was an experimental model to combine Medicaid and Medicare and integrate financing for primary and acute health services and long-term care services under a §1115 waiver. By renewal time, other states had developed combination approaches without a §1115 waiver and its difficult budget test, and Minnesota agreed to change to the (a)(c) combination at that time. Medicare authority also shifted over time, from special payment authority and variances under the Medicare statute, to Medicare Special Needs Plan authority.
More information is available at: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&d DocName=id_006271&RevisionSelectionMethod=LatestReleased.

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