Dual-Eligibles Not Opting Into State Care Coordination Programs

To better align the care of beneficiaries insured under both the Medicaid and Medicare programs, CMS invited states to participate in a 3-year demonstration project. The initiative, part of a provision of the Affordable Care Act (ACA), was an intiaitive aimed at helping dual-eligibles understand their benefits as well as to ensure that they received the services they needed. However, it seems that many beneficiaries have opted out of these care coordination programs that are offered across the country.

In total, 11 states agreed to join the pilot program. Still, the number of dual-eligibles who volunteered to have their care coordinated remains low. Of the 94,000 in Massachusetts who qualified, only 13,000 enrolled while 21,000 had opted out as of May 1, 2014. In California, only 40,000 of an estimated 450,000 dual-eligibles had opted into the state’s program as of July 1, 2014.

“The biggest problem we found our members encountered was thinking that they were required to opt-out, since the opt-out forms were included in the notification letters,” ‎said Russell Hoyle, marketing director at Health Plan of San Mateo in San Francisco.

Although dual-eligibles account for only 13% of the US population, they constitute for 40% of all Medicaid spending and nearly 30% of Medicare spending. Finding ways to encourage beneficiaries to enroll in coordination programs is necessary to ensure that their care is more cost-effective.

“Given the fact that the demonstration introduces a significant change to the delivery system, it makes sense that continued access to one's provider is a primary concern for beneficiaries,” said Fay Gordon, a staff attorney at National Senior Citizens Law Center. “Dual-eligible individuals are low-income beneficiaries, and their needs were not a priority in previous transitions to private managed-care systems.”

Other officials whose states are participating in the program — including Ohio and Illinois —said they are not concerned about enrollment numbers.

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Many Dual-Eligibles Opt Out of Care Coordination [Modern Healthcare]