The Complex Art of Making It Simple: Factors Affecting Enrollment in Integrated Care Demonstrations for Dually Eligible Beneficiaries
- Beneficiary Participation Rates: Over the course of the demonstration, participation rates in four states – Ohio, Rhode Island, Virginia, and Michigan – have tended to fall at or above the 75th percentile among all states’ beneficiary participation rates. Participation rates in three states – Illinois, South Carolina, and Texas – have generally fallen near the median, while those in California, New York, and Massachusetts have tended to fall at or below the 25th percentile range.
- Major Factors Affecting Enrollment: The study findings indicate that dually eligible beneficiaries are more likely to enroll, and remain enrolled, in integrated Medicare-Medicaid plans when the process of enrolling is easy, the benefits of doing so are tangibly and quickly demonstrated, and integrated care plans are cast as a preferred option over non-integrated care arrangements.
- Primary factors associated with increased enrollment included: use of passive enrollment, alignment of FAI demonstration and state MLTSS program features, and positive beneficiary relationships with care coordinators and use of specific care coordination techniques. Secondary factors associated with increased enrollment included: use of Medicaid deeming policies, collaboration with trusted community-based organizations, strong MMP provider networks, and emphasis on certain outreach messages.
- One primary factor was associated with decreased enrollment: insufficient MMP support and engagement with LTSS providers. Secondary factors associated with decreased enrollment included: beneficiaries’ ability to enroll in, disenroll from, or change MMPs at any time; influence from acute care providers; state systems and data exchange issues; and the complexity of content in beneficiary passive enrollment notices. One factor was found to be associated with enrollment, but the directional impact depended on the respondent type – some states perceived use of an independent, third party Enrollment Broker as a factor that increased enrollment, while some MMPs perceived this as a hindrance to enrollment.
The Centers for Medicare & Medicaid Services (CMS) launched the Financial Alignment Initiative (FAI) demonstration in 2011 to test models of coordinated care that hold promise for reducing the cost of care and improving health outcomes for people eligible for both Medicare and Medicaid – dually eligible beneficiaries. In the FAI capitated model, 10 states and CMS contract with integrated Medicare-Medicaid plans (MMPs), which are paid a fixed monthly rate for each member to provide and coordinate Medicare and Medicaid benefits. Total enrollment in the FAI has been lower than anticipated. In 2017, on average, about 29 percent of eligible individuals were enrolled in MMPs across the 11 demonstrations operating in 10 states that year. However, the share of eligible beneficiaries enrolled in MMPs has varied across states, from about 4 percent in New York to more than 67 percent in Ohio, and some MMPs have been more successful than others in maintaining or growing enrollment over time.
This study sought to identify which program elements, state policies, and health plan characteristics and strategies are associated with variation in beneficiary participation rates and enrollment trends in each state’s demonstration. The study examined the experience of all 10 FAI capitated model demonstration states over the life of each state’s demonstration, took into account the views of state officials and MMP representatives, and considered a broader set of factors that might affect enrollment than prior studies. This study also used both quantitative and qualitative measures to assess the factors associated with enrollment in all 10 FAI capitated model demonstration states. Thirteen factors were found to be associated with enrollment in FAI demonstrations – seven factors were associated with higher enrollment and five with lower enrollment. One factor that was identified as potentially impactful to enrollment was associated with increased or diminished enrollment based on whether interview respondents represented a state Medicaid department or an MMP.