Medicare Watch

Your Weekly Medicare Consumer Advocacy Update

New York’s Plan to Integrate Care for Dual-Eligibles

August 29, 2013 Volume 4, Issue 34

CMS Releases MOU with New York to Integrate Care for Dual-Eligibles

This week, the Centers for Medicare & Medicaid Services (CMS) released its Memorandum of Understanding (MOU) with the New York State Department of Health (NYSDOH) to introduce a new model for integrating and coordinating care for 170,000 people eligible for both Medicare and Medicaid, known as “dual-eligibles.” The new Fully Integrated Duals Advantage, or FIDA, demonstration will be implemented in New York City, Long Island and Westchester County, and is scheduled to begin on July 1, 2014.

The MOU outlines many of the provisions of the FIDA demonstration, with additional program details to be negotiated as part of a Three-Way Contract among CMS, NYSDOH and new FIDA insurance plans. The Coalition to Protect the Rights of New York’s Dually Eligible (CPRNYDE), a project led by the Medicare Rights Center and part of Community Catalyst’s Voices for Better Health initiative, advocated for many consumer protections included as part of the MOU:

  • An integrated appeals system, which streamlines the Medicare and Medicaid appeals processes and provides continuation of benefits during pending appeals. The integrated appeals system does not include Part D prescription drug appeals, but the MOU alludes to the opportunity for continued discussion about that issue.
  • The establishment of a new FIDA Participant Ombudsman, which will independently advocate on behalf of dual-eligibles enrolled in the demonstration and support their access to person-centered care in the community.
  • A requirement for FIDA plans to develop meaningful ongoing stakeholder and member engagement and participate in continuous quality improvement. The MOU also encourages FIDA plans to include their enrollees in governance but stops short of requiring such participation.

While CPRNYDE advocated for a purely voluntary enrollment process for the demonstration, which was not included, we note that NYSDOH and CMS did include a passive enrollment process that:

  • allows beneficiaries to opt out of the demonstration entirely;
  • allows beneficiaries to switch into a different FIDA plan (or other plan for which they might be eligible) on a monthly basis; and
  • will develop and employ an intelligent assignment algorithm that prioritizes continuity of providers and services.

Medicare Rights and CPRNYDE will continue to work with NYSDOH, health plans and provider groups to develop the forthcoming three-way contract to ensure that the implementation of this new demonstration, which affects some of New York’s frailest and most vulnerable residents, improves the quality, accessibility and affordability of their care.

Read Medicare Rights Center President Joe Baker’s statement on the MOU’s release.

Read New York States’ FIDA Update and MOU Discussion

CMS Report Compares Long-Term Care Costs for Duals and Non-Duals

The Centers for Medicare & Medicaid Services (CMS) recently released a report comparing the Medicare and Medicaid expenditures of older dual eligible beneficiaries, those who qualify for both programs, with non-dual beneficiaries, based on their long-term care (LTC) use. CMS found that both medical and LTC expenditures were higher for dual eligible beneficiaries than non-duals.

Dual eligibles are among the most vulnerable people served by both the Medicare and Medicaid programs, and they are also some of the most costly. Dual eligibles account for 16 percent of Medicare enrollees, but about 25 percent of total Medicare expenditures. In Medicaid, dual eligibles are even more costly; duals account for 18 percent of Medicaid enrollees and 46 percent of all expenditures. CMS found that in seven states—Arkansas, Florida, Minnesota, New Mexico, Texas, Vermont and Washington—dual eligibles that utilized LTC had more cardiovascular diseases, cancer, dementia, diabetes and developmental disabilities than non-duals. Additionally, both duals and non-duals in LTC had higher total expenditures than beneficiaries that did not utilize LTC.

According to the authors of the CMS report, the results of the study have some policy implications: efforts to address cost controls in the dual eligible population should focus on LTC and improving care coordination, especially as it relates to finding effective ways to address chronic illness. According to the report, managed care may be an opportunity to accomplish those goals, but further research would need to be conducted—older adults enrolled in managed care programs were excluded from this study.

Read the CMS report.

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Medicare Reminder

Medicare covers blood tests every five years to test cholesterol, lipid and triglyceride levels.

Heart disease is also referred to as cardiovascular disease. Original Medicare will pay 100 percent of its approved amount for these tests, even before you have met the Part B deductible. You will not pay a copay or a deductible for these screenings if you see doctors or other health care providers who take assignment. Doctors who take assignment cannot charge you more than the Medicare approved amount. You do not need to show signs of heart disease or have any particular risk factors for Medicare to cover the full cost of these tests.

If you are in a Medicare Advantage plan (private health plan) you should contact your plan to find out what rules and costs apply. Medicare Advantage (MA) plans cover all preventive services the same as Original Medicare. This means MA plans will not be allowed to charge cost-sharing fees (coinsurances, copays or deductibles) for preventive services that Original Medicare does not charge for as long as you see in-network providers. If you see providers that are not in your plan’s network, charges will typically apply.

Learn more about Medicare coverage of preventive services at



As part of its monthly infographic series, “Visualizing Health Policy,” The Kaiser Family Foundation recently released a look at long-term care services and supports for older Americans. The infographic includes information that projects the growth of the long-term care population in the next 37 years and the size of the senior population that will need long-term care due to cognitive and physical impairment. The infographic also shows the number of Americans who receive long-term care from an unpaid family member, a breakdown of total long-term care spending, and the transfer of Medicaid spending on long-term care to community-based care.

View the infographic.

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