Advancing Integrated Care For Dual-Eligible Individuals Through Multisector Plans For Aging

Editor’s Note

This article is the latest in the Health Affairs Forefront major series, Medicare and Medicaid Integration. The series features analysis, proposals, and commentary that will inform policies on the state and federal levels to advance integrated care for those dually eligible for Medicare and Medicaid. The series is produced with the support of Arnold Ventures. Included articles are reviewed and edited by Health Affairs Forefront staff; the opinions expressed are those of the authors. Submissions will be accepted on a rolling basis until October 31, 2024.

While policy makers have sought solutions to integrate Medicare and Medicaid for decades, progress is still limited, as states are faced with several challenges, including:

Competing priorities. State Medicaid agencies must manage a long list of program issues and day-to-day processes. This includes program oversight across populations with diverse and often distinct needs (including new mothers, infants, young adults, older adults, dual-eligible individuals, and people with disabilities); processing program eligibility and enrollment; addressing information technology system challenges; certifying and regulating providers and health plans; providing for appeals, grievances, and hearings; collecting and submitting data to the federal government; and many other responsibilities. Currently, Medicaid agencies are also overwhelmed with the unwinding of the public health emergency further diverting attention from older adults and individuals with disabilities. Designing and managing a Medicare-Medicaid integrated program competes with these priorities.

Resource constraints. State Medicaid agencies are staffed to provide expertise in Medicaid policy and program design; however, integrated program design requires understanding Medicaid and Medicare policies, which are very different. Some philanthropies are funding direct technical support and resources for states to develop Medicare expertise and build leadership capabilities in Medicare policy, but these efforts alone cannot fully solve state capacity constraints. This lack of Medicare expertise, coupled with other resource limitations such as budgetary and staffing constraints or the lack of a “champion” on the issue, impedes a state’s ability to pursue Medicare-Medicaid integration.

Stakeholder buy-in and consensus. Stakeholder groups have varying and often competing interests in policies and programs that support older adults and people with disabilities. These stakeholders include the individuals enrolled in the program, their families, consumer advocacy organizations, medical and nonmedical providers, health plans, a state’s legislature, the governor’s office, and other entities. It can be difficult for states to bring together these sometimes-divergent perspectives and priorities, which can stall program design and implementation.

To address these challenges, a large number of states are implementing multisector plans for aging (MPAs), a “cross-sector, state-led strategic planning resource that can help states transform the infrastructure and coordination of services for their rapidly aging population, as well as people with disabilities.” Not only are MPAs resulting in state action on pressing aging issues, but they can also support a process by which states can navigate the infrastructure and political constraints that have historically prevented states from advancing Medicare-Medicaid integration efforts.

Multisector Plans For Aging Can Help States Address These Challenges

MPAs are a blueprint for states to help their residents age well, and as a result, can be a strong tool for Medicare-Medicaid integration.

State development of an MPA compels issue prioritization. An MPA requires the state to identify goals and objectives that focus on the well-being of not just existing older adults and individuals with disabilities, but also future aging generations. As such, an MPA naturally enables prioritization of program design for issues impacting dual-eligible individuals. In addition, an MPA can mandate action on a topic through an executive order, such as New York Governor Kathy Hochul’s executive order, which provided guidance on the MPA stakeholder advisory committee structure and responsibilities.

State development of an MPA implies there are state “champions” with interests that could align with Medicare-Medicaid integration. MPA development is driven by either executive or legislative champions, ensuring state-level leadership support from the outset. This positions MPA-related efforts for additional focus and resources from influential stakeholders on relevant topics, including integrated care for dual-eligible individuals. During the most recent gubernatorial campaign season and in an effort to demonstrate to voters which candidates might be champions for aging issues, AARP in Oregon asked candidates for their support of and commitment to a comprehensive state plan for aging. The winning candidate, now Governor Tim Kotek, described an MPA in her response, explaining the need for “a comprehensive plan, from housing to transportation to other issues, so people can age in a way that they can be successful, and we can all be successful.”

State development of an MPA brings together stakeholders to drive consensus and decision making. Public-, private-, and independent-sector stakeholders, along with state-level leadership, are typically part of an MPA process. Participants might include health plans and other organizations that provide coverage for dual-eligible individuals, providers, consumer groups, workforce advocates, and state lawmakers and officials, all with vested interests in aging and disability policy as well as Medicare-Medicaid program design. Convening these diverse perspectives and interests forces difficult conversations and produces consensus on key issues. For example, in 2022, Vermont held six listening sessions across the state, conducted a survey with 2,800 responses, and facilitated targeted focus groups with historically marginalized communities to engage stakeholders and gather input in support of MPA development. Stakeholders can also sign up for monthly updates along with meeting and comment notifications to continue to shape Vermont’s MPA.

The infrastructure developed through an MPA process can also help drive state-level decision making on related future key issues. For example, several states leveraged the relationships and collaborative processes resulting from the MPA process to guide state development of home- and community-based services (HCBS) spending plans for the enhanced Federal Medical Assistance Percentage made available through the American Rescue Plan Act of 2021. In California, several items in the state’s MPA (known as the master plan for aging) were addressed through the state’s HCBS spending plan, which largely impacts dual-eligible individuals, such as reducing the assisted living waitlist by 3,700 spots and the development of a grant program for direct-care workforce training.

State development of an MPA creates a mechanism for accountability and transparency. Using either legislation or executive orders creates a public framework for the MPA that advocates can use to hold a state accountable in its budgetary and policy decision making. In addition, states often create websites, dashboards, or other mechanisms to track progress on efforts related to MPA development and implementation. Best practices for MPAs also include identifying responsible state-level departments and agencies to further build accountability for progress. Although the MPA is still in development in Tennessee, a group leading the development of the MPA’s framework partnered with East Tennessee State University Center for Rural Health to create a data dashboard featuring state- and county-level data on aging; this data will inform future policy decisions. The group supporting the dashboard creation includes the governor’s administration, the Department of Health, the Department of Intellectual and Developmental Disabilities, the state Medicaid agency, AARP TN, and the Area Agencies on Aging and Disability.

Steps States Can Take To Advance Integration Using An MPA

States can leverage the existing stakeholder processes and infrastructure development for their MPA to focus specifically on advancing Medicare-Medicaid integration. Currently, 24 states are in different stages of MPA development (exhibit 1). MPA progress in states is changing rapidly, and the statuses reflected below are as of (June 22, 2023). For the purposes of these statuses, the following definitions apply:

• States with developed or implemented MPAs have a completed and publicly available plan, with implementation apparent through updates and activities reported by the state.
• States with legislation passed or executive orders have information on these efforts that is publicly available.
• States that are fostering development have introduced legislation, have state-led stakeholder processes/meetings/advocacy or state-led cross-department collaboration underway, or are part of the Center for Health Care Strategies Learning Collaborative.

Exhibit 1: State activity regarding multisector plans for aging (MPAs)

Source: Authors’ analysis.

States with in-development or active MPAs are using them in different ways to improve experiences for older adults and individuals with disabilities. Example activities include:

• Developing a centralized public data dashboard to better understand the needs and experiences of older adult residents, including access to long-term services and supports (LTSS) in real time;
• Updating choice counseling programs (for example, State Health Insurance Assistance Program [SHIP]), to help people dually eligible for Medicare and Medicaid better understand their care choices; and
• Building capacity among No Wrong Door systems for LTSS, Area Agencies on Aging, and Aging and Disability Resource Centers to better facilitate seamless and timely access to services in an evolving medical and nonmedical care environment.

MPA Case Study: Advancing Medicare Innovation And Integration In California

One additional example of a state leveraging its MPA to advance Medicare-Medicaid integration is the state of California’s work to create the Office of Medicare Innovation and Integration in response to different initiatives in the state’s MPA.

Governor Gavin Newsom released an executive order in 2019 calling for the development of an MPA in California; the MPA was released in January 2021. In response to two initiatives included in the MPA (initiatives 34 and 35), the Office of Medicare Innovation and Integration (OMII) was established within California’s Department of Health Care Services (DHCS, the state’s Medicaid agency). The OMII launched in July 2021 with the mandate of supporting strategies to improve access to LTSS for Medicare-only beneficiaries and providing leadership and guidance on DHCS policies for beneficiaries dually eligible for Medicare and Medi-Cal (California’s Medicaid program).

Under a strategic initiative of the MPA, DHCS and our organization, The SCAN Foundation, convened national experts and officials at the California Department of Aging to develop the OMII’s charter. Resultingly, the OMII’s charter has broad buy-in while ambitiously addressing several MPA initiatives for the 2023–24 implementation year. Now as a funded office, the OMII actively facilitates better integrated services across Medicare and Medi-Cal (MPA initiative 29), plans and develops models that expand LTSS access for people with Medicare only (MPA initiative 34), and convenes Medicare Advantage plans and the Centers for Medicare and Medicaid Services to “explore innovative strategies and common goals to improve quality, access, affordability, and equity" for Californians with Medicare (MPA initiative 30). Most recently, through its State Medicaid Agency Contract with Dual-Eligible Special Needs Plans (D-SNPs), the OMII required plans to include palliative care services for members with serious illness in 2024.

State Approaches

Depending on where a state is in its MPA activity, there are different approaches to consider for improving experiences for dual-eligible individuals.

States Developing Or Implementing An MPA

States in the process of developing or implementing an MPA should consider how to deploy MPA momentum and resources to establish a dedicated state office or team working on Medicare integration efforts. The California DHCS OMII is a strong example for similarly situated MPA states to consider, as a way to advance overall Medicare efforts and, specifically, Medicare-Medicaid integration. Some states (notably Indiana and Virginia) have enhanced Medicare-Medicaid integration and improved policies and programs for older adults by employing a single staff member focused on Medicare-Medicaid integration within a state agency. This approach creates the space for state staff to focus on learning Medicare policy and opportunities, allowing for a formal conduit between the state and Medicare health plans, providers, and other stakeholders, which is essential in integrated programs.

States With Legislation Introduced/Passed Or An Executive Order To Establish An MPA

States in the process of establishing an MPA should include explicit initiatives that would advance Medicare-Medicaid integration. This might include initiatives that improve integration between medical and nonmedical services, data/evaluation requirements to understand outcomes for and experiences of dual-eligible individuals or those receiving both Medicaid LTSS and Medicare services, or efforts to improve coordination among D-SNPs, state Medicaid providers, and community-based social service providers. States establishing an MPA should also leverage the momentum to engage with their state legislature on the value of Medicare-Medicaid integration.

States Fostering Development Of An mpa

State- or community-based stakeholders may also lead the push to develop an MPA. In these cases, stakeholders should leverage their connections to engage varied perspectives in MPA consideration and development work. Groups operating at the state level may have unique insights into existing integration efforts and the ability to identify opportunities to build on these efforts. For community-based organizations and other stakeholder groups, the state should welcome and encourage those groups to consider opportunities associated with dual-eligible individuals. This might include ensuring SHIPs or other aging and disability network providers are part of MPA discussions and are able to share their experiences assisting dual-eligible individuals. Consumer advocates are also critical to include as they can ensure that elements important to dual-eligible individuals are incorporated in the dialogue. The state may also engage providers and programs serving dual-eligible individuals to ensure they understand the value of Medicare-Medicaid integration. In addition, in states that already have a robust integrated program, the state should consider how the MPA might further engage community-based organizations and stakeholder groups in ongoing refinements to integrated program design.

States With Limited Or No MPA Activity

States without an MPA and without any activity to develop an MPA should consider pursuing one. In addition to the opportunity presented by MPAs in advancing state-level actions on the integration of the Medicare and Medicaid programs, these plans provide a key tool for states looking to support their aging populations. The SCAN Foundation has published resources for states considering standing up an MPA, including how to build on existing attributes in the state (such as state planning committee efforts and equity strategies), and has supported the development of resources to help state-level actors begin developing MPAs.

Moving Forward

The MPA is a strong tool for states to build consensus around and act on aging and disability initiatives. States and stakeholders see the value in MPA development, as evidenced by the rapid adoption and increased interest across the country. It is important to leverage the momentum, collaboration, and appetite for action that MPAs create among varied stakeholders to pursue or advance Medicare-Medicaid integration and improve experiences and outcomes for dual-eligible individuals.

Authors’ Note

The authors are employees of The SCAN Foundation, an independent public charity that has supported development and implementation of California’s master plan on aging and the multisector plan for aging learning collaborative through the Center for Health Care Strategies along with our philanthropic partners.