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February 01, 2014

The Dual Eligible Demonstration

Fay Gordon

(Note: The pdf for the issue in which this article appears is available for download: BIFOCAL Vol. 35, Issue 3.)

If everything goes as planned, by January 1, 2015, hundreds of thousands of individuals could be enrolled in new delivery systems where combined Medicare and Medicaid services are provided through managed care plans. Of course, nothing ever happens exactly as planned. However, nine states1 are on tap to implement a dual eligible demonstration within the next year, making this a critical time in both planning and implementation of the new systems.

The changes, called dual eligible demonstrations, will significantly alter the way that low income older adults and persons with disabilities receive their Medicare and Medicaid services. Participating dual eligibles will be able to receive both sets of benefits through a managed care plan that will get a combined stream of capitated payments for all covered services. Individuals will be passively enrolled into the plans but can opt out at any time. The demonstrations have the combined goals of providing more coordinated care and reducing costs.

In the past year, advocacy around the dual eligible demonstrations has started to shift from shaping their design to monitoring the implementation. In this early implementation period, issues like provider outreach, beneficiary communication, and care continuity require lawyers and consumer advocates to engage with their state while monitoring client transitions.

Demonstration background

The dual eligible demonstrations are a product of Affordable Care Act (ACA). The ACA granted the Centers for Medicare and Medicaid Services (CMS) the authority to develop new structures to coordinate the way that Medicare and Medicaid delivers care for dual eligible individuals (beneficiaries who participate in both programs). In the past year and a half, CMS approved new demonstrations in nine states (Massachusetts, Ohio, Illinois, California, Virginia, New York, South Carolina, and Washington) aimed at streamlining both programs. Proposals from several other states are still pending. These states are planning to implement what CMS is calling the financial alignment model. The model allows states to contract with private managed care plans to coordinate Medicare and Medicaid benefits for dual eligible individuals.

The one unifying feature of dual eligible individuals is poverty. Dual eligible individuals are low-income older adults and individuals with disabilities with a wide range of health and long-term care needs. As states began crafting new delivery systems, they were overwhelmingly drawn to models that placed responsibility for benefit coordination in private, managed care plans. Consumer advocates responded with concerns about managed care plans limiting access to services and care for the Medicare and Medicaid beneficiaries.

As a result of united advocacy from aging and disability groups, states and CMS addressed many of these high level concerns in their implementation agreements and guidance. The policy today is much stronger and consumer oriented than anticipated in the original state proposals a year ago. All state demonstration programs will include an independent, conflict free ombuds program,2 an initial voluntary enrollment period, protections against enrollment in poor performing plans,3 a person-centered care planning process, and aid paid pending during plan level appeals.4

In addition to the above list, advocates worked with states to develop important enhancements to care delivery. For example, in New York, the state developed a streamlined appeals process. For the first time, dual eligibles will be able to follow a single path for Medicare and Medicaid appeals. In California, the demonstration will offer some additional transportation and dental benefits previously unavailable to dual eligibles under traditional Medicaid and Medicare.

Monitoring implementation and assisting consumers

Current policy guidance establishes baseline consumer protections. The next challenge is the actual real life transition to the new system. Early lessons from state implementation highlight four areas consumer advocates should actively monitor in the weeks and months leading up to state enrollment.

Meaningful and clear notices

Dual eligible individuals will receive at least two notices informing them of the opportunity to enroll in a managed care plan or opt-out of passive enrollment in the demonstration. They will also be receiving information from the plans into which they are passively enrolled and other communications about plan changes. Drafting notices that communicate the complexity of the program in an easy to navigate, consumer-friendly manner and coordinating all notices so that they work together is a challenge. Notices should be drafted at a sixth grade or below reading level, and tested with consumers to ensure readability. They need to be available in accessible formats for individuals with disabilities and to be translated into the key languages of beneficiaries. The process takes time and careful planning. States need to allow enough time to consult with advocates and share drafts for comment. Experience to date has shown that some states have underestimated the time and resources needed to do the job right.

Trained enrollment assisters

All states will use an independent third party entity, called an enrollment broker, to facilitate enrollment into the demonstration. States will also rely on State Health Insurance Programs (SHIPs) to provide unbiased counseling. Adequate funding for the SHIPs and training for both SHIPs and enrollment brokers are essential to an enrollment process that is smooth and that honors consumer choice.

Continuity of care

The demonstration agreements all include provider network adequacy standards generally on par with Medicare and Medicaid programs. Simply contracting with an adequate network of providers is critical, but not enough. It also is very important that individuals transitioning into the plans do not experience any gaps in coverage. All demonstration programs have care continuity protections that allow individuals to continue to see their providers for some period of time until they can transition to new providers. Making sure that those policies work smoothly for consumers and for their doctors and other providers requires a great deal of provider education. Plans must also establish clear and simple systems so that consumers joining the plans can make the transition smoothly and safely without risk to their health or well being.

Assistance with appeals and transitions

All state agreements include a commitment to ensuring Medicare and Medicaid appeals rights. But the appeals system is complex and many dual eligibles find that they cannot navigate it on their own. To make this protection meaningful, dual eligible individuals need access to independent, conflict free ombuds assistance. The ombuds also is uniquely situated to spot systemic problems early and get them fixed before large numbers of consumers suffer. CMS has provided some funding for the ombuds program and it is one of the more exciting elements of the demonstrations. The challenge for states is to design an ombuds program that is robust and serves all plan members, particularly reaching out to those who are least able to advocate for themselves.

Resources for more information

The demonstration is constantly evolving and CMS frequently issues new policies and contracts. Monitoring the demonstration and providing appropriate information to consumers is challenging with many moving pieces. The National Senior Citizens Law Center is tracking the demonstration progress and monitoring implementation. For more information, please see or contact our office for more information.

1 The following states received federal approval to implement a dual eligible demonstration: Massachusetts, Illinois, Ohio, Virginia, California, New York, South Carolina, Minnesota and Washington.

2 CMS Press Release: New funding to improve care coordination for Medicare-Medicaid enrollees, (June 27, 2013).

3 Memo from CMS to Organizations Interested in Participating as Medicare-Medicaid Plans, (January 13, 2014).

4 Information detailed in CMS-state Memorandum of Understanding. For more information, see


Fay Gordon

About the Author: Fay Gordon is a Staff Attorney at the National Senior Citizens Law Center in Washington, DC.