Following a recommendation of the Medicaid Redesign Team (MRT) II in March 2020, the Office of Health Insurance Programs (OHIP) within the New York State Department of Health (DOH) has been diligently spearheading a number of related initiatives that are designed to promote integrated care for Medicaid members who are dually eligible for Medicare & Medicaid (dual eligible members or duals). This Dual Eligible Integrated Care Roadmap (or the Roadmap) outlines why DOH has made integrated care for dual eligible members a priority in the Medicaid program and describes the coordinated initiatives for improving integrated care.

Members qualifying for both Medicare and Medicaid are referred to as dual-eligibles, or as "duals." For the purposes of this paper, duals will refer to those individuals who are Medicare beneficiaries with full Medicaid benefits (i.e. Full Benefit Dual Eligibles) unless otherwise indicated.¹

The healthcare coverage for duals is often fragmented and lacks coordination. Members frequently receive Medicare benefits from one health plan or from Medicare fee-for-service (FFS), while receiving their Medicaid benefits from a separate health plan or Medicaid FFS. Duals are one of the most complex populations and the bifurcation of the sources of their health benefits leads to inefficiencies, a lack of coordination and potentially diminished health outcomes.²

On the other hand, integrated care occurs when a member receives both Medicare and Medicaid services through the same health plan (Managed Care Organization or MCO). States that promote integrated care for duals have the opportunity to improve outcomes, enhance member satisfaction and reduce costs.

Integrated care brings with it a number of benefits to members, health care providers, MCOs, and the State.

• Members receive a simplified process for interacting with their MCO for care coordination, service receipt, benefit communications and maximization, and integrated appeals and grievances processes (where available). Members will also have the advantage of having one interdisciplinary care team that assists them with their medical and behavioral health needs as well as long term services and supports (LTSS), if applicable.
• Health care providers may see an increase in the ability to provide continuous care for members newly becoming dual, improved care coordination between Medicare and Medicaid benefits, and streamlined administrative procedures with MCOs, including simplified billing.
• MCOs will benefit from the ability to engage in enhanced care coordination and to achieve administrative efficiencies. MCOs will also benefit from more streamlined communication with states and Centers for Medicare and Medicaid Services (CMS) related to financial management, reporting requirements, coordination of benefits, and enrollment and disenrollment processes.
• New York will benefit from integrated care via reduced duplication of billing and more data insights into their dual eligible Medicaid population, which may lead to better care outcomes and fewer administrative expenditures.

CMS has a number of resources describing the additional benefits of integrated care³.

Despite this potential for improved outcomes, only approximately 4% of duals in New York State currently receive integrated care, as illustrated in Table 1. These factors led to the MRT II recommendation to undertake the duals initiatives outlined in this Roadmap aimed at improving duals integration for NYS's Medicaid beneficiaries. Through these initiatives, the Department is seeking to achieve a 250% increase in the number of duals receiving integrated care through an aligned contract by the end of 2023.

Table 1: Percentage of Duals by Integration as of June 2021

*D-SNPs are Dual Special Needs Plans
**Note that while PACE does not utilize DSNPs to create alignment, it is included as an integrated product
***Note the primary channel for plan enrollment for these duals is MLTCP; however, there are a small number of duals enrolled across other available plans that fit these criteria.

Note in Table 1, that members receiving integrated care through an aligned contract, or are ‘aligned', receive Medicaid and Medicare services via companion MCOs operated by the same organization. In other words, these members are enrolled in a Medicaid managed care plan for their Medicaid coverage, and, except for PACE, are also enrolled in a companion Medicare D- SNP product for their Medicare coverage. For a full listing of what integrated plans are available today, please see Appendix A.

Following recommendations from the MRT II, which were enacted into state law as part of the State Fiscal Year 2020-21 budget, DOH has established four goals for moving forward with integrated care for duals. These goals are guiding DOH in creating this Duals Integration Roadmap:

1. Create more opportunities to build alignment between Medicare and Medicaid through integrated MCO offerings.
2. Streamline MCO offerings and promote informed member choice.
3. Enable fewer member transitions and build stronger continuity of care; and
4. Simplify administrative infrastructure for providers and MCOs.

These goals were formulated with lessons learned from New York State's past integration efforts and current integration challenges in mind, including consideration for the following key factors:

• Medicare Choice - under the principles of Medicare coverage choice, as codified in federal regulations, individuals may not be auto-enrolled into an integrated product. Accordingly, creating a smooth pathway for duals to elect an integrated product offering must rely on key, visible, and repeated opportunities to fully inform members regarding their options for dual coverage and the benefits associated with each option. In addition, choice principles require New York State to maintain a robust Medicaid fee-for-service or partial capitation option.
• Prior Experience - the Fully Integrated Dual Advantage (FIDA) Demonstration was the prior iteration of duals integration and experienced challenges ranging from insufficient member outreach and education, adequacy of Medicare and Medicaid MCO reimbursement rates, participation by MCOs not fully experienced in managing this complex population to poor provider engagement from the State.
• Engagement - for duals integration to be successful, DOH must work with members, providers, MCOs, and other stakeholders to educate and inform, as well as absorb and incorporate valuable feedback; and
• Integrated Grievance and Appeals - FIDA established Integrated Grievances and Appeals as the gold standard appeals process for integrated care.

Understanding these past barriers to successful implementation enables promotion of improved mechanisms for duals integration going forward.

Graphic 1: New York State Goals for Integrated Care for Dual Eligibles

To achieve its Goals for Integrated Care, DOH is implementing six related and scaffolded reform initiatives. These reforms include:

• Streamlining enrollment pathways.
• Enhancing dual eligible health plan coverage and benefits.
• Leveraging new contracting requirements.
• Developing member and provider education.
• Expanding enrollment opportunities to the federally authorized Program of All-Inclusive Care for the Elderly (PACE).
• Utilizing an integrated grievances and appeals process, where possible.

The Overview of Dual Eligible Integrated Care Projects below lists the current progress that DOH has made in implementing these integrated care initiatives and the continued ways in which DOH is growing the integrated duals infrastructure. DOH intends to supplement these initiatives as new opportunities are identified, whether through federal reforms, its experience during the COVID-19 Public Health Emergency (PHE) or proposed changes to align Medicaid eligibility tests for different groups of Medicaid members.

Graphic 2: Overview of Dual Eligible Integrated Care Projects

Reflecting the completion of several years of effort, DOH has created a new program to enable further growth of integrated duals, offering a distinct capitation rate in MMCP or HARP specific to this population. This program is discussed in additional detail in Section B below

DOH welcomes stakeholder feedback on additional initiatives that would promote integrated care for New York State's dual eligible population.

a. Streamlining Enrollment Pathways (Default Enrollment)

Perhaps the most high-profile initiative in this Roadmap is Default Enrollment for Medicaid members who become newly eligible for Medicare. Default Enrollment is a CMS enrollment procedure whereby Medicaid members seamlessly enroll into the aligned Medicare D-SNP of their current Mainstream Medicaid Managed Care Plan (MMCP) or Health and Recovery Plan (HARP) as they first become Medicare eligible. Under the same process, eligible MMCP/HARP members in receipt of LTSS are seamlessly transferred to the organization's MAP, where available, and default enrolled in the MAP-affiliated D-SNP. In line with federal requirements, this process preserves member choice by allowing members to "opt-out" of Default Enrollment if they would prefer another option for their Medicare and Medicaid coverage.

The Department views Default Enrollment as one of the primary drivers of increasing integrated care, as in the past, most newly dual Medicaid members would be disenrolled from their MMCP or HARP plan and exit to Medicaid FFS upon becoming Medicare eligible. In order to participate in Default Enrollment, MCOs must operate an MMCP or HARP product with an aligned D-SNP and successfully complete an application with CMS and DOH.

Graphic 3: Default Enrollment pathways

MCOs apply to become eligible for Default Enrollment and meet criteria established by DOH and CMS as described in the New York State Default Enrollment Plan Application. MCO criteria include operating an MMCP or HARP and an aligned Medicare D-SNP to establish proper alignment between programs for dual eligibles. Other requirements include having a 3.0 or higher CMS STAR rating for quality and committing in advance to meet the reporting requirements established within the application.

On April 1, 2021, Default Enrollment was launched in New York with three qualifying MMCPs. As of June 2021, four MMCPs are participating in Default Enrollment. In addition to the current MMCPs expanding the county coverage in which they are utilizing Default Enrollment, DOH expects additional MMCPs to participate beginning in 2022. In the first three months of the process, approximately 2,500 members have been successfully Default Enrolled, whereas historically these members would have been diverted to Medicaid FFS and not to integrated care. Default Enrollment is vital to DOH's integration goals as it allows the members to begin their Medicare journey in an integrated product from the earliest time they can be integrated. The program has now been in operation for ten months, and as of January 2022, there have been approximately 17,000 members successfully default enrolled.

b. Enhance Dual Eligible Plan Coverage and Benefits

c. Leveraging New Contracting Requirements

d. Developing Member and Provider Education Initiatives:

e. Expanding PACE Enrollment Opportunities

f. Unify Medicare and Medicaid Grievance and Appeals Process for D-SNPs

The Department is committed to working with the stakeholder community to enable the success of these integrated care initiatives. This Dual Eligible Integrated Care Roadmap presents a high- level overview of the initiatives that are planned and underway to further the goals of integration for dual eligible members in New York State.

Additional details on specific initiatives and materials for plans and stakeholders will be forthcoming. Please submit any questions to dualintegration@health.ny.gov.

• Aligned: An aligned member, or a member in an aligned plan, refers to a member enrolled in a Medicaid managed care plan who is also enrolled in the organization's Medicare D- SNP designated to operate in an integrated manner with the Medicaid managed care plan.
• Default Enrollment: Default Enrollment is a Centers for Medicare & Medicaid Services (CMS) enrollment procedure whereby a Medicaid member who is prospectively identified as becoming Medicare eligible (becoming a dual), may be seamlessly enrolled into their MMCP or HARP's affiliated D-SNP at the time they become dual-eligible.
• D-SNP: Dual Special Needs Plan or D-SNP is a specialized type of Medicare Advantage plan for duals.
• Duals: Dually Eligible Beneficiary or dual is a Medicaid recipient who is also eligible for Medicare.
• FBDE: Full Benefit Dual Eligible of FBDE is a Medicare beneficiary with full Medicaid benefits (as opposed to individuals in programs that only provide partial coverage of the Medicare premium or co-insurance costs, called "partial duals").
• HARP: Health and Recovery Plan or HARP is a specialized comprehensive Medicaid managed care plan offering integrated physical health, mental health, and substance abuse services for adults with significant behavioral health needs.
• IB-Dual: The Integrated Benefits for Dually Eligible Enrollees Program or IB-Dual is a special integrated premium group within a MMCP or HARP for non-LTSS dual members who elect to enroll in the MMCP/HARP's aligned D-SNP. MMCP/HARPs must apply to the Department of Health (DOH) to operate the IB-Dual program; approval is added to the MCO's certificate of authority.
• Integrated care: Integrated care occurs when a dual is enrolled in both a Medicaid managed care plan and a Medicare D-SNP, where both MCOs are operated by the same organization, and the MCOs work together as to appear and function as one MCO for the benefit of the member.
• LTSS: Long Term Services and Supports or LTSS means health care and supportive services provided to individuals of all ages with functional limitations or chronic illnesses who require assistance with routine daily activities such as bathing, dressing, preparing meals, and administering medications. LTSS is comprised of community-based services such as home health services, private duty nursing, consumer directed personal assistance services, adult day health care program, personal care services, and institutional services including long term placement in residential health care facilities.
• MAP: Medicaid Advantage Plus or MAP is a specialized Medicaid managed care plan for duals in receipt of LTSS and meeting other eligibility requirements, which is exclusively aligned with a Medicare D-SNP (all MAP members must be enrolled in the affiliated D- SNP, all members of the affiliated DSNP must be enrolled in the MAP).
• Managed Care Organization (MCO): A managed care organization is a health care provider or a group or organization of medical service providers who offers managed care health plans. It is a health organization that contracts with insurers or self-insured employers and finances and delivers health care using a specific provider network and specific services and products.
• Medicaid Advantage: Medicaid Advantage is a specialized Medicaid Managed care plan designed to provide non-LTSS duals enrolled in a Medicare Advantage plan with a "wrap around" partial Medicaid benefit to improve coordination between Medicare and Medicaid service delivery for members. This MCO type will sunset at the end of 2021.
• Medicare Advantage: Medicare Advantage or Medicare Part C is an MCO providing coverage to a member for Medicare Part A and Medicare Part B (Inpatient and Outpatient); members often get coverage for Part D (prescription drug coverage), as well.
• MLTCP: Managed Long Term Care Plan or MLTCP is a specialized Medicaid Managed care plan offering a partial benefit (partially capitated) for coverage of LTSS for Medicaid recipients meeting certain eligibility requirements.
• MMCP: Mainstream Medicaid Managed Care Plan or MMCP is a Medicaid managed care plan that provides a comprehensive benefit package to their members. Most Medicaid recipients in New York State are enrolled in an MMCP for their Medicaid coverage.
• Non-LTSS: Non-LTSS is term used to refer to members not in receipt of long term services and supports.
• PACE: Program of All Inclusive Care for the Elderly or PACE is a special integrated MCO for dual members in receipt of LTSS; members are not in a D-SNP.

While integrated care only covers approximately 4% of duals in New York State, DOH has been focused on increasing the integrated offerings for both LTSS and non-LTSS members. The below table shows what plans offer integrated products today. More integrated plans are expected to come online next year.

Table 1: Percentage of Duals by Integration as of June 2021

Table 2: Integrated Plan Offerings in New York State

Developing Member and Provider Education Initiatives

Following a recommendation of the Medicaid Redesign Team (MRT) II in March 2020, the Office of Health Insurance Programs (OHIP) within the New York State Department of Health (DOH) is spearheading a number of related initiatives that are designed to promote integrated care for Medicaid members who are dually eligible for Medicare & Medicaid (Dual Eligible Members or duals). These initiatives are discussed in detail in the Duals Integration Roadmap.

One of the integrated care initiatives being worked on by the Department is Developing Member and Provider Education Initiatives. This initiative is intended to facilitate the achievement of NYS' Goals for Integrated Care for Dual Eligibles, seen below.

Specifically, the Member and Provider Education Initiative will promote informed member choice (Goal #2) and enable fewer member transitions and build stronger continuity of care (Goal #3). New York is partnering with Medicare Rights Center (MRC) and New York Medicaid Choice (NYMC) to implement the Member and Provider Education Initiative.

The Member and Provider Education Initiative currently comprises four components:

1. Refining marketing strategies and creating materials to highlight integrated products, including:
   • Consumer-friendly language for beneficiaries, caregivers, families, and professionals for a website
   • Shareable outreach materials for both beneficiaries and professionals on New York's integrated care landscape.
   • A collection of professional-facing handouts that state and county agencies, and others can use to understand New York's various integrated care products, including information on eligibility, enrollment, transitions, coverage and care coordination, benefits, and appeals and grievances.
   • A collection of consumer-facing handouts on New York's various integrated care products, including information on eligibility, enrollment/transitions, coverage, and care coordination, and appeals and grievances.
2. Enabling plan use of integrated care fact sheets to educate consumers, including:
   • Performing special mailings of the fact sheets to targeted populations.
3. Creating additional materials and training for providers and other stakeholders, including:
   • Providing information via the Medicaid Update for providers on integrated care options.
   • Continuing FAQs for consumers and stakeholders regarding Default Enrollment and other initiatives.
   • Establishing an FAQ for professionals on New York's integrated care landscape and how to help beneficiaries understand their options.
   • Conducting trainings for plans and Local districts, such as the training DOH conducted on the default enrollment process for BH Medical Directors in April 2021.
4. Adding a landing page on the State's website to highlight integrated care for duals and showcase members' options, including:
   • Exploring all pathways to increase information on integrated care in the online space.
   • Incorporating a guide-me section of the website to explore Medicare and integrated care options.
   • Adding a link to the New York Medicaid Choice webpage to allow consumers and caregivers to further explore integrated care options and how to enroll.