Individuals Covered By Both Medicare and Medicaid (Duals)

AHCCCS is working to increase alignment and improve service delivery for people covered by both Medicare and Medicaid. These individuals, commonly referred to as “duals,” are currently navigating multiple systems to receive care. This fragmentation often results in poor communication, uncoordinated health care decisions and a lack of a patient-centered perspective. The AHCCCS program has moved toward increasing the connection between these two programs within the Medicare Dual Special Needs Plans (D-SNP) model by contractually requiring its health plans to serve as D-SNPs and promoting enrollment or alignment of dual eligible members into the same health plan for both Medicaid and Medicare to the greatest extent. Enrolling in specialized duals-only Medicare plans allow individuals to receive all of their health care, including the payment for prescriptions and benefits, from a single, integrated source.

Integration Initiatives

Medicare and Medicaid Alignment for Duals

AHCCCS has shown that achieving alignment between two distinct and separate programs – Medicaid and Medicare – improves the quality and lowers the cost of care provided to dual eligible members. Many members with full Medicare-Medicaid eligibility have complex health needs and may be better served by a plan that can offer more benefits and support (a D-SNP), instead of a Medicare Advantage plan or traditional Medicare. Medicare Advantage Dual Special Needs Plans (D-SNPs) are one of three types of SNPs that were authorized in the Medicare Modernization Act of 2003 and began operating in Arizona in January of 2006. D-SNPs were intended to allow Medicare Advantage plans to specialize in serving beneficiaries who are dually eligible for Medicare and Medicaid, although there was no requirement initially that D-SNPs have any formal relationship with state Medicaid agencies. Since 2013, in an effort to improve care coordination for AHCCCS dual eligible members, AHCCCS requires the Contractor, or its corporate affiliate, to be a Medicare Advantage Dual Eligible Special Needs Plan in all service areas in which they hold a Medicaid contract. Arizona has taken every opportunity to align members into the same health plan.

Consequently, Arizona leads the nation in having the highest percentage of duals aligned in the same plan for Medicaid and Medicare outside of demonstration authority. Working with contracted plans, AHCCCS has been able to successfully pursue strategies that have resulted in increased alignment. Today, Arizona has over 60,000 members enrolled in the same plan for Medicare and Medicaid, exemplifying how to improve the delivery system for members that receive services through both of these large complex systems.

Avalere Health conducted a study to determine the impact that plan alignment makes for dual eligible members. Avalere compared national data for duals enrolled in traditional Medicare fee-for-service to aligned dual eligible members served by AHCCCS health plan, Mercy Care Plan. Avalere found that the aligned AHCCCS duals exhibited:

  • 31% lower rate of hospitalization;
  • 43% lower rate of days spent in a hospital;
  • 9% lower Emergency Department use; and
  • 21% lower readmission rate.

AHCCCS has increased alignment by 20,000 members in the past two years and has a continued goal of increasing dual alignment from the current 60,000 to 75,000 members. AHCCCS is also pursuing various strategies in conjunction with the National Association of Medicaid Directors (NAMD) and CMS’s Medicare Medicaid Coordination Office, to achieve overall sustainability of the D-SNP platform.

To find out more, or to enroll, current dual AHCCCS members should contact their health plan.

Based on positive outcomes related to greater alignment, AHCCCS has taken measures to increase alignment wherever possible. For instance, as part of changes related to the October 2013 acute care procurement, the AHCCCS administration aligned approximately 8,000 dual eligible members by moving them into their Medicare D-SNP’s companion Medicaid plan. Additional alignment efforts are planned for upcoming years.

General Mental Health/Substance Abuse Service Delivery for Duals Enrolled in Acute Health Plans

The mission and guiding principles of AHCCCS include a focus on care coordination as a vehicle for appropriate care and containing costs. Ensuring that members get the health care they need, the growth of the dually eligible population (those who receive Medicare AND Medicaid benefits) and related ongoing integration efforts have been key factors in the decision to make changes for dually eligible (also known as ‘duals’) members. Of the 1.6 million AHCCCS members, over 141,000 are classified as duals (as of mid-2015).

Beginning October 1, 2015, this change requires contracted acute health plans to provide general mental health and substance abuse (GMH/SA) services to adult dual members. This is a change to the existing delivery method where the Tribal and Regional Behavioral Health Authority (T/RBHA) contractors serve dual members’ for their general mental health and substance abuse needs. By taking a proactive approach, AHCCCS will be well-positioned to effectively navigate possible changes to CMS’ Medicare Advantage program should the definition and scope of a Dual Eligible Special Needs Plan (a specialized Medicare plan for duals) change in the future. Non-dual acute members will still use the T/RBHA system for their behavioral health needs just as they do today.

In total, over 80,000 members will be affected by this shift in October 2015. This population includes dual members enrolled in an AHCCCS acute health plan who also are enrolled in any Medicare Part A and/or B arrangement. Children, as well as members with Serious Mental Illness (SMI); or those enrolled in ALTCS plans, are excluded from this effort. Individuals with SMI will not be served in this manner—they will receive care in the integrated RBHAs in Maricopa County and in Greater Arizona (Mercy Maricopa Integrated Care, Health Choice Integrated Care, and Cenpatico Integrated Care).

Enrolled American Indians will continue to have the current array of choices offered to them in addition to the new fully integrated acute plan; therefore some American Indians will be served by acute plans for acute and behavioral health services and some only for acute services. We anticipate that as dual members, Medicare will often continue to be the primary payers of behavioral health services.

For additional information regarding the general mental health and substance abuse integration for dual members please access the following documents:

Additional Information Regarding Duals

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