On February 22, Illinois became the fourth state to move forward with a demonstration project striving to integrate care for people eligible for both Medicare and Medicaid (dual eligibles). The Memorandum of Understanding (MOU) between Illinois and the Centers for Medicare & Medicaid Services (CMS) sketches out the terms of what will be a three-way contract between the federal government, the state and selected private health plans (“plans”) that will provide integrated Medicare and Medicaid-covered benefits to dual eligibles.

The Illinois demonstration will run from October 2013 through December 2016 in two regions. The MOU does not specify how many of the 135,825 eligible beneficiaries in the two regions will be enrolled. Plans will be required to provide the full spectrum of Medicare, Medicaid, and waiver program services—including adult day care, meal delivery, and speech and physical therapy—under a capitated financing model. Eight plans have been selected to serve enrollees. The Illinois demonstration contains numerous positive features:

  • Enrollment: The demonstration begins with a voluntary enrollment period, which will provide participating health plans an opportunity to gradually build the number of beneficiaries they serve; eligible individuals may opt into the demonstration to begin receiving services on October 1, 2013. Beginning January 1, 2014, the demonstration may enroll eligible beneficiaries via passive enrollment. To prevent plans from taking on more beneficiaries than they can handle, the MOU limits the number of people who can enroll into each plan in a month.
  • Continuity of care: Enrollees are entitled to keep seeing out-of-network providers for 180 days following enrollment, which helps ensure enrollees are not forced to abruptly transition to a new provider. After 180 days, the state may make single-case agreements so beneficiaries can continue meeting with out-of-network physicians providing “an ongoing course of treatment.”
  • Care coordination: Each enrollee will be assigned a care team led by a care coordinator. The team and enrollee will jointly develop a care plan strategy. Plans must review the care plans of high-risk enrollees every 30 days and those of moderate-risk enrollees every 90 days.
  • Ombudsman: The state will create an ombudsman to advocate and investigate on behalf of enrollees. Contrary to the ombudsman envisioned by California’s MOU, the Illinois ombudsman will be independent from the state Medicaid agency.
  • Beneficiary input: Plans are required to obtain “meaningful beneficiary input” each quarter from an independent beneficiary advisory committee. The MOU states the committee is to include beneficiaries, caregivers, advocates, and representatives of community groups.
  • Long-Term Services and Supports: Plans must offer contracts to long-term services and supports providers. This will help ensure that existing providers will continue to serve beneficiaries rather than plans establishing redundant service centers.

While the Illinois MOU contains many promising features, much work remains to ensure the demonstration provides higher quality and more person‐centered care. The MOU shows weaknesses in the following areas:

  • Readiness of plans: While plans will need to show the capability to provide “the full continuum of Medicare and Medicaid Covered Services to Enrollees,” the MOU offers no detail about the readiness review. A rigorous readiness review process is needed to ensure that plans in the demonstration can accommodate the intensive health needs of dual eligible enrollees. Plan preparedness is a major area of concern in all of the states participating in the demonstration.
  • Mental health: The MOU does not address coverage of mental health peer support services. Future planning documents should strive to address this shortcoming.
  • Adequacy of the capitated payment: Medicaid’s contribution to the capitated payment is determined by which of four categories a beneficiary falls into, based on his/her setting of care. And while the MOU wisely imposes a medical loss ratio threshold of 85 percent, it does not protect plans from catastrophic losses in the case of an extremely costly pool of enrollees. If plans cannot remain fiscally sound, beneficiaries may go without care they need. CMS and the state should develop strategies to ensure that plans are not exposed to major losses so beneficiaries will get the care they need.
  • Savings targets: As is true with the other MOUs released so far, the demonstration’s savings expectations—a 1 percent reduction in spending growth in the first year, 3 percent in the second, and 5 percent in the third—may not be realistic, and how the savings targets were developed is unclear. More detail on the rationale behind the savings expectations is needed.
  • Cultural competence: While the state and CMS will require plans and providers to accommodate individuals’ communication needs and provide care in a culturally competent way, there is little detail on how this will be achieved.

The Illinois MOU must be modified and further developed to address shortcomings, especially pertaining to its financing and readiness testing of the eight participating health plans. With many more MOUs forthcoming in the next few months, Illinois should seize the opportunity to lead other states by developing a sustainable demonstration model that produces better outcomes for patients and lower program costs.

— Christophe Stuck-Girard, Legal Intern, Integrated Care Advocacy Project