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Early Insights From Ohio’s Demonstration to Integrate Care and Align Financing for Dual Eligible Beneficiaries

Ohio was the third state to launch a 3-year capitated financial alignment demonstration to integrate Medicare and Medicaid payments and care for beneficiaries who are dually eligible for Medicare and Medicaid.  Concurrently, Ohio implemented mandatory capitated managed care through separate Medicaid waiver authority.  Ohio refers to both initiatives as MyCare Ohio.  This report describes the early implementation of Ohio’s capitated Medicare-Medicaid financial alignment demonstration.  Findings are based on interviews conducted with a diverse group of state leaders, including representatives from state agencies; medical, behavioral health, and social services providers; consumer advocates; and health plans involved in the design and early implementation of the demonstration.  The report also includes data on enrollment in the demonstration to provide context for the qualitative findings.

MyCare Ohio launched in May 2014, and as of January 2015, had enrolled 94,525 beneficiaries, over 82 percent of the 115,000 state residents initially estimated to be eligible for the financial alignment demonstration.  Most beneficiaries (72 percent) were enrolled in the demonstration (including both Medicare and Medicaid services), with the remainder (28 percent) enrolled only in Medicaid managed care. First, beneficiaries were automatically assigned to plans and enrolled in mandatory Medicaid managed care.  During this time, enrollment in the financial alignment demonstration (including Medicare services) was voluntary, and the enrollment rate for Medicare services averaged about 16 percent during the opt-in enrollment period.  The demonstration enrollment rate for Medicare services increased to 72 percent once Medicare auto-assignment began.

The Ohio financial alignment demonstration includes the following features:

  • covers a comprehensive population of adult dually eligible beneficiaries, including seniors, people with physical disabilities, and people with behavioral health needs;
  • builds upon concurrent implementation of mandatory Medicaid managed care;
  • bifurcates the enrollment process for most demonstration participants, by first offering an opt-in period for Medicare benefits, while beneficiaries were automatically enrolled in Medicaid managed care, followed by passive managed care enrollment for their Medicare benefits six to eight months later;
  • includes Medicaid home and community-based waiver services for seniors and people with physical disabilities in the health plan benefit package and capitated rates; and
  • requires health plans to partner with Area Agencies on Aging (AAAs) and other entities with experience working with people with disabilities to coordinate home and community-based waiver services for beneficiaries age 60 and over.

Beneficiaries, the state, plans, and providers faced several challenges during the early implementation stage of MyCare Ohio, such as:

  • delayed enrollment due to the complexities involved with launching a new program, such as conducting beneficiary and provider outreach, performing health plan readiness reviews, and building provider networks;
  • the calculation of appropriate capitated payment rates to account for different populations, such as beneficiaries who enroll in the demonstration for both Medicare and Medicaid benefits versus those who enroll only in Medicaid managed care and for those who are and are not receiving long-term services and supports (LTSS);
  • complexities in the enrollment process including communicating complicated information to beneficiaries and overcoming IT system challenges in locating and enrolling beneficiaries;
  • delayed initial assessments of demonstration enrollees by health plans; and
  • education of independent providers about health plans’ claim reimbursement systems to process timely payments for services.

Some of these issues were related to the concurrent implementation of mandatory Medicaid managed care but affected the capitated financial alignment demonstration, which encompasses both Medicare and Medicaid services.

Strengths of the implementation process that were identified included:

  • the AAAs’ connections to the community and knowledge about available resources and the LTSS assessment and service planning process;
  • incorporation of continuity of care provisions to ease beneficiaries’ transition to managed care; and
  • inclusion of quality measures related to home and community-based services and LTSS rebalancing among the criteria that health plans must meet to earn the quality withhold portion of the capitated rates in the financial alignment demonstration.

As one of the early capitated dual eligible financial alignment demonstrations to be implemented in the country, Ohio’s initial experience can provide important insights for other states as they move their demonstrations forward in the coming months.  Stakeholders characterized the first six months of MyCare Ohio as “rocky” and “disruptive” and were eager to move past the initial implementation phases to focus on bringing a fully coordinated system of care to thousands of beneficiaries. Because the transition to mandatory Medicaid managed care was happening concurrently with the integrated care demonstration, it is important to note that not all concerns were solely demonstration issues; some would have occurred in the context of the transition to Medicaid-only managed care. This case study provides a very early look at the demonstration. Because stakeholders agreed that it is too early to tell whether the demonstration is making progress on key objectives, such as providing better coordinated care, improving health outcomes, and realizing cost savings, it will be important to assess Ohio’s and other states’ demonstrations over time as more information becomes available.

Issue Brief

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.