Demonstrations to Improve the Coordination of Medicare and Medicaid for Dually Eligible Beneficiaries: What Prior Experience Did Health Plans and States Have with Capitated Arrangements?

Health Plan Background and Experience

Whereas the states and CMS structure the policies, procedures, and monitoring of the Initiative, much of the day-to-day work ultimately depends on health plan actions and competency (for example, via provider network development and the manner in which they promote quality and coordinate care). Because the demonstration health plans are melding the detailed requirements of both Medicare and Medicaid, and addressing the complex needs of dually eligible beneficiaries, their past experience is important, both in considering their regulatory experience and their familiarity with serving dually eligible beneficiaries.

Our analysis of health plans focuses on those in the five states that had enrolled beneficiaries in capitated financial alignment demonstrations by December 2014 (California, Illinois, Massachusetts, Ohio, and Virginia). A total of 29 health plans from 24 firms are participating in the demonstrations in those states; details on their prior experience and the quality ratings of plans operated by the same organizations are discussed in this section. Although additional states are opening enrollment in 2015, their health plans are not included here in detail, as the set of participating health plans may evolve during the launch of the demonstration (as it has in some other states). Brief information on health plans in these states also is provided in this section. Health plans in Minnesota’s administrative alignment demonstration also are not reviewed here in detail, as this demonstration adds only some administrative alignment functions to existing integrated contractors (which all had existing FIDE SNP and Medicaid contracts).

Experience of Participating Health Plans in Demonstration States Operational in 2014

Table 5 summarizes the key characteristics of the 29 health plans participating in the demonstration, including the prior experience they or their affiliated companies (those under the same parent company) have had in serving Medicare, Medicaid, or dual eligible enrollees within the state, as well as Medicare or Medicaid enrollees out of state. A few of the organizations operating demonstration health plans (Centene, Humana, Molina, and Anthem) have plans in more than one of these five states. These four companies accounted for 9 of the 29 plans in the demonstration. Ten of the health plans were local and had no Medicare or Medicaid enrollment out of state. The landscape of health plans varies by state, with Massachusetts and California including many local plans – all of which also have familiarity with dually eligible beneficiaries in MMC – and Illinois, Ohio, and Virginia including mainly national, for-profit plans.

Table 5: Selected Organizational Characteristics and Prior Experience of Capitated Demonstration Health Plans, by State
  Prior Medicare Advantage (MA) Enrollment in State (2014)a Prior Medicaid Managed Care (MMC) Enrollment in State Out-of-State Experience
State Demonstration Health Plan (Parent Organization, when Different)a Tax Statusa Non-SNP MA Enrollment Dual SNP Enrollment Other SNP Enrollmentd Enrollment (2012)b Dual Eligibles in Medicaid Health Plan (2011)c MA MMC
CA Anthem Blue Cross, including CareMore For Profit 72,951 1,141 20,289 448,492 Yes Yes Yes
CalOptima (Orange County Health Authority)e, f Nonprofit 0 16,014 0 376,053 Yes No No
Care1st Health Plan For Profit 22,584 13,545 0 28,625 Yes Yes Yes
Community Health Group Nonprofit 0 1,216 0 122,225 Yes No No
Health Net For Profit 116,471 33,284 3,972 719,907 Yes Yes Yes
Health Plan of San Mateo Nonprofit 0 8,747 0 59,983 Yes No No
IEHP DualChoice (Inland Empire Health Plan) Nonprofit 0 11,559 0 501,503 Yes No No
L.A. Care (Local Initiative Health Authority for L.A. County) Nonprofit 0 6,994 0 997,719 Yes No No
Molina Healthcare of California For Profit 0 8,498 0 201,440 Yes Yes Yes
Santa Clara Family Health Plan (Santa Clara County Health Authority) Nonprofit 0 0 0 116,644 Yes No No
IL Aetna Better Health For Profit 42,144 0 0 18,000g No Yes Yes
BlueCross BlueShield of Illinois (Health Care Service Corp.) Nonprofit 5,801 0 0 0g Yes Yes
Cigna-HealthSpring CarePlan of Illinois For Profit 12,223 3,385 0 0g Yes Yes
Health Alliance Connect For Profit 12,570 0 0 0g Yes No
Humana Health Plan, Inc. For Profit 84,077 21 280 0g Yes Yes
IlliniCare Health (Centene) For Profit 0 0 0 17,800g No Yes Yes
Meridian Complete (Caidan Enterprises) For Profit 86 81 0 7,300g No Yes Yes
Molina Healthcare of Illinois For Profit 0 0 0 0g Yes Yes
MA Commonwealth Care Alliance, Inc. Nonprofit 0 5,357 0 4,236 Yes No No
Fallon Total Care or Fallon Healthf Nonprofit 13,192 3,685 0 14,212 Yes No No
Tufts Health Plan — Network Health Nonprofit 105,215 199 0 124,174 Yes No No
OH Aetna Better Health For Profit 156,428 0 0 0 Yes Yes
Buckeye Health Plan (Centene) For Profit 0 1,284 0 168,143 No Yes Yes
CareSource Nonprofit 0 1,076 0 920,940 No No Yes
Molina Healthcare of Ohio For Profit 0 517 0 262,932 No Yes Yes
UnitedHealthcare Community Plan For Profit 75,267 8,306 4,256 122,630 No Yes Yes
VA Anthem HealthKeepers For Profit 4,167 0 584 220,835 No Yes Yes
Humana Health Plan, Inc. For Profit 120,184 1,529 777 0 Yes Yes
Virginia Premier CompleteCare (Virginia Commonwealth U. Health System Authority) Nonprofit 0 0 0 151,566 No No No
a Analysis of CMS Medicare Advantage enrollment and Landscape files, 2014.
b CMS. “2012 Medicaid Managed Care Enrollment Report.”
c CMS. “2011 Medicaid Managed Care Enrollment Report.”
NOTES: Table includes states with active enrollment in capitated financial alignment demonstrations as of December 2014. All health plan enrollment noted reflects that of in-state health plans operated by the same parent organization as the demonstration health plan. Previous Medicaid MMC enrollment reflects MCO and HIO enrollment only.
Numbers in bold reflect the three largest health plans statewide in a given state’s product line (Medicare Advantage, D-SNP, other SNP, or MMC).
d “Other SNP” experience reflects chronic condition SNP enrollment. The exceptions: part of Anthem’s (CA) enrollment and all of UnitedHealthcare’s (OH) enrollment is in institutional SNPs.
e CalOptima’s D-SNP plan was sanctioned by CMS in January 2014 and CalOptima thus was not eligible for demonstration enrollment. As of November 2014, CalOptima’s D-SNP was again open for enrollment, though enrollment in its demonstration plan will begin no sooner than July 2015. /
f Two health plans also have PACE plans with small numbers of enrollees – Fallon (MA) and CalOptima (CA).
g In 2012, Aetna Better Health and IlliniCare were the only contractors for Illinois’s Integrated Care Program (ICP) (for elderly, blind, and disabled Medicaid-only enrollees). In its 2013 and 2014 expansion of ICP, Illinois also contracted with all of the financial alignment demonstration health plans as Medicaid-only plans for ICP. As of October 2014, each of the Illinois demonstration plans also had a few thousand Medicaid enrollees each in ICP. Illinois “Enrollment for Integrated Care Program (ICP).”

Of the two states with previous enrollment of dually eligible beneficiaries in capitated MMC:

  • California is including 10 health plans in its demonstration, with a heavy base of local nonprofit plans, along with some for-profit plans with strong ties to the state. As discussed above, California allowed only its existing Medicaid plans in the demonstration counties to participate; thus, all plans have significant Medicaid enrollment. It is important to note that California previously did not generally include LTSS under its health plans (except in the COHS plans);1 the Medicaid plans’ experience with dually eligible beneficiaries thus was mostly with the minimal other services covered by Medicaid for dually eligible beneficiaries. California is phasing in MLTSS under its Medicaid health plans concurrent with the demonstration. All health plans except for one (Santa Clara Family Health Plan) also have D-SNP enrollment; three also have general Medicare Advantage product lines.
  • Massachusetts’s demonstration includes three local nonprofit plans that all participate in its integrated Senior Care Options (SCO) program. These plans have experience with Medicare/Medicaid integration, though the care needs of those in the demonstration (dually eligible beneficiaries who are under 65 and disabled) differ from the needs of those in SCO (elderly dually eligible beneficiaries). Though Massachusetts initially selected three additional health plans (which do not participate in SCO and are for-profit) for its demonstration, these plans withdrew, mainly citing concerns about the demonstration’s payment rates. This development left the three nonprofit health plans that have more specialized experience with dually eligible beneficiaries.2 One participating firm also has a large Medicare Advantage line.

Of the three states with no previous enrollment of dually eligible beneficiaries in capitated MMC:

  • Illinois’s demonstration includes eight health plans. Most plans in Illinois did not have in-state Medicaid enrollment when they first contracted for the demonstration. In general, the state had very low risk-based MMC penetration. Health plans related to two of the demonstration plans (Aetna and IlliniCare/Centene) were the contractors for the state Medicaid’s ICP, which began in 2011 for Medicaid-only beneficiaries who are elderly or disabled. However, as Illinois moved rapidly toward risk-based MMC and the recently expanded ICP, it contracted with all of its demonstration health plans for this expansion, which began slightly before the demonstration. These plans thus are developing in-state Medicaid experience at the same time as they begin the demonstration. Six of the health plans have at least some in-state Medicare experience, including two plans that are among the largest Medicare plans in the state.
  • Ohio is including five health plans in its demonstration; four of these have a large Medicaid presence in the state as well as D-SNPs. An additional health plan related to one of the state’s largest Medicare plans (Aetna) also is participating, though it does not have any in-state Medicaid enrollment.
  • Virginia’s demonstration includes three health plans, two of which are related to Medicaid plans that are among the largest in the state. One of the plans (Anthem) has a small number of Medicare enrollees in the state, while the other (Virginia Premier) is a local Medicaid plan with no Medicare experience. The third plan (Humana) operates one of Virginia’s largest in-state Medicare plans, though has no previous in-state Medicaid enrollment.

Almost all of the organizations operating health plans across these states have at least some in-state Medicare Advantage enrollment, though not necessarily enrollment in D-SNPs. The few organizations with no in-state Medicare experience are either local, state Medicaid-focused plans (Santa Clara Family Health Plan in California and Virginia Premier in Virginia) or national health plans with Medicare experience in other states (IlliniCare/Centene and Molina in Illinois). About one-third of the organizations have in-state enrollment in both regular Medicare Advantage and D-SNPs. The type of Medicare plans of organizations operating health plans varies by state in some cases; almost all of California’s plans have D-SNPs, whereas plans in Illinois primarily had regular Medicare Advantage. (As shown in Table 3, Illinois has very limited D-SNP enrollment.) A handful of organizations also have some enrollees in other SNP types (for people with chronic conditions or requiring an institutional level of care).

Almost all organizations also have significant in-state Medicaid experience that predated the demonstrations. The main exception is in Illinois – most organizations operating health plans in Illinois did not have such experience when they first contracted with the state. Only two other organizations across the other states had no in-state Medicaid enrollment, though those plans have large in-state Medicare Advantage market shares (Humana has 63% in Virginia and Aetna has 20% in Ohio);3 instead, they are building on significant local experience in Medicare.

Experience of Participating Health Plans in Demonstration States Beginning in 2015

Table 6 displays high-level information on the previous in-state experience of organizations operating health plans expected to be in the demonstration states that begin enrollment in 2015. As discussed above, these health plans are not discussed here in detail, as the specific participating health plans may still change.

In general, these states are contracting with national for-profit plans with the exception of New York, which is including many local nonprofit, provider-based health plans already in its MLTC program. New York and Texas both are building on existing in-state health plans for their demonstrations, but these plans’ backgrounds vary widely. All Texas plans have previous in-state Medicare (including D-SNP) and Medicaid enrollment. However, New York’s plans all have Medicaid experience (some of them only in MLTSS), but about one-third have no prior Medicare experience. Though New York’s plans have specialized experience in MLTSS, and some have it in integrated care (via Medicaid Advantage Plus), the lack of Medicare experience indicates that some will have a steep learning curve in that area. As for other 2015 states, health plans in Michigan and South Carolina have a range of backgrounds, with some lacking previous in-state Medicare and/or Medicaid enrollment (especially in South Carolina).

Table 6: Prior Experience of Capitated Demonstration Health Plans in Demonstration States
Planned to Begin Operations in 2015, by State
State Health Plansa Health Plans’ Prior In-State Experienceb
Michigan AmeriHealth, CoventryCares, Fidelis SecureCare, Meridian Health Plan, Midwest Health Plan, Molina, Upper Peninsula Health Plan Five have Medicare and Medicaid experience, one has only Medicare, and one has neither.
New York Based on Managed Long Term Care plans:Aetna Better Health of New York, AgeWell, AlphaCare, Amerigroup, Archcare Community Life, Centerlight Healthcare, Centers Plan for Healthy Living, Elderplan, Elderserve Health, Fidelis Care of NY (NYS Catholic Health Plan), GuildNet, Managed Health (HealthFirst), Health Insurance Plan of Greater New York (HIP), Independence Care Systems, Integra, MetroPlus, Montefiore HMO, North Shore-LIJ Health System, Senior Whole Health, VillageCareMAX, VNS Choice, Wellcare All have MLTC experience, and some have other Medicaid experience (including eight that also have Medicaid Advantage Plus plans – see Table 4).Fifteen plans also have Medicare experience and seven plans do not.
South Carolina Absolute Total Care (Centene), Advicare, Molina, Select Health of South Carolina (AmeriHealth) One has only Medicaid experience, one has only Medicare, and two have neither.
Texas Based on STAR+PLUS health plans:Amerigroup, Cigna-Healthspring, Molina, Superior (Centene), UnitedHealthcare All have prior Medicare and Medicaid plans.
a Musumeci M, “Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS,” Washington DC: Henry J. Kaiser Family Foundation, July 2014. Update on New York: “FIDA Plans by Region.”
b Analysis of CMS Medicare Advantage enrollment and Landscape files, 2014; CMS. 2012 Medicaid Managed Care Enrollment Report.; state and health plan websites.
NOTES: Minnesota’s administrative demonstration, which modified existing contracts with FIDE SNPs in Minnesota Senior Health Options, includes Blue Plus, HealthPartners, Itasca Medical Care, Medica Health Plans, Metropolitan Health Plan, PrimeWest Health, South Country Health Alliance, and UCare Minnesota.

Available Information on Quality Ratings of Participating Health Plans

Given the complex needs of the dual eligible population, it is important to understand what is known about the quality of care provided by health plans participating in the demonstration. Quality ratings of the existing related Medicare and Medicaid plans can give insight into the infrastructure and culture that health plans bring to the demonstrations.

Table 7 summarizes data on available quality ratings for the existing in-state Medicare and Medicaid health plans related to demonstration plans, including both the Medicare Advantage star rating for the plan (general Medicare and D-SNP, when available) and Medicaid plan rankings by the National Committee on Quality Assurance (NCQA). The quality scores range from 1 to 5, with 5 being the highest. Medicare Advantage plans with 4 stars or more qualify for additional bonus payments, and NCQA highlights scores of 4 or 5 as being better across three performance categories.4 Medicare Advantage star ratings are assessed at the contract level, not the health plan level. Thus, unless a company offers only SNPs under its contract, the quality scores will reflect the overall performance of all health plans under a contract, not necessarily the performance of the D-SNP. For this reason, and because the metrics may not account for enrollee characteristics in D-SNPs, many believe that star ratings may unfairly disadvantage D-SNPs.5 It is also important to note that while LTSS are a key part of the demonstrations, the quality measures that states use for LTSS vary greatly and there is no standardized set of measures that allows for comparison in this brief.6

The data show considerable diversity in scores, both across plans and states. Across the states, Massachusetts’ demonstration plans have consistently high quality scores, with two of the three plans scoring at the top of the ratings in Medicare and Medicaid, and the third, a specialized plan, scoring highly for its D-SNP offering. In contrast, and not surprising given its limited MMC experience, Illinois plans (with one exception) have no available Medicaid quality ratings. Only four of its contracted plans have Medicare quality ratings for in-state plans, including two with a rating for D-SNPs. (The ratings for these plans vary from 3.5 to 4.5.)

In Ohio and Virginia, all of the plans have ratings, but often just for one program (generally because they do not have a plan to be rated). Ohio’s five plans include three with MMC ratings, one of which also has a Medicare rating for D-SNPs, and two with only general Medicare Advantage ratings. Though there is variation by plan and element, these ratings tend to be about average (3 or 3.5), with plans worse on some dimensions (Centene’s Buckeye plan rated 2 on Medicaid prevention, CareSource’s 2.5 on D-SNP) and higher on others (CareSource with a 4 for consumer satisfaction and Molina with a 4 for treatment). In Virginia, two of the three plan ratings were average on two dimensions, but had a 4 for quality of treatment. The third, a Humana plan, did not have a Medicaid plan in the state and had average Medicare ratings (3.5).

Among these states, California stands out because of the relatively large number of plans with low MMC ratings from NCQA. Of the 10 participating plans, 8 had reported scores. Almost all have the lowest rating for consumer satisfaction (1); a few have below average ratings (1 or 2) for prevention or treatment. The D-SNP of the best performing Medicaid plan (CalOptima, a COHS health plan in Orange County) was sanctioned by CMS in January 2014 due to “widespread and systemic failures” that impacted its D-SNP enrollees’ access to care; for this reason, demonstration enrollment in that county has been delayed until at least July 2015.7 However, the D-SNP scores for California plans are better (mostly 3 and 3.5) than their Medicaid scores.

Table 7: Quality Ratings of In-State Health Plans Related to Demonstration Health Plans, by State
  Medicarea, c Medicaid – NCQAb, d
State Demonstration Health Plan Name Medicare Advantage Stars D-SNP Stars Overall Score Consumer Satisfaction Prevention Treatment National Rank
CA Anthem Blue Cross, including CareMore 4 4 75 1 3 3 106
CalOptima (Orange County Health Authority) N/A 3.5 82 1 5 4 29
Care1st Health Plan 3.5 3.5 76 1 2 3 102
Community Health Group N/A 3.5 74 2 2 2 110
Health Net 4 4 70 1 2 2 119
Health Plan of San Mateo N/A 3.5 NR
IEHP DualChoice (Inland Empire Health Plan) N/A 3 73 1 3 2 112
L.A. Care (Local Initiative Health Authority for L.A. County) N/A 3 76 3 3 3 99
Molina Healthcare of California N/A 3 77 1 3 3 95
Santa Clara Family Health Plan (Santa Clara County Health Authority) N/A N/A NR
IL Aetna Better Health 4 N/A NR
BlueCross BlueShield of Illinois (Health Care Service Corp.) NR N/A N/A
Cigna-HealthSpring CarePlan of Illinois 3.5 3.5 N/A
Health Alliance Connect 4.5 N/A N/A
Humana Health Plan, Inc. 4 4 N/A
IlliniCare Health (Centene) N/A N/A NR
Meridian Complete (Caidan Enterprises) NR NR 85 4 5 5 10
Molina Healthcare of Illinois N/A N/A N/A
MA Commonwealth Care Alliance, Inc. N/A 4.5 NR
Fallon Total Care or Fallon Health 4.5 4.5 87 5 5 5 2
Tufts Health Plan – Network Health 4.5 4.5 87 5 5 5 1
OH Aetna Better Health 3.5 N/A N/A
Buckeye Health Plan (Centene) N/A NR 77 3 2 3 98
CareSource N/A 2.5 79 4 3 3 66
Molina Healthcare of Ohio N/A NR 79 3 3 4 82
UnitedHealthcare Community Plan 3.5 3.5 78 3 3 3 90
VA Anthem HealthKeepers 3.5 N/A 79 3 3 4 73
Humana Health Plan, Inc. 3.5 3.5 N/A
Virginia Premier CompleteCare (Virginia Commonwealth U. Health System Authority) N/A N/A 79 3 3 4 62
Key: 1 – 2 (Worse); 3 (Average); 4 – 5 (Better)
a 2014 Medicare Star Ratings Data.
b National Committee on Quality Assurance (NCQA). “Health Insurance Plan Rankings 2014–2015.”
NOTES: Includes states with active enrollment in capitated financial alignment demonstrations as of December 2014. All health plan experience noted reflects that of in-state health plans operated by the same parent organization as the demonstration health plan.
c Medicare Advantage stars: out of 5 stars; 5 = excellent; 4 = above average, 3 = average, 2 = below average, 1 = poor. N/A = organization has no in-state health plan. NR = not rated. For any organization with multiple plan ratings in a state (preferred provider organization (PPO) vs. health maintenance organization (HMO)), HMO ratings are shown, due to HMO similarity to the demonstration health plan product line. In cases in which an organization has more than one star-rated HMO in a state (Anthem in CA and Humana in IL), the rating for the larger plan is shown. For more information on the star rating system, see
d NCQA: 2014—2015. N/A = parent company has no in-state health plan. NR = not ranked. The overall score is out of 100, and the ranking is out of 136 nationally ranked plans. All ranked plans (and IlliniCare) also are NCQA accredited. More information on rankings is available at NCQA, Health Insurance Plan Rankings: Ranking Resources.
L.A. Care (CA) and CareSource (OH) Medicare plans received a Medicare Low Performing Icon for 2014. CalOptima’s D-SNP was sanctioned by CMS in January 2014.
The State Context of the Demonstrations Conclusion

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