A bipartisan bill aiming to streamline and coordinate care for the nation’s more than 12 million dually eligible individuals — people who are enrolled in both Medicare and Medicaid — is being called “landmark legislation” by one aging services provider group.
The Delivering Unified Access to Lifesaving Services (DUALS) Act of 2024 was introduced last week by Sen. Bill Cassidy (R-LA) and a bipartisan group of Senate Finance Committee members.
The bill would establish a new title of the Social Security Act, creating a state integrated care program for dually eligible individuals. LeadingAge said that the bill incorporates several recommendations from its 2017 white paper about integrating service delivery, including the need for a single care coordinator for each beneficiary, a standardized health risk assessment to identify individual needs, a comprehensive care plan delivered by an interdisciplinary care team, and a single pooled payment to the integrated care plan that brings together Medicare and Medicaid contributions.
LeadingAge provided a letter of support for the DUALS Act last week as well.
“Community-based operators, such as independent living, assisted living and memory care providers, may have new opportunities to partner with these integrated care plans and be paid for services they provide to support the inidivdiuals’ social determinants of health that may have previously fallen through the cracks,” LeadingAge Vice President of Integrated Services and Managed Care Nicole Fallon told McKnight’s Senior Living. “In fact, the legislation allows these ICPs to customize supplemental benefits for a dual-eligible enrolled in their plan, and expand the styles of supplemental benefits that ICPs can make available to dual eligible individuals.”
Fallon said the bill would create a new section of the Social Security Act that combines Medicare and Medicaid funds, creating opportunities for all types of senior housing that provide services such as transportation, meals, stable housing and other key supports.
12.2 million individuals
Approximately 12.2 million low-income or disabled people are jointly enrolled in the Medicare and Medicaid programs. This diverse population includes people who have multiple chronic conditions, physical disabilities, mental illness or cognitive impairments.
Dually eligible beneficiaries account for a disproportionate share of healthcare spending. They make up 19% of Medicare enrollments, for instance, but account for 34% of Medicare spending, according to the bill sponsors. In the Medicaid program, 14% of enrollees are dually eligible, but they account for 30% of Medicaid spending.
Most of those individuals are covered by separate Medicare and Medicaid plans that don’t coordinate care or align enrollment, leading to poor outcomes and inefficient healthcare spending, according to the authors of the bill.
Under the bill, each state would be required to select, develop and implement a comprehensive, integrated health plan for dually eligible individuals. The goal is to ensure that those individuals have access to an integrated set of services, providers, rules and payments, easing navigation in addressing their healthcare and social needs and improving outcomes.
Other components of the bill include automatic enrollment of each individual into an available integrated care plan that includes the person’s existing primary care practitioner as as an in-network provider, establishing an ombudsman for dually eligible individuals, limiting enrollment assistance to independent brokers, developing an aligned program for institutional special needs plans to be financially responsible for providing integrated services, and making it more difficult for Medicare Advantage plans to market plans that look like plans for dually eligible individuals.
The bill also would require every state to allow Programs of All-Inclusive Care for the Elderly, or PACE, to be established, open enrollment to any time in a given month, and extend PACE coverage to people aged fewer than 55 years.
“It gives [the Centers for Medicare & Medicaid Services] more authority to establish, regulate and monitor integrated care — in fact, the bill ensures dual eligibles not only have access to an integrated care model, but are enrolled into such a model,” the LeadingAge letter read. “This legislation will eliminate the current confusion around which program covers which service, while also permitting the integrated care plans to offer a broader set of supplemental benefits to this population regardless of chronic conditions.”
LeadingAge President and CEO Katie Smith Sloan said that accessing care and services for dually eligible individuals today is a “fraught endeavor that ends in frustration and — worse yet — inadequate results.” She said the legislation is a “true win” and a start at redesigning the “patchwork approach” of delivering long-term services and supports.
Years in making
The Duals Working Group met in November 2022 to seek feedback from stakeholders to develop this legislation, releasing draft legislation in May 2023.
The bill sponsors said that the COVID-19 pandemic further exposed the need for reforms to systems of care for dually eligible individuals, who were more than three times as likely to be hospitalized due to complications from the virus compared with Medicare-only beneficiaries.
