According to CMS, the  contracts are an opportunity to improve the integration of Medicare and  Medicaid benefits, and the agency has implemented this requirement with  the goal of “increased integration and coordination” for dual-eligible  beneficiaries. A larger proportion of dual-eligible beneficiaries in D-SNPs, as well as  dual-eligible beneficiaries in FFS, were under age 65 and disabled in  2011 compared with those in other MA plans (see fig. Among the  characteristics in our analysis, the largest difference between D-SNPs  and other MA plans was the proportion of full-benefit beneficiaries in each  plan type: 80 percent of dual-eligible beneficiaries in D-SNPs and   75 percent of dual-eligible beneficiaries in FFS were eligible for full  Medicaid benefits, compared with just 34 percent of dual-eligible  beneficiaries in other MA plans. Health Status of Dual- Eligible Beneficiaries in D-SNPs Was Similar to That of Dual-Eligible Beneficiaries in FFS and Other MA Plans

Dual-eligible beneficiaries in D-SNPs had very similar health status as  measured by their 2010 risk scores, the year for which the most recent  data were available, when compared with dual-eligible beneficiaries in  FFS and other MA plans. While the  models of care we reviewed described in varying detail how the D-SNPs  plan to provide other services, such as health risk assessments, to  beneficiaries, most D-SNPs did not provide—and are not required to  provide—estimates of the number of dual-eligible beneficiaries that would  receive the services. D-SNPs Offered Fewer of Their 10 Most-Common Supplemental Benefits Than Other MA Plans

D-SNPs provide fewer supplemental benefits, on average, than other MA  plans. Of the 10 supplemental benefits offered by more than half of  D-SNPs, 7 were offered more frequently by other MA plans and 3 were  offered more frequently by D-SNPs.benefits were offered much more frequently by D-SNPs compared to  other MA plans: they offered dental benefits one-and-a-half times more   (See fig. D-SNPs Reported More- Comprehensive Care Coordination Services and Greater Beneficiary Interaction Than Other MA Plans

Of the 15 D-SNPs we interviewed, 9 were in organizations that offered  both D-SNPs and other MA plans, and representatives from 7 of those  D-SNPs told us that their care coordination services are different from  those in their organization’s other MA plan offerings. Although Some D-SNP Contracts with State Medicaid Agencies Expressly Provide for Benefit Integration or Care Coordination, Most Do Not

CMS stated that contracts between D-SNPs and state Medicaid agencies are an opportunity to increase benefit integration and care coordination.However, only about one-third of the 2012 contracts we reviewed  contained any provisions expressly providing for D-SNPs to deliver  Medicaid benefits, thereby achieving benefit integration. Only about one- fifth of the contracts expressly provided for active care coordination  between D-SNPs and Medicaid agencies, which indicates that most care  coordination was done exclusively by D-SNPs, without any involvement of  state Medicaid agencies. Further, D-SNP representatives and state  Medicaid officials expressed concerns about resources needed to  contract with D-SNPs, and uncertainty about the future of D-SNPs. For D-SNPs contracting with state Medicaid agencies to provide all or  some Medicaid benefits, the capitated payment reflected variation in  coverage and conditions. Because D-SNPs are  required by Medicare to provide care coordination services to dual-eligible  beneficiaries, these services are often provided without reimbursement or  payment from the state Medicaid agency. Additional standardized information would allow CMS to meet its goals for  accountability for effective and efficient use of resources. Recommendations for Executive Action

To increase D-SNPs’ accountability and ensure that CMS has the  information it needs to determine whether D-SNPs are providing the  services needed by dual-eligible beneficiaries, especially those who are  most vulnerable, the Administrator of CMS should take the following four  actions:  require D-SNPs to state explicitly in their models of care the extent of  services they expect to provide, to increase accountability and to  facilitate evaluation;  require D-SNPs to collect and report to CMS standard performance  and outcome measures to be outlined in their models of care that are  relevant to the population they serve, including measures of  beneficiary health risk, beneficiary vulnerability, and plan  performance;  systematically analyze these data and make the results routinely  available to the public; and  conduct an evaluation of the extent to which D-SNPs have provided  sufficient and appropriate care to the population they serve, and  report the results in a timely manner. However, as we noted in the draft report, we  believe such information could be useful in later evaluating whether   D-SNPs met their intended goals. SNP Alliance representatives generally agreed with our  recommendations.
Why GAO Did This Study

About 9 million of Medicare's over 48 million beneficiaries are also eligible for Medicaid because they meet income and other criteria. These dual-eligible beneficiaries have greater health care challenges than other Medicare beneficiaries, increasing their need for care coordination across the two programs. In addition to meeting all the requirements of other MA plans, D-SNPs are required by CMS to provide specialized services targeted to the needs of dual-eligible beneficiaries as well as integrate benefits or coordinate care with Medicaid services. GAO was asked to examine D-SNPs' specialized services to dual-eligible beneficiaries. GAO (1) analyzed the characteristics of dual-eligible beneficiaries in D-SNPs and other MA plans, (2) reviewed differences in specialized services between D-SNPs and other MA plans, and (3) reviewed how D-SNPs work with state Medicaid agencies to enhance benefit integration and care coordination. GAO analyzed CMS enrollment, plan benefit package, projected revenue, and beneficiary health status data; reviewed 15 D-SNP models of care and 2012 contracts with states; and interviewed representatives from 15 D-SNPs and Medicaid agency officials in 5 states.

What GAO Found

About 9 percent of the dual-eligible population is enrolled in 322 Medicare dual-eligible special needs plans (D-SNP), a type of Medicare Advantage (MA) plan. All dual-eligible beneficiaries are low income, but those in D-SNPs tended to have somewhat different demographic characteristics relative to those dual-eligible beneficiaries in other MA plans. On the basis of the most current data available (2010-2011), compared to those in other MA plans, dual-eligible beneficiaries in D-SNPs were more frequently under age 65 and disabled, more likely to be eligible for full Medicaid benefits, and more frequently diagnosed with a chronic or disabling mental health condition. In spite of these differences, the health status of D-SNP enrollees as measured by their expected cost to Medicare was similar to the health status of dual-eligible enrollees in other MA plans in 2010. D-SNPs provide fewer supplemental benefits--benefits not covered by Medicare fee-for-service (FFS)--on average, than other MA plans. Of the 10 supplemental benefits offered by more than half of D-SNPs, 7 were offered more frequently by other MA plans and 3 were offered more frequently by D-SNPs. Yet D-SNPs spent proportionately more of their rebate--additional Medicare payments received by many plans--to fund supplemental benefits compared to other MA plans, and less to reduce Medicare cost-sharing, which is generally covered by Medicaid. The models of care GAO reviewed, of 107 submitted for 2012, described in varying detail how the D-SNP planned to provide specialized services, such as health risk assessments, and meet other requirements, such as measuring performance. However, the Centers for Medicare & Medicaid Services (CMS), which administers Medicare and oversees Medicaid, did not require D-SNPs to use standardized measures in the models of care, which would make it possible to compare the performance of D-SNPs. While D-SNPs are not required to report that information to CMS, such information would be useful for future evaluations of whether D-SNPs met their intended results, as well as for comparing D-SNPs. CMS stated that contracts between D-SNPs and state Medicaid agencies are an opportunity to increase benefit integration and care coordination. Our review of the contracts indicated only about one-third of the 2012 contracts contained any provisions for benefit integration, and only about one-fifth provided for active care coordination between D-SNPs and Medicaid agencies, which indicates that most care coordination was done exclusively by D-SNPs, without any involvement of state Medicaid agencies. However, some D-SNP contracts with state Medicaid agencies specified that the agencies would pay the D-SNPs to provide all or some Medicaid benefits. Representatives from the D-SNPs and Medicaid officials from the states GAO interviewed expressed concerns about the contracting process, such as limited state resources for developing and overseeing contracts, as well as uncertainty about whether Congress will extend D-SNPs as a type of MA plan after 2013, and the implementation of other initiatives to coordinate Medicare and Medicaid benefits for dual-eligible beneficiaries that could replace D-SNPs. To increase D-SNPs' accountability, GAO recommends improving D-SNP reporting of services provided to dual-eligible beneficiaries and making this information available to the public. In its comments on a draft of GAO's report, CMS generally agreed with our recommendations.