Taking care of Medicare and Medicaid's dual-eligibles: A job for Super- , er, Ombudsman

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Staff Writer Tim Mullaney
Staff Writer Tim Mullaney

Giving long-term care stakeholders a reason to cheer, California recently requested a federal waiver to implement Cal MedConnect, a demonstration project meant to improve care coordination for people who qualify for both Medicare and Medicaid.

These dual-eligibles often have complex, chronic conditions and account for a disproportionate share of government spending on healthcare — they are also commonly in need of long-term services and supports (LTSS), and so the California program will integrate LTSS as managed care benefits.

This all sounds good, but if you've been keeping track of the dual-eligible demonstration program (official title: the Financial Alignment Initiative), you may be raising a skeptical eyebrow rather than applauding. The initiative has been criticized repeatedly since it was launched in two years ago this month. Many of the 26 participating states are now moving back start dates or are shying away from their original proposals, which prompted the director of the Medicare-Medicaid Coordination Office at CMS, Melanie Bella, to defend the program in May.

Happily, the agency followed up on Bella's comments by announcing something more concrete: $12 million in grants available to participating states, for the formation of an ombudsman program.

The announcement even earned a thumbs-up from one of the program's most vocal critics, Sen. Jay Rockefeller (D-WV).

I spoke with a CMS official about this dual-eligible ombudsman program, and he provided some insight for long-term care providers. Here are the highlights:

·      The dual-eligible ombudsmen will primarily be helping beneficiaries work with their health plan to know what they need to access new benefits, such as behavioral health benefits that may be offered for the first time or in a different way under the demonstration project.

·      A resident might work with both a long-term care ombudsman and a Financial Alignment Initiative ombudsman, but CMS and the Administration for Community Living are working to ensure coordination between the programs. This means that if there's a facility issue, the FAI ombudsman might contact the LTC ombudsman, and vice-versa, if there's a question about benefits. The goal is to make life easier for residents, who shouldn't have to know the “magic words” to get the answers they need, the official said.

·      The FAI ombudsman will be a beneficiary advocate, and will not work with providers on their reimbursement questions under the demonstrations. However, if there's a dispute between a provider and a health plan, and this is causing the beneficiary problems in accessing care, this is “absolutely” something the ombudsman should get involved with. The program can be seen as a provider benefit, however, to the extent that it takes some pressure off providers or social workers in helping residents with their benefits.

Last week, the Kaiser Family Foundation released an issue brief breaking down the initiated FAI demonstrations. The demonstrations offer a valuable opportunity to improve care coordination and reduce unnecessary institutionalization of duals, the brief notes, but it cautions, “the high care needs of many dual eligible beneficiaries increases their vulnerability when care delivery systems are changed.”

The ombudsman funding should help protect this vulnerable population during a potentially confusing period. Even if it's too early to applaud this program that still faces numerous challenges, there are at least some reasons to lower skeptical eyebrows and cross fingers instead. 

Tim Mullaney is the staff writer at McKnight's. Follow him on Twitter at @TimMullaneyLTC.

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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.