Demonstration Project Faces Challenges—Misunderstanding, Bias

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By Mindy Yochelson

Nov. 19 — Attempts to educate health-care providers about the merits of the Centers for Medicare & Medicaid Service's demonstration for dual eligibles has been one of the top challenges for managed care plans in their efforts to deter beneficiaries from opting out of the program, conference attendees were told Nov. 18.

Michael Monson, Centene Corp.'s vice president for long-term care and dual eligibles, said that because dual eligible members, most of whom have been passively or automatically enrolled in the demos, are permitted to leave at any time, opt-out rates have ranged from 25 percent to as high as 45 percent in California.

Providers, particularly nursing homes, have encouraged opt-outs because they don't understand the product, Monson said during a summit on the demonstration sponsored by World Congress.

Care Integration

Authorized by the Affordable Care Act, the CMS demonstration—called the Financial Alignment Initiative—integrates medical care and support services from the federally run Medicare and state-run Medicaid programs.

The managed care plan is one of three parties—along with CMS and the state—to sign a contract to provide all services for dual eligibles under Medicaid and Medicare Part A, Part B and Part D into an entity known as a Medicaid-Medicare Plan (MMP).

Among the benefits of an MMP for a member are a single point of contact for services with one ID card that is intended to lead to simplified access to care and improved communication about available services and support.

States also have complained about provider influence, particularly nursing facilities. A Virginia state representative recently told a webinar that nursing homes have orchestrated “mass opt outs” from the demo. An Illinois representative talked about resistance by durable medical equipment suppliers.

WellPoint's Efforts

Like Monson, WellPoint Vice President Lisa B. Wagamon also blamed provider opposition on a lack of understanding about the demonstration.

WellPoint is working on demonstrations in California and Virginia—as well as in Texas and New York—which are to begin in 2015.

“What we're finding, in the Virginia market especially, that it's not the medical community that is asking members to disenroll,” Wagamon said, but the long-term care facilities.

The facilities are concerned that the MMPs will deny care, give them orders and not reimburse them, according to Wagamon who is in charge of provider solutions for Medicare Medicaid duals. One health system told her “we don't want you in here looking under our covers.”

She said that one nursing home in Virginia took the letters that had been sent out alerting residents that they had been passively enrolled in an MMP and sent them back to WellPoint unopened in one large envelope “to let us know that they had all opted out.”

“We try to explain to them that it's a partnership” Wagamon said, and to alert them to the services and care coordination that beneficiaries are entitled to as members.

No Information Released

Adult day care centers have been problematic when managed care companies need help locating a beneficiary that has been assigned to the demo, she said.

When the managed care company observes a report that indicates a member has gone to a day care center, the MMP will contact the center to get a phone number or address. However, the centers have refused to divulge the information, she said.

The medical community, on the other hand, lacks understanding about who and what is a dual-eligible beneficiary. She said the doctors view members only as Medicare beneficiaries, in part because members may be “embarrassed” to tell the doctor they are dually eligible, which makes it difficult to encourage the doctors to join the managed care network.

In addition to the mass training that is given to providers by the states, WellPoint is “going out to each office that will let us in,” Wagamon said. Company reps will ask the doctors, for example, how the MMP's care coordinators can help them with some of their problematic patients, such as those who don't show up for appointments. Results have been mixed, she said.

California's Issues

In California, disenrollment has been a particular problem. About 40 percent have opted out in the five counties that have the program operational, with almost 50 percent in Los Angeles County, according to a state report.

Provider influence on enrollment is a big problem, particularly in Los Angeles, Diane Sargent, senior director of dual eligible product management and program implementation at Health Net Inc., told the conference.

High levels of opt-out rates have been found in certain ethnic neighborhoods, particularly in areas with community providers who don't accept managed care, she said.

For example, a You Tube video posted in Armenian by one provider warns beneficiaries not to join the demo. High levels of opt outs also have been found in Korean neighborhoods, she said.

A beneficiary who receives a “confusing notice” about enrollment is “likely to go to a trusted adviser” who is a fee-for-service physician, Sargent said.

In addition, she added, beneficiary advocates in the state haven't been “pleased with the passive enrollment process.”

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Ward Pimley at


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