The twelve million beneficiaries dually eligible for Medicare and Medicaid have complex medical and psycho-social needs. Dual-eligible beneficiaries face significant barriers to receiving whole-person, coordinated, and equitable care due to lack of integration between Medicare and Medicaid programs. This lack of integration results in dual-eligible beneficiaries and their care partners navigating two sets of policies and a complex, fragmented, and highly inefficient system of care. Medicare-Medicaid integration has potential to better streamline and coordinate care, enhance the beneficiary experience, and improve health outcomes, health equity, and value of health care spending. There are numerous efforts at integrating Medicare and Medicaid at the federal and state levels that have demonstrated promising results.
North Carolina (NC) is amidst a major Medicaid transformation from fee-for-service (FFS) to managed care and other value-based care transformation efforts. Through this approach, Medicaid managed care plans will provide coverage to a majority of Medicaid-only beneficiaries through Prepaid Health Plan (PHP) contracts. As part of this transition, the NC Department of Health and Human Services (NC DHHS) is statutorily required to transition Full-Benefit Dual Eligible (FBDE) beneficiaries (NC residents with full Medicaid benefits who are also enrolled in Medicare) into Medicaid managed care by 2026. Currently, the vast majority of dual-eligible beneficiaries in the state do not have access to integrated Medicare and Medicaid services. The state outlined some broad parameters to inform an integration strategy in a 2017 report of the Joint Legislative Oversight Committee on Medicaid and NC Health Choice. However, key policy design and implementation questions remain, including eligibility, structure, plan design, phase-in of populations and services, and program oversight.
To support the development of a central policy and implementation plan, a team from the Duke University Robert J. Margolis, MD, Center for Health Policy (Duke-Margolis Center), supported through a grant by Arnold Ventures, developed pragmatic, evidence-based options for Medicare-Medicaid integration in NC for FBDE beneficiaries, guided by the following objectives:
- Describe the vision and goals for Medicare-Medicaid integration in the NC context;
- Identify options for deploying managed care to achieve integration for dual-eligible beneficiaries that build on current NC Medicaid Transformation efforts and help promote health equity; and
- Determine strategies that help align key Medicare and Medicaid components to promote integration.
In this report, we describe the proposed vision, goals, and options to support beneficiary-centered Medicare-Medicaid integration in NC. Our recommendations were informed by a 21-month, multi-component project encompassing a targeted literature review; interviews with more than 60 participants1, the majority from NC; in-depth analysis of combined NC Medicaid and Medicare data2; guidance from a project Advisory Panel and multi-stakeholder convenings; and regular meetings with NC DHHS and other state and federal experts in Medicare-Medicaid integration. This approach leveraged the expertise of Duke-Margolis faculty, data scientists, and senior policy advisors and builds on the Center’s ongoing collaboration with NC DHHS in its care transformation efforts.
To help situate the recommendations, we first outline the existing landscape of dual-eligible beneficiaries in NC, including the challenges they currently face, and present state and federal regulatory considerations and key policy and programmatic parameters. We then discuss the options for integration and characterize key program components such as model of care, performance measurement, and implementation supports central to realizing the vision and goals.
Informed by our experience developing evidence-based integration options for the North Carolina Department of Health and Human Services, the insights within the guide can provide direction to states that plan to develop a tailored integration strategy.
Senior Policy Fellow
Assistant Professor, Population Health Sciences
Margolis Core Faculty
Faculty Director of Undergraduate and Graduate Studies
Senior Advisor and Founding Director, Margolis Scholars Program
Assistant Professor in Population Health Sciences and Public Policy
Margolis Core Faculty
Anti-Racism and Equity Committee Member