The "Dual Eligible" Medicare-Medicaid Enrollee Demonstration: Can It Both Improve Care and Save Money?

States have proposed a "passive enrollment process" to initiate the demonstration programs. This means that the state will automatically enroll eligible individuals, without their say. Beneficiaries will have an opportunity to disenroll or "opt out" at certain clearly designated points. The rationale for passive enrollment is to get a sufficient mass of enrollees to make the program work effectively. A large and notable group of national aging, disability, and healthcare consumer organizations has opposed the passive enrollment process, urging a voluntary, opt-in model instead, using high-quality information and enrollment assistance, and offering a choice of providers, as in the Medicare program. They submit that passive enrollment into an experimental program is not a fair approach for a population of poor enrollees with chronic conditions and high healthcare needs. "Dual eligible" beneficiaries are those qualified to receive both federal Medicare benefits for older individuals and people with disabilities, as well as federal/state Medicaid benefits for lowincome patients. By definition, then, they are older or have a disability, and they are poor. There are over nine million dual Medicare-Medicaid enrollees, over two-thirds of whom receive full benefits from both programs. According to the Centers for Medicare and Medicaid Services (CMS), while these individuals make up 16 percent of Medicare and 15 percent of Medicaid enrollees respectively, they account for 27 percent of total Medicare expenditures and 39 percent of Medicaid spending. Many have multiple, chronic conditions. Many are receiving long-term supports and services. Their medical needs are high. Currently, these dual eligible individuals are served in an uncoordinated fashion by both programs, with no single focus on their overall needs in a holistic way. It is difficult for them to navigate the intricacies and requirements of the two very different systems. Indeed, they may often slip between the cracks of care systems and fail to get the treatments and services they need. In July 2011, CMS invited states to apply for "two financial alignment models" that would coordinate care for dual eligible enrollees - one through a capitated managed care system and one through a fee-for-service model. To raise the stakes, these highly innovative programs will do something that has remained largely untried and untested, particularly in managed care - integrating primary medical care, behavioral health ca