Managed Care Coming for Beneficiaries covered by both Medicare and Medicaid

Andrew Spear

By Vince McKelvey

In an effort to improve health care services for Ohioans who are eligible for both Medicaid and Medicare, the state will require about 114,000 low-income older or disabled Ohioans in 29 counties to enroll with a managed care organization starting in March 2014.

The move is part of a three-year demonstration project intended to improve people’s health and curb state and federal health care spending.

Under the Integrated Care Delivery System project, enrollees will have a single point of contact for health services—the managed care organization—and will work with a care manager to build a personalized comprehensive health plan. That plan will include behavioral health and long-term care services as well as standard medical care.

While managed care will be required for Medicaid services, people may choose to continue to receive Medicare services as they do now. But officials hope people will enter managed care for all services.

State officials say a lack of coordination between Medicaid — the federal-state health care program for the poor — and Medicare — the federal health care program for people who are 65 and older, or disabled — can lead to duplicated services and conflicting treatments.

The result is “a diminished quality of care,” said Ohio Medicaid director John McCarthy. “The current system is confusing and difficult to navigate, and no single entity is accountable for the whole person.”

Home care emphasis

The federal government has approved the pilot, which emphasizes home- and community-based care and seeks to increase resources for wellness programs, preventive care and community services.

AARP Ohio and the Ohio Association of Area Agencies on Aging have been involved since the state began developing the project two years ago. Both associations are working to see that the project has the resources to help people make a smooth transition and achieves its anticipated benefits.

“We’re totally committed to making this successful in Ohio, but we also want to keep our eye out for ways that it can go awry,” said Larke Recchie, executive director of the area agencies association.

The pilot applies to adults who qualify for both Medicare and Medicaid because of their income and their age or disability status and who live in the demonstration areas clustered around Akron, Cincinnati, Cleveland, Columbus, Dayton, Toledo and Youngstown.

The state has chosen five health plans — Aetna, Buckeye, CareSource, Molina and UnitedHealthcare — to provide managed care and has assigned them to specific regions. Residents of each region will have a choice of at least two managed care organizations.

Help to enroll


Counselors from independent agencies will be available to help people through the enrollment  process. “There’s a lot of education that’s needed,” Recchie said.

Under managed care, enrollees will be limited to the providers who are part of their network. As a result, some people may eventually have to change care providers. But McCarthy said they are “guaranteed continuity of care for one year.” Residents of assisted living facilities and nursing homes would be able to remain in their current facility at least three years.

One concern for advocates is that the managed care organizations have no experience in long-term care support and services. But Recchie said the Area Agencies, which will coordinate community services for all enrollees over 60, have extensive experience in long-term care, which can help the managed care companies navigate this arena.

Bill Sundermeyer, AARP Ohio associate state director for advocacy, said he’s concerned about ensuring quality in a system where for-profit companies will be choosing health providers and negotiating payments.

“There are some very good things about this, and there are some things that we’re just going to have to work through,” Sundermeyer said. “Our major concern is how does all of this affect the consumer, and does the consumer … get better care?”

Vince McKelvey is a freelance writer based in Dayton, Ohio.