Innovating for Medicare Beneficiaries

Medicare beneficiaries with chronic conditions and daily living challenges struggle to navigate a complex system of care whether they have both Medicare and Medi-Cal, or are Medicare only. While states do not have fiscal responsibility for the Medicare program, there is an opportunity to influence care delivery and enhance approaches to improve access and coordinate medical and nonmedical services in support of community living.

Photo by Kristin Chalmers for Community Catalyst

The Challenge

States are responsible for implementing the Medicaid program and therefore have traditionally focused efforts on building infrastructure for Medicaid beneficiaries. Policymakers and stakeholders are now recognizing the importance of building Medicare capacity to support Medicare-only beneficiaries with complex care needs as well. Many of these individuals are part of the “forgotten middle” – older adults who do not have sufficient financial resources to pay for health care and long-term services and supports (LTSS), yet do not meet eligibility requirements for many government-funded programs, including Medicaid.

Similarly, dually eligible beneficiaries face challenges in accessing streamlined services, i.e., fragmentation in how LTSS services are delivered across both systems of care.

The Opportunity

States can position themselves to improve equitable access to high-quality care and services for the Medicare population. Establishing the infrastructure needed to build and sustain Medicare capacity over time will help states develop the expertise to create innovative models of care. There is a need for:

  • State-level policy leadership to create a person-centered system of care for dual-eligible adults and Medicare-only beneficiaries with complex care needs; and
  • Medicaid agency staff to develop knowledge of Medicare’s evolving landscape of policies, regulations, and market activity.

Ensuring Success Within the Office of Medicare Innovation and Integration

The California Department of Health Care Services (DHCS) Office of Medicare Innovation and Integration (OMII) was established in 2021 and tasked with expanding the health and human service focus beyond Medicaid to improve health outcomes, quality, affordability, and equity for all Medicare beneficiaries in California (6.6 million), including those that are dually eligible (1.6 million).

In partnership with DHCS OMII, we have supported efforts to develop a better understanding of California’s Medicare population to inform policy and program development.

Building Medicare Savvy Among State Medicaid Staff

With our support alongside Arnold Ventures and The Commonwealth Fund, the Center for Health Care Strategies (CHCS) launched the Medicare Academy in October 2022 to support Medicaid agencies focused on building the Medicare capacity needed to advance integrated care and build the infrastructure needed to sustain Medicare capacity over time.

The 10-month long Academy is working with eight states – Colorado, Hawaii, Maine, North Carolina, Texas, Virginia, Washington, and Wisconsin – to build the Medicare knowledge they need to:

  • Develop and oversee Medicare-Medicaid integration programs; and
  • Engage in longer-term policy and program refinement.

Our Thought Partners

ATI Advisory

ATI Advisory is a research and advisory services firm that helps health care and government leaders transform care delivery for older adults with complex needs and their families.

Center for Health Care Strategies

Center for Health Care Strategies is a nonprofit dedicated to improving health care quality for low-income people, those with chronic illnesses and disabilities, vulnerable older adults, and racially and ethnically diverse populations who are experiencing disparities.

Chapman Consulting

Chapman Consulting is a consulting firm with expertise in federal and state health policy, researching and evaluating the current landscape and its impacts to provide comprehensive and actionable strategies.

National Opinion Research Center

The National Opinion Research Center (NORC) at the University of Chicago is one of the world’s premier social science research organizations. NORC’s mission is to conduct rigorous research on key social problems and policy issues.