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Options for Including Medicare

Key Considerations

The majority of Medicaid-funded LTSS beneficiaries, regardless of age, also have Medicare coverage.  Most Medicaid spending for dually enrolled Medicare-Medicaid beneficiaries is for LTSS. 

When a beneficiary has both Medicare and Medicaid coverage, primary and acute care and prescription drugs are primarily reimbursed by Medicare.  Medicare also pays for some behavioral health services and services that interact with and can impact the delivery of LTSS. 

For these reasons, you may decide to include Medicare services in your MLTSS program and select an MLTSS contractor that has the capacity to manage the full range of primary, acute, mental health, and LTSS services.  (click here for a brief example.)

Key considerations include the following:

  • A fully integrated program is more complex and will take longer to implement than a program that includes only Medicaid services.

  • You will need to attract or help develop MLTSS contractors that are able and willing to manage the full range of services.  Typically, managed care contractors have experience with medical services but not with LTSS.  Community provider organizations may have significant LTSS experience but no experience delivering health services or bearing significant financial risk.

  • Medicare enrollment may not be mandatory.  You may require enrollment for Medicaid services, but the Medicare portion of an integrated program must always be voluntary.



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