GENERATIONS – Journal of the American Society on Aging

mary and preventive medical care for people with the most complex care needs. Again, these provisions help open the door to the possibilities, but at nowhere near the scale to make home- and community-based care a viable alternative to avoidable emergency room, hospital, and nursing home admissions. A Focus For the Future If we are to succeed in making home- and community-based care a viable alternative for a large proportion of beneficiaries with chronic conditions, we need: More investment in technology and care transformation. We must encourage the cre- ation and adoption of technologies that improve connectivity between individuals with chronic conditions, their caregivers in the home, and their care teams. These include telehealth and other monitoring and communication technolo- gies. We also need to develop and apply technol- ogies that can help transform the care process for in-home care—to improve efficiency, expand the capabilities and responsibilities of the in- home workforce, empower caregivers, and make in-home care more affordable and practical as an alternative to institutional care for people with complex care needs. Expansion of integrated care for dual eli- gibles . We must authorize and encourage states that have integrated care available to require dual beneficiaries to select and enroll in the inte- grated plan of their choice. At the same time, we need to drive transformation to a person-cen- tered system that is accountable for quality and outcomes. We also should do more to encourage plans to attract, specialize in, and improve out- comes for beneficiaries with complex care needs. Development of MA-only models that incorporate non-medical supports and ser- vices. For beneficiaries without Medicaid (and to avert Medicaid spend-down), we need to incor- porate non-medical supports and services in the core package of MA-plan benefits—giving pro- viders the flexibility to include in individual care

It is a small step in the direction of home-based care, but it is an important first step. A significant component of this shift is the targeted, non-medical MA supplemental bene- fit option established by the Act that serves as a test case for offering LTSS-type benefits in Medi- care. Initially, the benefits CMS allows plans to offer are likely to be limited and tentative. Con- gress and CMS have a long way to go before they allowMA plans the flexibility to fit to an individ- ual with complex conditions those specific non- medical services and supports he or she needs to remain independent and at home. Another important consequence of the Act is that it moves the ball forward on achieving true integration of Medicare and Medicaid benefits for people who are covered in both programs (known as dual eligibles). There is no good rea- son for carving up coverage for Medicare benefi- ciaries who receive Medicaid benefits. All people ‘We need to shift our resources to build the capacity to support people where they are.’ with dual eligibility should have their coverage through fully integrated plans that operate for the enrollee as if it were a single plan—today only 12 percent of duals are enrolled in integrated plans (Lester and Chelminsky, 2018). The CHRONIC Care Act begins to expand availability of integrated plans in states that have Medicaid Managed LTSS (MLTSS). Half of the states, however, do not have MLTSS. In states that do have MLTSS and make integrated plans available, the majority of dual eligible ben- eficiaries in the state are not enrolled in integra­ ted plans. Thus, much more needs to be done to educate beneficiaries about and enroll them in these plans. Finally, the Act expands opportunities to bring a level of primary care into the home, through telehealth and the Independence at Home model, to provide a stronger link to pri-

30 | Spring 2019

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