Plan Watch

Program Keeps Dually-Eligible Adults Out of Nursing Home

Emblem Health is starting slowly with an effort that demographics nearly guarantee will catch on in New York and across the country

Frank Diamond
Managing Editor

Managed care has combated the difficulties of old age with its emphasis on prevention and disease management. An insurer in New York wants to take this a step further with a program that seeks to hold off the indignity of being placed in a nursing home.

Emblem Health is launching a program this month called the Medicaid Advantage Plus Managed Long-Term Care plan for people who qualify for both Medicare and Medicaid. Besides existing Medicare benefits, enrollees will also receive a range of medical and personal care services in their home and community that will provide assistance with activities such as bathing, getting dressed, shopping for food, and other activities of daily living. Emblem Health will also provide comprehensive care management to make sure members can stay in the community for as long as possible.

There are a growing number of similar programs throughout the country. An example is the Program for All-Include Care (PACE), that can be found in quite a few states, including New York, Massachusetts, Pennsylvania, and Florida. “This is the leading edge of programming for disabled and senior Medicare beneficiaries who have current and long-term health care needs,” says Stuart Lefkowich, Emblem Health’s vice president for Medicare.

What makes it a particularly good fit for Emblem Health is the fact that the plan has about 150,000 Medicare enrollees. “We have a very large Medicare population,” says Lefkowich. “In that population there is a group of people with care needs that would qualify for this program. We’ve reached out to about 100 of those people so far and many of them are interested in the program and have already signed up for it.”

He expects that there will be about 25 enrollees initially and that more will be added each month. “We want this to go right. The people who typically qualify for this program are either elderly or disabled, and so they get on Medicare.” They’re also poor or nearly poor, so they have Medicaid. They have care needs that are typically met in a nursing home.

The linchpin of the program is the participation of a nurse care manager. “That’s the only way this works,” says Lefkowich. “They are very involved with this population. It’s a relatively small case load, so that they can provide needed personalized service.”

Enrollees will have access to network physicians, social workers, and a host of other care providers. “The care manager is the one who sets up the plan and monitors it and makes sure it’s the personalized plan the person needs,” says Ilene Margolin, Emblem Health’s senior vice president in charge of public affairs and communication. “But then the actual services will be provided by others.”

Costs unknown

Of course, the costs will be something of an X factor. “It really depends on the needs of the individual,” says Lefkowich. “The costs can vary greatly, depending on how much care the individual receives. Someone who is very, very ill or disabled might require around-the-clock care that’s going to be extremely expensive. Someone else may need someone to come in every once in a while or may go to a day center, and it’s much less expensive.”

The Medicaid Advantage Plus Managed Long-Term Care plan is not so much a matter of branching out as digging in, says Lefkowich. “A lot of the people eligible are currently members so we provide many services for them today. This program gives us the ability to do this in a more comprehensive way.”

A blueprint for high-volume, high-quality lung cancer screening that is detecting cancer earlier—and helping to save lives

Clinical Brief

Multiple Sclerosis: New Perspectives on the Patient Journey–2019 Update
Summary of an Actuarial Analysis and Report