Expanding Health Care Coverage

Grantee Name

New York Health Plan Association

Funding Area

Expanding Health Care Coverage

Publication Date

October 2015

Grant Amount


Grant Date:

December 2012 – December 2013

Individuals who qualify for both Medicare and Medicaid, known as dual eligibles, are among New York State’s costliest and most complex Medicaid beneficiaries.

Given their health care needs, dual eligibles often require a wide array of services from multiple providers. Most dual eligible receive care through Medicare and Medicaid fee-for-service programs, which are fragmented and uncoordinated because of conflicting program rules and perverse incentives between the two programs.

New York State is taking advantage of a new federal demonstration opportunity related to dual eligibles, known as FIDA (Fully Integrated Duals Advantage program), and has established a new managed care program that fully integrates all Medicare and Medicaid physical health care, behavioral health care, and long-term supports and services. Although FIDA offers an opportunity to improve care and realize savings, there were many unknowns and risks associated with how this program would work when fully implemented. To support a smooth transition of FIDA, NYHealth awarded the New York Health Plan Association (HPA) a grant to provide technical assistance and to help with the FIDA implementation process.

Outcomes and Lessons Learned

  • Provided information to the State, health insurance plans, and other stakeholders on the rate-setting process for establishing FIDA, with the intent to foster health plan participation in the integration process.
  • Contracted with Milliman to conduct an actuarial analysis and hosted stakeholder meetings to improve understanding of the rate-setting methodology, assumptions, and decisions related to the development of the FIDA capitation rate, as well as how the rate would differ from the general Medicare and Medicaid populations; and
  • Developed two publicly disseminated reports. The first report, “New York Fully Integrated Duals Advantage Program: Perspectives of a Certifying Actuary,” directly impacted the design of the New York State demonstration, which was subsequently expanded to include individuals receiving facility-based long-term supports and services. The second report, “Examination of Medicare A/B Capitation Rates for 2014,” influenced changes made to the rate-setting methodology, which will have a long-term impact on the success of the program and its sustainability in the future.

HPA held a public forum to discuss the proposed methodology, which fostered follow-up conversations with the New York State Department of Health. These discussions resulted in population changes included in FIDA, such as the inclusion of individuals in institutional long-term care. The project provided a platform for robust dialogue among managed care plan representatives and consumer advocates, which led to a common message on the need for premium adequacy.