Expanding Health Care Coverage

Project Title

New York State Duals Demonstration Capitation Analysis

Grant Amount


Priority Area

Expanding Health Care Coverage

Date Awarded

December 10, 2012


Capital Region






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

Dual eligibles often require a complex array of services from multiple providers. Most, however, receive their care through Medicare and Medicaid fee-for-service programs, which are fragmented and uncoordinated. New York State is moving rapidly to take advantage of a new federal demonstration opportunity, known as FIDA (Fully Integrated Duals Advantage Program); FIDA will integrate the two funding streams and provide a comprehensive package of services. With funding from NYHealth, the New York Health Plan Association (HPA) offered technical assistance and provided independent analysis to help ensure the overall success of the FIDA demonstration. HPA conducted its work in two phases.

In phase I, HPA engaged the services of Milliman, one of the nation’s premier actuarial and consulting firms, to provide a New York State-specific analysis of the rate-setting process. Milliman developed a comprehensive analysis of the issues involved in building a FIDA rate, including identifying components of the rate, data requirements, and new benefits. It also conducted telephone and in-person meetings with consumer representatives to solicit their input and brief them on the findings. Finally, Milliman produced a phase I report on the rate-setting process, data sources, and relevant population factors.

In phase II, Milliman examined the potential difference in rates when calculated on the general Medicare population compared to when calculated using a duals-specific average. Upon receiving a data set from the New York State Department of Health that combines Medicaid and Medicare data, Milliman tested the adequacy of the proposed Medicare methodology. This analysis explains the difference in costs, with the purpose of highlighting factors that will ensure sound rate setting. As with phase I, Milliman produced a final report of findings that will be shared with a range of stakeholders.

Read the reports associated with this grant:

“New York Fully Integrated Duals Advantage Program: Perspectives of a Certifying Actuary”

“Examination of Medicare A/B rates for 2014”