Advocates are key players in states’ dual eligible demonstration roll-outs

By Fay Gordon and Amber Cutler

Over the summer, for tens of thousands of low-income older adults and people with disabilities in California, the sight of a blue envelope in the mailbox signaled the beginning of a complete change in their healthcare services. Those envelopes contained a notice explaining how their enrollment in California’s dual eligible demonstration, known as Cal MediConnect, would change the way they receive their Medicare and Medicaid benefits. 

Dual Eligible Demonstrations Go Live

Older adults and people with disabilities in California are not alone. After several years of debate and design, implementation of the federal Financial Alignment Initiative, also known as the dual eligible demonstration, is live in California and four other states (Massachusetts, Ohio, Virginia and Illinois). In these five states, people eligible for Medicare and Medicaid (dual eligibles) are being passively enrolled into managed care plans responsible for providing all of their Medicare and Medicaid services. More states will follow suit in the next 12 months.

The demonstrations offer significant promise—an opportunity to coordinate a complex network of services and systems for people having a wide range of care needs. It is not easy, however, to effectively communicate automatic enrollment into managed care plans to consumers.

Dual eligible individuals disproportionately have low literacy levels, limited proficiency in English, higher rates of homelessness and are hard to reach. Results from early demonstration states show the importance of engaging advocates who know and work with dual eligibles, informing them of demonstration system changes and creating a feedback loop that is essential to solving problems that arise.

A Word to the Wise: Lessons Learned

The following are a few lessons from the early demonstration states:

  • Engage Advocates Early in the Process. It takes time and expertise to plan, draft, test and revise notices and communication materials that accurately convey the complexity of these new programs and make it easy for duals to make an enrollment choice. Eager to launch enrollment, some states rushed when creating materials and avoided engaging advocates in a thoughtful planning process for drafting notices. Notices that were not tested or redrafted resulted in confusion, and a difficult-to-navigate enrollment process.

Professionals in aging understand the language, comprehension and accessibility needs of dual eligibles. States should tap into this resource early on and engage them to assist in the preparation and review of enrollment documents and materials. States can better contemplate and map out the enrollment design process by forming an enrollment committee of state agencies, providers and professionals in aging.

  • Inform Advocates of Demonstration System Changes. A notice alone cannot fully communicate the complexity of these new programs and what they might mean for any one person’s access to care. Individuals and their caregivers will look to professionals for assistance and explanation. In California, many individuals who were confused by the notices turned to trusted providers, like their adult day services center, for assistance with enrollment decisions.

States are wise to recognize the important role these community-based organizations and providers serve. They should invest time and resources into building these organizations’ capacity to assist beneficiaries with enrollment options, and any related problems. Each state should have a plan for training and disseminating up-to-date information to all professionals who serve older adults on a daily basis.

  • Create a Feedback Loop. Even if a state adequately tests its enrollment systems, dual eligibles may still receive notices when they should not, receive the wrong type of notice or be erroneously enrolled in a plan they didn’t choose. Aging service providers will often be the first to spot such issues.

In Illinois, when people received notices dis-enrolling them from their Part D plans (as part of the passive enrollment into the demonstration), the local State Health Insurance Assistance Program was there to explain to people why they were receiving these notices. They also were able to work with other service providers and advocates to alert their state Medicaid agency and the federal Centers for Medicare and Medicaid Services (CMS) to the confusion caused by the Part D notices. In response, CMS is working to revise future notices.

An efficient feedback loop, in which on-the-ground problems are quickly funneled to state and federal agencies, and where agencies can quickly disseminate information to those who help consumers, is critical to smoothing out enrollment challenges. The National Senior Citizens Law Center’s (NSCLC) workgroup of consumer representatives from demonstration states provides this connection from the state level to the federal agencies. The NSCLC runs a similar group for California advocates, with a feedback loop that proved to be essential during early implementation challenges. Using this model to engage aging service providers could be highly effective for other states.

It is an overwhelming task to inform a highly diverse population of an extremely complex healthcare system change. Nothing about coordinating a Medicare and Medicaid system is simple. Early state engagement with those in the field of aging is a vital first step to ensuring a safe transition for older adults and people with disabilities who enroll in these new programs. For more information on the dual eligible demonstrations and resources for advocates on the enrollment process, visit

Fay Gordon and Amber Cutler are staff attorneys at the National Senior Citizens Law Center, headquartered in Washington, D.C.