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

This NYHealth-supported report, written by Milliman, Inc., in association with New York Health Plan Association, is intended to inform health plans and key stakeholders of the potential capitation rate-setting methodologies and assumptions for developing the dual-eligible integration demonstration program in New York State.

Individuals who qualify for both Medicare and Medicaid, known as dual eligibles, are among New York State’s costliest and most complex Medicaid beneficiaries. On average, each dual eligible costs the State $30,384 per year—the highest rate in the nation and twice as much as the national average of $15,459.

New York State is moving rapidly to take advantage of a new federal demonstration opportunity related to dual eligibles, the Fully Integrated Duals Advantage Program (FIDA). New York will establish a new managed care program that fully integrates all Medicare and Medicaid physical health care, behavioral health care, and long-term supports and services. When fully implemented, the FIDA demonstration program could affect approximately 150,000 New Yorkers.

In developing a single, actuarially sound capitation rate to cover the costs of a combined Medicaid and Medicare program, this report provides recommendations to ensure that the FIDA rate-setting process is robust, accurate, and transparent.

This is the first of two reports written by Milliman, Inc., in association with New York Health Plan Association, on the dual-eligible integration demonstration program in New York State. Read the second report, “Examination of Medicare A/B Capitation Rates for 2014.”