To Opt-In or Opt-Out? The Choice Behind Financial Alignment for Dual-Eligible Beneficiaries in Ohio

Eleven states implemented the Financial Alignment Initiative (FAI) to better align and care for beneficiaries eligible for Medicare and Medicaid. However, dually eligible beneficiaries could opt-out of the Medicare portion of the demonstration, potentially reducing the initiative's effectiveness. This study describes the extent and effects of opting-in/opting-out in Ohio during the demonstration. Data from the Ohio Department of Medicaid (November 2021) were analyzed, alongside interviews from 36 organizations providing long-term services and supports or acute care services. Of the 42% who opted out, 46% were aged 65 years and older, 43% were aged 45 to 64 years, and 29% were under 45 years. Opt-out rates were 39% for community well members, 44% for those receiving community-based long-term care, and 51% for long-stay nursing facility residents. Care managers and service providers reported challenges with those who opted out, including lack of access to care, poor communication, and insufficient information during care transitions. These issues created barriers to accessing coordinated care for dually eligible beneficiaries, particularly those with complex chronic conditions, limiting the success of the initiative in improving care quality and cost-effectiveness.