DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
SMDL #18-012 
RE: Ten Opportunities to Better Serve 
Individuals Dually Eligible for Medicaid 
and Medicare  
 
December 19, 2018 
 
Dear State Medicaid Director: 
 
Over 12 million individuals are concurrently enrolled in Medicaid and Medicare. Such dually 
eligible individuals may either be enrolled first in Medicare by virtue of age or disability and 
then qualify for Medicaid on the basis of income, or vice versa. Dually eligible individuals 
experience high rates of chronic illness, with many having multiple chronic conditions and/or 
social risk factors.i Forty-one percent of dually eligible beneficiaries have at least one mental 
health diagnosis, and about half use long term services and supports (LTSS).ii  
 
Dually eligible individuals account for a disproportionately large share of expenditures in both 
the Medicare and Medicaid programs. Historically, dually eligible individuals have accounted 
for 20 percent of Medicare enrollees, yet 34 percent of Medicare spending. The same individuals 
have accounted for 15 percent of Medicaid enrollees and 33 percent of Medicaid spending.iii  
Medicare and Medicaid were originally created as distinct programs with different purposes. Not 
surprisingly, the programs have different rules for eligibility, covered benefits, and payment, and 
the programs have operated as separate and distinct systems despite a growing number of people 
who depend on both programs for their health care.  
 
We often hear from states interested in how Medicare and Medicaid can work better together. A 
number of states have already launched ambitious initiatives to better serve dually eligible 
individuals, including those states that are testing demonstrations, such as the models under the 
Medicare-Medicaid Financial Alignment Initiative, in collaboration with Centers for Medicare & 
Medicaid Services (CMS). We will be outlining new demonstration-related opportunities for 
these and other states in the coming months.  
 
This letter describes ten opportunities  none of which require complex demonstrations or 
Medicare waivers  to better serve individuals dually eligible for Medicare and Medicaid, 
including through new developments in managed care, using Medicare data to inform care 
coordination and program integrity initiatives, and reducing administrative burden for dually 
eligible individuals and the providers who serve them. A number of these opportunities are 
newly available to states through Medicare rulemaking or other CMS burden reduction efforts.  
We are happy to engage with you and your staff on one, many, or all of the items described in 
this letter. The CMS Medicare-Medicaid Coordination Office (MMCO) works across CMS and 
with states to better serve dually eligible individuals, including through efforts to better align the 
Medicare and Medicaid programs and demonstrations to test new approaches to integrated 
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  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
service delivery and financing. Throughout this letter, we have included points of contact in 
CMS and its resource centers.  
 
1.  Medicare-Medicaid integrated care 
 
One promising path to better serving dually eligible individuals is through creating more 
seamless experiences for beneficiaries across Medicare and Medicaid and aligning incentives 
and administrative processes across the two programs. Generally, we refer to these approaches as 
integrated care. Below, we describe opportunities to support integration through capitated 
managed care. 
 
a.  Integrating care through dual eligible special needs plans  
 
Dual eligible special needs plans (D-SNPs) are specialized Medicare Advantage plans that 
exclusively serve dually eligible individuals. Over two million individuals are enrolled among 
almost 400 D-SNPs across the country. Several states have built integrated care programs by 
contracting with Medicaid managed care organizations that also offer D-SNPs. However, states 
still face challenges in creating seamless beneficiary experiences across programs, building 
sufficient enrollment volume, and supporting continuity of integrated care through state managed 
care procurement and contracting processes.   
 
Through Medicare rulemaking finalized earlier this year (the Final Parts C & D Rule for 
2019), we have created new opportunities for states to increase and maintain enrollment in these 
managed care options for dually eligible individuals by permitting use of default enrollment of 
newly Medicare-eligible dually eligible individuals into integrated D-SNPs and passive 
enrollment to maintain enrollment in integrated D-SNPs.iv In addition, CMS has been partnering 
with states to improve member materials used by integrated D-SNPs and assist state oversight of 
their contracted D-SNPs. 
 
During the 2019 rulemaking process, Congress passed and the President signed the Bipartisan 
Budget Act (BBA) of 2018, making D-SNPs a permanent feature of the Medicare program and 
creating new possibilities to improve experiences for dually eligible individuals. CMS is seeking 
public comment on new proposed regulations (See CMS-2018-0110-0001)v to implement 
provisions to:  
 
  Better unify appeals and grievance processes across Medicaid and Medicare for D-SNP 
members, so that beneficiary issues with Medicare and Medicaid services no longer 
follow completely separate tracks, and  
 
  Establish new minimum standards of Medicaid integration for D-SNPs. 
 
 
2 
  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
Additionally, Section 50311(b) of the BBA of 2018 established MMCO as a dedicated point of 
contact for states to address misalignments between the two programs and promote integration 
of D-SNPs and Medicaid managed care.  
 
We appreciate the input we have already received from states, the National Association of 
Medicaid Directors, and other stakeholders on the BBA of 2018, and we look forward to 
continued collaboration. 
 
i.  OPPORTUNITY #1  State contracting with D-SNPs  
 
States have a powerful tool to promote integrated care through contracts with D-SNPs. The 
Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 amended section 
1859(f)(3)(D) of the Social Security Act to require D-SNPs to maintain a contract with each state 
in which they operate. These contracts are commonly called MIPPA contracts or State 
Medicaid Agency Contracts (SMACs).  
 
Minimum requirements for MIPPA contracts are described at 42 CFR 422.107. States have the 
flexibility to determine the scope of Medicaid services and financial responsibility that D-SNPs 
must assume. States also have the flexibility to add additional state-specific requirements  or 
decide it is not in their best interest to execute the contract at all.vi We encourage states to use 
these MIPPA contracts to support and shape local integrated care approaches. For 
example: 
 
  Some states, including Idaho, Minnesota, New Jersey and Massachusetts, require that D-
SNPs only enroll those individuals who are also in an affiliated Medicaid managed care 
product, thus ensuring that D-SNP enrollees are receiving Medicare and Medicaid 
services through the same parent organization. 
 
  Arizona requires D-SNPs and affiliated Medicaid plans to coordinate all aspects of 
enrollees health, including use of Medicare and Medicaid data to coordinate services. 
The state requires that there be a contact person at each plan responsible for sharing the 
information needed to coordinate care when the benefit coverage switches from 
Medicare to Medicaid, and a point of contact for coordinating care related to cost-sharing 
protections and balance billing.  
 
  Florida requires D-SNPs to facilitate Medicaid eligibility redeterminations for enrollees, 
including helping with applications for medical assistance and conducting enrollee 
education regarding maintenance of Medicaid eligibility. 
 
  Tennessee requires D-SNPs to notify the enrollees Medicaid managed care plan of 
inpatient admissions and coordinate with the Medicaid plan regarding discharge 
planning. The requirements also include following up with enrollees and their Medicaid 
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  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
plans to provide needs assessments or develop person-centered plans of care for 
enrollees using managed long-term services and supports (MLTSS). 
 
Additional information on these and other examples of how states have used the MIPPA 
contracts to integrate care are available through the Integrated Care Resource Center.vii  
State staff interested in learning more can contact Paul Precht in the CMS Medicare-Medicaid 
Coordination Office at Paul.Precht@cms.hhs.gov.  
 
ii.  OPPORTUNITY #2  Default enrollment into a D-SNP 
 
Default enrollment is a mechanism for facilitating enrollment in integrated care, while 
maintaining continuity of Medicaid managed care services, when Medicaid beneficiaries become 
eligible for Medicare. We established new Medicare regulations on default enrollment in April 
2018 through the Final Parts C & D Rule for 2019. States can find the new regulation governing 
 and outlining the federal minimum requirements  for default enrollment at 42 CFR 
422.66(c).viii Through default enrollment, Medicaid beneficiaries in capitated managed care  
and who remain in Medicaid managed care upon newly gaining Medicare eligibility  may be 
automatically enrolled into a D-SNPix affiliated with the individuals Medicaid managed care 
organization (MCO). Individuals retain the ability to opt out of default enrollment to instead 
receive their Medicare services through Medicare Fee-For-Service (FFS), Programs of All-
inclusive Care for the Elderly (PACE), or another Medicare Advantage plan. 
 
States can use default enrollment to facilitate enrollment into managed care arrangements 
in which dually eligible individuals receive all of their Medicaid and Medicare services 
through the same organization.x We structured the new regulations to empower state Medicaid 
agencies in this process, so a D-SNP can only utilize default enrollment where the state 
approves. States interested in supporting default enrollment will need to (a) indicate approval in 
the MIPPA contracts, and (b) provide data to the participating health plans to identify those 
individuals who are becoming newly Medicare-eligible in advance of their Medicare initial 
coverage election period. We encourage interested states and D-SNPs to contact us early in the 
process of considering options related to default enrollment.    
 
We recently hosted and recorded a webinar for states on default enrollment.xi State staff 
interested in learning more can contact Sharon Donovan in the CMS Medicare-Medicaid 
Coordination Office at Sharon.Donovan1@cms.hhs.gov.   
 
iii.  OPPORTUNITY #3  Passive enrollment to preserve continuity of 
integrated care  
 
While enrollment in a Medicare Advantage or standalone Part D plan is generally initiated by 
beneficiaries, in certain limited instances CMS may passively enroll individuals into Medicare 
health or drug plans.xii In these instances beneficiaries receive notification that they can choose 
another plan.   
4 
  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
 
In an effort to promote integrated care, continuity of care, and partnership with states, CMS 
recently codified a new, limited expansion of its regulatory authority to conduct passive 
enrollment in the Final Parts C and D Rule for 2019. States can find the regulatory language for 
this limited D-SNP passive enrollment authority at 42 CFR 422.60(g). This change authorizes 
CMS to passively enroll full-benefit dually eligible individuals from an integrated D-SNP 
that is no longer available to the individual into another comparable D-SNP in instances 
where integrated care coverage would otherwise be disrupted. CMS will conduct such 
enrollments after consulting with a state Medicaid agency and where other conditions are metxiii 
to ensure continuity and quality of care. Plans receiving passive enrollment are required to 
provide notices to enrollees that explain their ability to decline the enrollment, return to Original 
Medicare, or choose another plan. 
 
Both the default enrollment and passive enrollment provisions are intended to help promote 
integrated care. Default enrollment is authorized only for people who are already enrolled in 
Medicaid managed care and become eligible for Medicare, among other requirements, while 
passive enrollment by CMS under the new provision is authorized only for beneficiaries who are 
already enrolled in an integrated D-SNP. State staff interested in learning more can contact 
Sharon Donovan in the CMS Medicare-Medicaid Coordination Office at 
Sharon.Donovan1@cms.hhs.gov.   
 
b.  OPPORTUNITY #4  Integrating care through PACE  
 
The Programs of All-Inclusive Care for the Elderly (PACE) provide comprehensive medical and 
social services to certain adults age 55 and older who meet a states nursing facility level of care 
criteria. Most PACE enrollees are dually eligible individuals.  
 
In PACE, interdisciplinary teams of health professionals work with PACE participants to 
coordinate care. PACE is now active in 31 states, serving over 40,000 participants. For many 
states, PACE is an important way of offering innovative integrated care for dually eligible 
individuals. The comprehensive service package enables most participants to remain in the 
community rather than a nursing facility. For most of its history, only not-for-profit 
organizations were permitted to sponsor PACE programs, but CMS now permits for-profit 
organizations to participate.xiv  
 
States make a prospective monthly capitation payment to a PACE organization for a Medicaid 
participant enrolled in PACE which:  
 
  Is less than what would otherwise have been paid under the state plan if not enrolled in 
PACE; 
 
  Takes into account comparative frailty of participants; and  
 
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  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
  Is a fixed amount regardless of changes in a participants health status.  
 
Earlier research suggests there may be opportunities to improve the cost-efficiency of PACE 
capitation rates in certain states, and we encourage states with PACE sites to periodically re-
examine their rate-setting methods to ensure they are appropriate.xv   
 
By incorporating PACE into a states integrated care strategy, a state may ensure continuing 
access to a proven community option. Interested state staff can find information on PACE 
through the Integrated Care Resource Center.xvi States can also contact their CMS regional office 
for more information.  
 
2.  Medicare data 
 
State efforts to better serve dually eligible individuals require access to both Medicare and 
Medicaid data. Lack of access to Medicare data or the internal capacity to link Medicare and 
Medicaid data for individual beneficiaries can make it difficult to coordinate all Medicare and 
Medicaid services. We are taking steps to unlock these important data and reduce the 
administrative burdens associated with obtaining them from CMS. Medicare data available to 
states include: 
 
  Medicare claim and summary data for use of Medicare Part A, B, and D services 
 
  Functional assessment data gathered as part of home health and skilled nursing services 
 
  Integrated Medicare-Medicaid data sets (MMLEADS) 
 
Twenty-nine Medicaid agencies currently receive Medicare data for the purposes of coordinating 
care for dually eligible individuals. Resources, including help with the data request process, use 
cases, ongoing shared learning calls, in-depth webinars, and recordings of past webinars for 
states on data-related issues, are available through our State Data Resource Center (SDRC).xvii  
 
We note, as detailed in a recent SMDL on Mechanized Claims Processing and Information 
Retrieval Systems (90/10), CMS provides, under 42 CFR 433.112(a), 90 percent enhanced 
federal financial participation (FFP) for Medicaid technology investments funded through an 
approved APD.xviii 
 
a.  OPPORTUNITY #5  Reducing the administrative burden in accessing 
Medicare data for use in care coordination 
 
CMS is empowering individuals by ensuring they can access their health care data, and  through 
Blue Button 2.0  providing a developer-friendly, standards-based data Application 
Programming Interface (API) to enable individuals to connect their Medicare claims data to the 
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  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
applications, services, and research programs they trust. This same drive to streamline access to 
data has led us to re-examine the ways we share Medicare data with states. 
 
CMS requires agreements to ensure that data requestors adhere to privacy and security 
requirements and data release policies. For states, we are significantly reducing the burdens 
associated with the process of obtaining and maintaining these agreements with CMS to access 
and use Medicare data, while ensuring the privacy and security requirements are maintained. 
States may now execute data request attestations (DRAs) through a streamlined process, 
replacing the previous Data Use Agreement (DUA) process. As of October 2018, twenty-
three states have transitioned from DUAs to DRAs, and we look forward to working with 
additional states.  
 
States with DUAs will hear from SDRC about transitioning to the DRA. If you have questions in 
the meantime, contact SDRC at sdrc@econometricainc.com. The SDRC will help complete all 
required forms, answer questions, and facilitate the submission process. 
 
b.  OPPORTUNITY #6  Program integrity opportunities 
 
When CMS originally began sharing Medicare claims and assessment data for dually eligible 
individuals with states, we restricted use to activities related to coordination of care. State 
Medicaid agencies can now utilize Medicare data for program integrity purposes (although 
it requires separate approval even if your state already has access to data for care coordination). 
Currently, there are seven states using these Medicare data for program integrity purposes. 
Program integrity uses include investigating improper provider billing and coding.  
 
If you are interested in learning more about ways to use Medicare data for program integrity and 
how to gain approval to use data for program integrity purposes, contact SDRC at 
sdrc@econometricainc.com. The SDRC can help complete required forms, answer questions, 
and facilitate the submission process. 
 
3.  Improving beneficiary experiences and reducing administrative burden  
 
We have identified numerous other opportunities for the federal government and states to 
improve beneficiary experiences and reduce overall administrative burden for states and 
providers serving dually eligible individuals, three of which are summarized below. States may 
pursue any of these opportunities as stand-alone updates or together with broader integrated care 
approaches.  
 
7 
  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
a.  Frequency of data exchange 
 
i.  OPPORTUNITY #7 -- MMA file timing 
 
Since 2005, states have been submitting files at least monthly to CMS to identify all dually 
eligible individuals, including full-benefit dually eligible beneficiaries (i.e., those who qualify for 
full Medicaid benefits ) and partial-benefit dually eligible beneficiaries (i.e., those who only get 
Medicaid help with Medicare premiums, and often for cost-sharing, but not full Medicaid 
benefits). The file is called the MMA file (after the Medicare Prescription Drug, Improvement 
and Modernization Act of 2003), but occasionally referred to as the State Phasedown file. 
CMS uses the MMA files for a variety of functions, including auto-enrolling full-benefit dually 
eligible beneficiaries into Medicare prescription drug plans and deeming full- and partial-benefit 
dually eligible beneficiaries automatically eligible for the Medicare Part D Low Income Subsidy 
(LIS, sometimes called Extra Help).  
 
States must submit at least one file each month. However, states have the option to submit 
multiple MMA files throughout the month (up to one per day). Most states submit at least 
weekly. 
 
We strongly encourage states to submit as frequently as possible. More frequent submission 
achieves state efficiencies, improves beneficiary experiences, and reduces burden for 
providers.xix   
 
State staff interested in learning about more frequent MMA file submission can contact Sharon 
Donovan in the CMS Medicare-Medicaid Coordination Office at 
Sharon.Donovan1@cms.hhs.gov. For technical system support, contact the MAPD Help Desk at 
mapdhelp@cms.hhs.gov or 1-800-927-8069. Or visit the MAPD Help Desk Web site at 
http://go.cms.gov/mapdhelpdesk. 
 
ii.  OPPORTUNITY #8  State buy-in file data exchange 
 
Under sections 1818(g) and 1843 of the Social Security Act, states and territories pay Medicare 
Part A and/or Part B premiums for certain residents dually eligible for Medicare and Medicaid. 
Under the state buy-in program, states can enter into Medicare Part A and B buy-in agreements 
to make it easier to enroll Medicaid recipients in Medicare and pay premiums on their behalf. 
Enrolling more individuals in Medicare can help limit state costs because Medicare is the 
primary payer for most medical care for dually eligible individuals. All states, three U.S. 
territories, and the District of Columbia have signed a Part B buy-in agreement; thirty-six states 
and the District of Columbia have also adopted a Part A buy-in agreement. 
 
States, the Social Security Administration (SSA), and CMS share data to facilitate buy-in 
processes for Medicare Parts A and B. As with the MMA files, greater frequency of buy-in data 
exchange between the states and CMS supports more timely access to coverage and reduces 
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  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
burdens for states, beneficiaries, and providers.xx States have the option to submit buy-in files to 
CMS daily or monthly. Likewise, states can choose to receive CMS response files daily or 
monthly. Over half of the states are now exchanging buy-in files with CMS daily. Daily 
submissions, and the ability to for states to receive daily response files from CMS, spread 
state staff workload more evenly across the month, permit errors to be corrected more 
quickly, and connect new beneficiaries more quickly to Medicare benefits.    
 
State staff interested in learning more about the frequency of state buy-in file submissions can 
contact Sharon Donovan in the CMS Medicare-Medicaid Coordination Office at 
Sharon.Donovan1@cms.hhs.gov. For technical support, state staff should contact Phyllis Martin 
in the CMS Office of Information Technology at Phyllis.Martin@cms.hhs.gov (and copy 
DPBCStateBuy-In@cms.hhs.gov).   
 
b.  OPPORTUNITY #9  Improving Medicare Part A buy-in 
 
Part A buy-in agreement permits a state to directly enroll eligible individuals in Part A at 
any time of the year, without late enrollment penalties assessed to a beneficiarys premium 
liability. States without Part A buy-in agreements cannot enroll persons in Medicare Part A until 
the individual first goes to that individuals local SSA office to complete a conditional 
enrollment application for Part A. Further, states without Part A buy-in agreements may only 
enroll persons in Part A during Medicares annual General Enrollment Period (January through 
March, with Medicare coverage beginning on July 1). States without a Part A buy-in agreement 
must pay any late enrollment penalties due to late Medicare Part A enrollment.  
Easing the administrative burden of Part A buy-in enrollments can produce state savings by 
increasing the number of Medicaid recipients who are enrolled in Medicare Part A. When that 
happens, Medicare becomes the primary payer for inpatient hospital and skilled nursing facility 
services.  
 
For supplemental security income (SSI) recipients in particular, Auto Accrete states (also called 
1634 states) already facilitate enrollments in Medicare Part B. Under a signed agreement 
between a state and SSA, when SSA finds someone eligible for SSI in an Auto Accrete state, 
he/she automatically receives Medicaid and is enrolled in Medicare Part B. Entering into a Part 
A buy-in agreement allows Auto Accrete states to ensure SSI recipients who are eligible for 
Medicare to be enrolled in Medicare Part A, in addition to Part B, without added costs for states 
(due to late enrollment penalties), delays, and the need for persons to complete the conditional 
enrollment for Part A application at their local SSA office.xxi Without a Part A buy-in 
agreement, applying for Part A buy-in requires an application and eligibility determination by 
both SSA and Medicaid, requiring beneficiaries and eligibility workers to complete a multi-step 
application process which is complex and administratively burdensome.   
 
We encourage interested state staff to contact Sharon.Donovan1@cms.hhs.gov in the CMS 
Medicare-Medicaid Coordination Office to discuss executing a Part A buy-in agreement. 
 
9 
  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
 
c.  OPPORTUNITY #10  Opportunities to simplify eligibility and enrollment 
 
Low-income Medicare beneficiaries who meet certain income and asset limits qualify for the 
Part D Low-Income Subsidy (LIS), which provides assistance with Medicare Part D premiums 
and cost-sharing. Many of these beneficiaries also qualify for Medicaid coverage of their 
Medicare Parts A and B premiums and cost-sharing through the Medicare Savings Programs 
(MSPs). The Social Security Administration (SSA) assesses LIS eligibility for many applicants, 
and section 1144(c)(3) of the Social Security Act requires that SSA send LIS application 
information to states for the purposes of initiating an MSP application.  
 
Many states have maintained definitions and verification rules for income and assets that differ 
from those used by SSA.xxii As a result, a determination of eligibilty for the LIS by SSA does not 
necessarly provide enough information to allow a state to determine a beneficiary is 
automatically eligible for MSP, even though many of those currently enrolled in LIS also meet 
their states eligibility standards for MSP.  
 
A number of states have used the authority described in section 1902(r)(2)(A) of the Social 
Security Act to better align the LIS and MSP income and/or asset critiera .xxiii Doing so can help 
achieve substantial efficiencies in the enrollment process, both for applicants and government 
eligiblity workers, and simplify outreach to potential beneficiaries.xxiv Prior studies of state 
experiences with MSPs have found significant administrative savings from reduced verification 
burdens, although each state should consider potential impacts based on local circumstances.xxv 
   
We remind states of the existing opportunities to simplify the eligibility and enrollment 
processes for applicants and eligibility workers, especially for the Medicare Savings 
Programs.  
 
State staff interested in further exploring these opportunities can contact their CMS regional 
office or Gene Coffey in the CMS Children and Adults Health Programs Group at 
gene.coffey@cms.hhs.gov.  
 
4.  We are here to help! 
 
The challenges of running a Medicaid agency are immense, and the opportunities described in 
this letter can get confusing. We are happy to talk with you or your staff to help assess the 
opportunities that work best for your state. We also provide resources for states, described 
below. 
a.  Technical support and peer-to-peer learning  
 
CMS sponsors the Integrated Care Resource Center (ICRC) to provide state-specific assistance 
to better understand the states dually eligible population, assess options for improving 
integration of care, and navigate aspects of the Medicare program that states can leverage to 
10 
  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
benefit Medicaid. To learn more and to contact ICRC, please visit 
http://www.integratedcareresourcecenter.com. 
 
CMS sponsors the State Data Resource Center (SDRC) to facilitate state access to, and use of, 
Medicare data on dually eligible individuals to support care coordination and program integrity. 
SDRCs technical advisors can help states determine how to use available data, assist with the 
process of obtaining Medicare data from CMS, and advise on methods for linking databases and 
creating analytic files. To learn more and to contact SDRC, please visit 
http://www.statedataresourcecenter.com. 
 
b.  Resources to help keep up with new policies and opportunities related to serving 
dually eligible beneficiaries 
 
MMCO will provide information to state Medicaid agencies on contracting with D-SNPs and 
other resources for states interested in exploring such plans as a platform for integration. We 
frequently send such information through email listservs. We encourage interested states to sign 
up to receive listserv updates through MMCOxxvi and the Integrated Care Resource Center.xxvii  
For any other comments or questions, or to explore other potential opportunities, please contact 
Tim Engelhardt, Director of the CMS Medicare-Medicaid Coordination Office, at 
Tim.Engelhardt@cms.hhs.gov. 
 
               
cc: 
/s/ 
Seema Verma 
Administrator 
 
 
National Association of Medicaid Directors 
 
National Academy for State Health Policy 
 
National Governors Association 
 
American Public Human Services Association 
 
Association of State Territorial Health Officials 
 
Council of State Governments 
 
National Conference of State Legislatures 
 
Academy Health 
11 
  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
Endnotes 
                                                           
i For discussion of social risk factors, see https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-
under-medicares-value-based-purchasing-programs.  
ii Medicare-Medicaid Coordination Office, National Profile 2012. Available at  
https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-
Office/Downloads/NationalProfile_2012.pdf.  
iii Ibid. 
iv The Medicare Advantage and Part D final rule is available at https://www.gpo.gov/fdsys/pkg/FR-2018-04-16/pdf/2018-
07179.pdf.  
v See at https://www.regulations.gov/document?D=CMS-2018-0110-0001  
vi Per MIPPA section 163(d)(3)   
vii See State Contracting with Medicare Advantage Dual Eligible Special Needs Plans: Issues and Options at: 
https://www.integratedcareresourcecenter.com/PDFs/ICRC_DSNP_Issues__Options.pdf. 
viii HPMS Memo. August 31, 2018. Default Enrollment Option for Newly Medicare Advantage Eligible Medicaid Managed 
Care Plan Enrollees (formerly known as Seamless Conversion Enrollment). 
ix A D-SNP must receive CMS approval of a default enrollment program prior to implementation. 
x States like Arizona and Tennessee have partnered with health plans and used seamless conversion (the predecessor to default 
enrollment) to increase the number of individuals who receive all of their Medicaid and Medicare services through the same 
organization. 
xi The webinar on default enrollment is available at https://www.integratedcareresourcecenter.com/webinar/aligning-coverage-
dually-eligible-beneficiaries-using-default-and-passive-enrollment. 
xii For example, CMS may initiate Medicare enrollment actions when low income beneficiaries are enrolled in a plan whose 
premium increased, or when a plan is not renewing or leaves the market. 
xiii See https://www.cms.gov/Medicare/Eligibility-and-
Enrollment/MedicareMangCareEligEnrol/Downloads/CY_2019_MA_Enrollment_and_Disenrollment_Guidance.pdf.  
xiv See https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-
Coordination-Office/PACE/PACE-Demonstration.html.   
xv Effect of PACE on costs, nursing home admissions, and mortality: 2006-2011, at 
https://aspe.hhs.gov/system/files/pdf/76971/PACEeffect_0.pdf.   
xvi https://www.integratedcareresourcecenter.com/resource-library?&field_resource_category%5B0%5D=271. 
xvii http://www.statedataresourcecenter.com/. 
xviii https://www.medicaid.gov/federal-policy-guidance/downloads/smd18005.pdf.  
xix For more information on the benefits of, and process for, increasing the frequency of MMA file exchange, please visit 
http://www.statedataresourcecenter.com/assets/files/MMA_QA.pdf. OMB control number for this reporting requirement: 0938-
0958. 
xx To effectuate the state payment of Medicare Part A or Part B premiums, a state submits data on a buy-in file to CMS. The 
states input file includes a record for each Medicare beneficiary for whom the state is adding, deleting coverage, or changing 
buy-in status. In response, CMS returns an updated transaction record that provides data identifying, for each transaction on the 
state file, whether CMS accepted, modified, or rejected it, as well a Part A or Part B billing record showing the states premium 
responsibility. In addition, the CMS file may push new updates obtained from SSA to the state, for example, changes in the 
Medicare Beneficiary Identifier number or change of address. Daily exchanges reduce burden by spreading state workload 
throughout the months as well as significantly reduce lags in resubmitting an improperly processed transaction and recouping and 
redistributing premiums. 
xxi See 42 C.F.R. 406.26. 
xxii The primary points of misalignment between LIS and MSPs are the value of life insurance policies, burial funds, and in-kind 
support. xxii General Accountability Office, Medicare Savings Programs: Implementation of Requirements Aimed at Increasing 
Enrollment, September 2012, available at http://www.gao.gov/products/GAO-12-871.      
xxii Amy Tiedemann and Kimberly Fox, Promising Strategies for Medicare Savings Program Enrollment: Modifying Eligibility 
Criteria and Documentation Requirements, Rutgers Center for State Health Policy, May 2005, available at 
http://www.cshp.rutgers.edu/Downloads/5300.pdf; Kim Glaun, Medicaid Programs to Assist Low-Income Medicare 
Beneficiaries: Medicare Savings Program Case Study Findings, Kaiser Commission on Medicaid and the Uninsured, December 
2002, available at https://kaiserfamilyfoundation.files.wordpress.com/2013/01/medicaid-programs-to-assist-low-income-
medicare-beneficiaries-medicare-savings-programs-case-study-findings-background-paper.pdf.  
 
 
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  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
 
                                                                                                                                                                                           
xxiv General Accountability Office, Medicare Savings Programs: Implementation of Requirements Aimed at Increasing 
Enrollment, September 2012, available at http://www.gao.gov/products/GAO-12-871.      
xxv Amy Tiedemann and Kimberly Fox, Promising Strategies for Medicare Savings Program Enrollment: Modifying Eligibility 
Criteria and Documentation Requirements, Rutgers Center for State Health Policy, May 2005, available at 
http://www.cshp.rutgers.edu/Downloads/5300.pdf; Kim Glaun, Medicaid Programs to Assist Low-Income Medicare 
Beneficiaries: Medicare Savings Program Case Study Findings, Kaiser Commission on Medicaid and the Uninsured, December 
2002, available at https://kaiserfamilyfoundation.files.wordpress.com/2013/01/medicaid-programs-to-assist-low-income-
medicare-beneficiaries-medicare-savings-programs-case-study-findings-background-paper.pdf.  
xxvi Sign up for the MMCO listserv at 
https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_7840.  
xxvii Sign up for the ICRC listserv at https://www.integratedcareresourcecenter.com/about-us/e-alerts.  
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