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1 Data based on Centers for Medicare & Medicaid 

Services (CMS) Enrollment Database, Provider 

Enrollment, Economic and Attributes Report, 

provided by CMS Office of Research, Development 

and Information, July 2010. 

2CMS FFY 2007 MSIS Data; Medicare Payment 

Advisory Commission, Aligning Incentives (June 

2010), Coordinating the Care of Dual-Eligible 

Beneficiaries, Chapter 5, 133. 

ADDENDUM B—FY 2012 WAGE INDEX

FOR RURAL AREAS—Continued 

CBSA 

code Nonurban area Wage index 

19 ........ Louisiana ......................... 0.8000 

20 ........ Maine .............................. 0.8892 

21 ........ Maryland ......................... 0.9500 

22 ........ Massachusetts 2 .............. 1.2186 

23 ........ Michigan .......................... 0.8858 

24 ........ Minnesota ........................ 0.9358 

25 ........ Mississippi ....................... 0.8000 

26 ........ Missouri ........................... 0.8000 

27 ........ Montana .......................... 0.8819 

28 ........ Nebraska ......................... 0.9227 

29 ........ Nevada ............................ 0.9681 

30 ........ New Hampshire .............. 1.0569 

31 ........ New Jersey1 .................... ............

32 ........ New Mexico .................... 0.9227 

33 ........ New York ........................ 0.8475 

34 ........ North Carolina ................. 0.8655 

35 ........ North Dakota ................... 0.7856 

36 ........ Ohio ................................. 0.8864 

37 ........ Oklahoma ........................ 0.8139 

38 ........ Oregon ............................ 1.0384 

39 ........ Pennsylvania ................... 0.8781 

40 ........ Puerto Rico3 .................... 0.4654 

41 ........ Rhode Island 1 ................. ............

42 ........ South Carolina ................ 0.8711 

43 ........ South Dakota .................. 0.8838 

44 ........ Tennessee ...................... 0.8165 

45 ........ Texas .............................. 0.8083 

46 ........ Utah ................................. 0.8955 

47 ........ Vermont ........................... 0.9931 

48 ........ Virgin Islands .................. 0.8276 

49 ........ Virginia ............................ 0.8119 

50 ........ Washington ..................... 1.0545 

51 ........ West Virginia ................... 0.8000 

52 ........ Wisconsin ........................ 0.9512 

53 ........ Wyoming ......................... 0.9866 

65 ........ Guam .............................. 0.9952 

1There are no rural areas in this State or 

District. 2There are no hospitals in the rural areas of 

Massachusetts, so the wage index value used 

is the average of the contiguous Counties. 3Wage index values are obtained using the 

methodology described in this proposed rule. 

[FR Doc. C1–2011–10689 Filed 5–13–11; 8:45 am] 

BILLING CODE 1505–01–D 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Chapter IV 

[CMS–5507–NC] 

Medicare and Medicaid Programs; 

Opportunities for Alignment Under 

Medicaid and Medicare 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Request for information. 

SUMMARY: This document is a request for 

comments on opportunities to more 

effectively align benefits and incentives 

to prevent cost-shifting and improve 

access to care under the Medicare and 

Medicaid programs for individuals with 

both Medicare and Medicaid (‘‘dual 

eligibles’’). The document also reflects 

CMS’ commitment to the general 

principles of the President’s Executive 

Order released January 18, 2011, 

entitled ‘‘Improving Regulation and 

Regulatory Review.’’ 

DATES: Comment Date: To be assured 

consideration, comments must be 

received at one of the addresses 

provided below no later than 5 p.m. July 

11, 2011. 

ADDRESSES: In commenting, please refer 

to file code CMS–5507–NC. Because of 

staff and resource limitations, we cannot 

accept comments by facsimile (FAX) 

transmission. 

You may submit comments in one of 

four ways (please choose only one of the 

ways listed): 

1. Electronically. You may submit 

electronic comments on this 

documentto http://www.regulations.gov. 

Follow ‘‘Submit a comment’’ 

instructions. 

2. By regular mail. You may mail 

written comments to the following 

address ONLY: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–5507–NC, P.O. Box 8013, 

Baltimore, MD 21244–8013. 

Please allow sufficient time for mailed 

comments to be received before the 

close of the comment period. 

3. By express or overnight mail. You 

may send written comments to the 

following address ONLY: Centers for 

Medicare & Medicaid Services, 

Department of Health and Human 

Services, 

Attention: CMS–5507–NC, Mail Stop 

C4–26–05, 7500 Security Boulevard, 

Baltimore, MD 21244–1850. 

4. By hand or courier. Alternatively, 

you may deliver (by hand or courier) 

your written comments ONLY to one of 

the following addresses prior to the 

close of the comment period: 

a. For delivery in Washington, DC— 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Room 445–G, Hubert 

H. Humphrey Building, 200 

Independence Avenue, SW., 

Washington, DC 20201. 

(Because access to the interior of the 

Hubert H. Humphrey Building is not 

readily available to persons without 

Federal Government identification, 

commenters are encouraged to leave 

their comments in the CMS drop slots 

located in the main lobby of the 

building. A stamp-in clock is available 

for persons wishing to retain a proof of 

filing by stamping in and retaining an 

extra copy of the comments being filed.) 

b. For delivery in Baltimore, MD— 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

If you intend to deliver your 

comments to the Baltimore address, call 

telephone number (410) 786–7195 in 

advance to schedule your arrival with 

one of our staff members. 

Comments erroneously mailed to the 

addresses indicated as appropriate for 

hand or courier delivery may be delayed 

and received after the comment period. 

FOR FURTHER INFORMATION CONTACT: Edo 

Banach, Division of Program Alignment, 

Federal Coordinated Health Care Office, 

at (410) 786–8911 or 

Edo.Banach@cms.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

Inspection of Public Comments: All 

comments received before the close of 

the comment period are available for 

viewing by the public, including any 

personally identifiable or confidential 

business information that is included in 

a comment. We post all comments 

received before the close of the 

comment period on the following Web 

site as soon as possible after they have 

been received: http:// 

www.regulations.gov. Follow the search 

instructions on that Web site to view 

public comments [insert instructions 

link]. 

Comments received timely will also 

be available for public inspection as 

they are received, generally beginning 

approximately 3 weeks after publication 

of a document, at the headquarters of 

the Centers for Medicare & Medicaid 

Services, 7500 Security Boulevard, 

Baltimore, Maryland 21244, Monday 

through Friday of each week from 

8:30 a.m. to 4 p.m. To schedule an 

appointment to view public comments, 

phone 1–800–743–3951. 

I. Background 

The Medicare and Medicaid programs 

generally cover different populations, 

but an estimated 9.2 million low-income 

Americans were eligible for both 

programs in 2008.1 Two-thirds of dual 

eligible beneficiaries are over age 65, 

while one-third qualify through a 

disability.2 Dual eligible beneficiaries 

represent some of the most chronically 


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3 In 2011, poverty is defined as $10,890 for an 

individual and $14,710 for married couples. 

Federal Register Notice, Vol. 76, No.13 Thursday, 

January 20, 2011. Available at: http://aspe.hhs.gov/ 

poverty/11fedreg.pdf. 

4Medicare Payment Advisory Commission, 

Aligning Incentives in Medicare (June 2010), 

Coordinating the Care of Dual-Eligible Beneficiaries 

Chapter 5, 132. Available at: http://medpac.gov/ 

documents/Jun10_EntireReport.pdf. 

5Chronic Disease and Co-Morbidity among Dual 

Eligibles: Implications for Patterns of Medicaid and 

Medicare Service Use and Spending. Kaiser 

Commission on Medicaid and the Uninsured,1. 

Kaiser Family Foundation. July 2010. Available at: 

http://www.kff.org/medicaid/upload/8081.pdf. 

6 Id, at 1. 

7The Lewin Group, Individuals Living in the 

Community with Chronic Conditions and 

Functional Limitations: A Closer Look (Washington, 

DC: Office of the Assistant Secretary for Planning 

and Evaluation, USDHHS, January 2010), at p. 22. 

http://aspe.hhs.gov/daltcp/reports/2010/ 

closerlook.pdf. 

8The Medicare Payment Advisory Committee 

(MedPAC), A Data Book: Healthcare spending and 

the Medicare program, June 2010. Available at: 

http://www.medpac.gov/documents/ 

Jun10_EntireReport.pdf. 

9 Kaiser Family Foundation, The Role of Medicare 

for the People Dually Eligible for Medicare and 

Medicaid. January 2011. Available at: http:// 

www.kff.org/medicare/upload/8138.pdf. 

10See Exec. Order No. 13563, 76 FR 14 (Jan. 18, 

2011). Available at: http://www.whitehouse.gov/thepress-office/2011/01/18/improving-regulation-andregulatory-review-executive-order (‘‘Improving 

Regulation and Regulatory Review’’). 

ill and costly individuals within both 

the Medicare and Medicaid populations. 

More than half of dual eligible 

beneficiaries have incomes below the 

poverty line 3 compared with 8 percent 

of non-dual eligible Medicare 

beneficiaries.4 Many have multiple 

severe chronic conditions, long-term 

care needs, or both. Forty-three percent 

of dual eligibles have at least one mental 

or cognitive impairment,5 while 60 

percent of dual eligibles have multiple 

chronic conditions.6 Nineteen percent 

live in institutional settings compared to 

only 3 percent of non-dual Medicare 

beneficiaries. Approximately 1.5 

percent of dual eligibles with chronic 

conditions and functional limitations 

live in their communities and 

represented 6 percent of the nation’s 

health care expenditures in 2006.7

Furthermore, dual eligibles account for 

a disproportionately large share of 

expenditures in both the Medicare and 

Medicaid programs. Dual eligible 

beneficiaries account for 16 percent of 

Medicare enrollees but 27 percent of 

Medicare spending; 8 in the Medicaid 

program, dual eligible beneficiaries 

make up 15 percent of the program 

enrollees but account for 39 percent of 

program spending.9

There are tremendous opportunities 

for CMS to partner with States, 

providers, beneficiaries and their 

caregivers, and other stakeholders to 

improve access, quality, and cost of care 

for people who depend on these two 

programs. 

Section 2602 of the Patient Protection 

and Affordable Care Act (Pub. L. 111– 

148, enacted on March 23, 2010, and 

Pub. L. 111–152 hereinafter collectively 

referred to as the ‘‘Affordable Care Act’’) 

created the Federal Coordinated Health 

Care Office (‘‘Medicare-Medicaid 

Coordination Office’’) and charged the 

new office with more effectively 

integrating Medicare and Medicaid 

benefits and with improving the 

coordination between the Federal and 

State Governments for dual eligible 

beneficiaries. Under sections 2602(c)(5) 

and 2602(c)(7) of the Affordable Care 

Act, the goals of the Medicare-Medicaid 

Coordination Office include eliminating 

regulatory conflicts and cost-shifting 

between Medicare and Medicaid and 

among related health care providers. 

Sections 2602(c)(1) through (4) of the 

Affordable Care Act further charge the 

Medicare-Medicaid Coordination Office 

with addressing issues relating to 

quality of care and beneficiary 

understanding, beneficiary satisfaction, 

and access under Medicare and 

Medicaid. 

II. The Alignment Initiative 

As part of the Medicare-Medicaid 

Coordination Office’s efforts to meet its 

responsibilities and goals, as outlined in 

the Affordable Care Act, and in direct 

support of Executive Order 13563 10

(Improving Regulations and Regulatory 

Review), which directs us to identify 

existing ‘‘rules that may be outmoded, 

ineffective, insufficient, or excessively 

burdensome, and to modify, streamline, 

expand, or repeal them’’ as appropriate, 

the Office is undertaking an initiative to 

identify and address conflicting 

requirements between Medicaid and 

Medicare that potentially create barriers 

to high quality, seamless, and costeffective care for dual eligible 

beneficiaries (‘‘the Alignment 

Initiative’’). The goal is to create and 

implement solutions in line with the 

CMS three-part aim, which includes, 

solutions that advance better care for the 

individual, better health for 

populations, and lower costs through 

improvement. The Alignment Initiative 

is not simply an effort to catalogue the 

differences between Medicare and 

Medicaid, or to make the two programs 

identical; rather, it is an effort to 

advance dual eligible beneficiaries’ 

understanding of, interaction with, and 

access to seamless, high quality care 

that is as effective and efficient as 

possible. Medicare and Medicaid were 

designed with distinct purposes, which 

naturally results in numerous 

differences between the two programs in 

terms of eligibility, payment, and 

covered benefits. The Medicare program 

is administered by the Federal 

Government, and is generally available 

to elderly individuals or individuals 

with disabilities. Medicare covers a 

wide range of health care services and 

supplies, including acute, post-acute, 

primary, and specialty care services, as 

well as prescription drugs. Medicaid is 

a joint Federal and State program that is 

administered by States for certain 

categories of low-income individuals. 

Although specific benefits may vary by 

State, in general Medicaid covers acute 

care, primary and specialty care, 

behavioral health care, and long-term 

care supports and services. 

For dual eligible beneficiaries, 

Medicare generally is the primary payer 

for benefits covered by both programs. 

Medicaid may then be available for any 

remaining beneficiary cost sharing. 

Medicaid may also provide additional 

benefits that are not (or are no longer) 

covered by Medicare. For example, 

Medicare covers skilled nursing facility 

services when a dual eligible beneficiary 

requires skilled nursing care following a 

qualifying hospital stay. During this 

time, Medicaid benefits may be 

available for amounts that are not paid 

by Medicare. Once the beneficiary no 

longer meets the conditions of a 

Medicare skilled level of care benefit, 

Medicaid may cover additional nursing 

facility services, including custodial 

nursing facility care. Although the two 

programs can work well together in 

financing health care for eligible 

beneficiaries, in some cases differential 

requirements between the two programs 

may create barriers to seamless, high 

quality care, creating a cost-shift 

between the two programs that may 

impede access to appropriate care. 

The first step of the Alignment 

Initiative is to identify opportunities to 

align potentially conflicting Medicaid 

and Medicare requirements. This 

document represents the first step. We 

have compiled what we believe to be a 

wide-ranging list of opportunities for 

legislative and regulatory alignment on 

areas identified to date. We are seeking 

public comment on the list of alignment 

opportunities. 

The list of alignment opportunities is 

intended to be a productive tool, with 

issues publicly shared for the purpose of 

improvement going forward. We believe 

public input in this early stage of the 

Alignment Initiative is critical to 

creating a foundation for future 

collaboration to address these issues. 

Comments from the public further the 

Alignment Initiative by engaging 

stakeholders in our work plan as future 


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11See Memorandum for the Heads of Executive 

Departments and Agencies, 74 FR 15, 3825 (Jan. 26, 

2009). Available at: http://edocket.access.gpo.gov/ 

2009/pdf/E9-1777.pdf (‘‘Transparency and Open 

Government’’). 

partners, while facilitating productive 

discussions on how Medicare and 

Medicaid can work more effectively and 

efficiently for dual eligible beneficiaries 

and those who care for them. 

Seeking public comment on the list of 

alignment opportunities is also in 

keeping with the President’s directive of 

January 26, 2009, to promote 

accountability, encourage collaboration, 

and provide information to Americans 

about their Government’s activities.11

Please see Section III of this document 

for a more detailed discussion of this 

first step. 

Once we receive public comments on 

the list of alignment opportunities, the 

next step in the Alignment Initiative is 

to continue to engage stakeholders, 

including beneficiaries, payers, 

providers, and States, to determine the 

barriers and sources of the current 

misalignments. We will then determine 

which issues to address and in what 

order and timeframe. All areas are 

important, but given the scope of the 

issues already identified, we recognize 

we cannot address all issues at once, 

and some may take longer than others. 

We will identify and address those 

opportunities that we have the resources 

and authority to address, and will 

consider including those alignment 

opportunities that would require a 

statutory change to address in the 

Secretary’s annual Report to Congress 

under section 2602(e) of the Affordable 

Care Act. 

We are committed to an open, 

transparent, and accountable process. 

We seek comment on this initiative 

generally, as well as the further areas for 

exploration for alignment specifically 

(see Section III. of this notice). We will 

provide periodic updates on the 

Alignment Initiative on our Web site at 

http://www.cms.gov/medicaremedicaid-coordination/ and intend to 

keep the public apprised of our work. 

III. Specific Alignment Opportunities 

In an effort to advance the goals 

identified in the Affordable Care Act, 

and in line with the CMS three-part 

aim—better care for individuals, better 

health for populations and lower costs 

through improvement—the MedicareMedicaid Coordination Office has been 

engaged in ongoing discussions with 

numerous and diverse stakeholders. The 

Medicare-Medicaid Coordination Office 

has used input from these discussions to 

develop a comprehensive list of areas in 

which the Medicare and Medicaid 

programs have conflicting requirements 

that prevent dual eligible individuals 

from receiving seamless, high quality 

care. Those areas fall into the following 

broad categories: 

(1) Coordinated Care. 

(2) Fee-for-service benefits (FFS). 

(3) Prescription Drugs. 

(4) Cost Sharing. 

(5) Enrollment. 

(6) Appeals. 

Each of these broad categories and the 

specific opportunities for alignment 

identified to date can be found in 

Addendum 1. We invite public 

comment on these opportunities. These 

include opportunities to align existing 

program requirements, as well as 

preventing future conflicts when new 

programs are scheduled to be 

implemented (for example, coordinating 

seamless transitions between Medicaid, 

Medicare, and coverage under the 

Health Insurance Exchanges that will be 

established under section 1311 of the 

Affordable Care Act). This list will be 

continually updated as progress is made 

and new opportunities are identified. 

We look forward to continued 

collaboration with stakeholders as the 

Alignment Initiative proceeds. 

IV. Questions and Comments 

We are interested in your comments 

on this initiative. As you consider your 

comments, we are particularly 

interested in your feedback concerning 

how misalignments between specific 

Medicare and Medicaid requirements 

impact access to high-quality care. We 

offer the following questions to help 

guide your consideration of this issue 

and review of this notice. These 

questions are framed by the various 

goals and requirements that Congress 

articulated in establishing the Federal 

Coordinated Health Care Office. 

• How can the Medicare and 

Medicaid programs better ensure dual 

eligible individuals are provided full 

access to the program benefits? 

• What steps can CMS take to 

simplify the processes for dual eligible 

individuals to access the items and 

services guaranteed under the Medicare 

and Medicaid programs? 

• Are there additional opportunities 

for CMS to eliminate regulatory 

conflicts between the rules under the 

Medicare and Medicaid programs? 

• How can CMS best work to improve 

care continuity and ensure safe and 

effective care transitions for dual 

eligible beneficiaries? 

• How can CMS work to eliminate 

cost-shifting between the Medicare and 

Medicaid programs? How about 

between related health care providers? 

Authority: Section 2602 of the Patient 

Protection and Affordable Care Act (Pub. L. 

111–148, enacted on March 23, 2010). 

Dated: March 16, 2011. 

Donald M. Berwick, 

Administrator, Centers for Medicare & 

Medicaid Services. 

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[FR Doc. 2011–11848 Filed 5–11–11; 11:15 am] 

BILLING CODE 4120–01–C 

DEPARTMENT OF TRANSPORTATION 

Federal Motor Carrier Safety 

Administration 

49 CFR Parts 385, 386, 390, and 395 

[Docket No. FMCSA–2004–19608] 

RIN 2126–AB26 

Hours of Service of Drivers 

AGENCY: Federal Motor Carrier Safety 

Administration (FMCSA), DOT. 

ACTION: Notice; availability of 

supplemental documents; reopening of 

comment period; correction. 

SUMMARY: This document corrects the 

docket number referenced in the 

Addresses and Instructions paragraphs 

to a proposed rule’s notice of 

availability of supplemental documents 

published in the Federal Register of 

May 9, 2011, regarding Hours of Service 

of Drivers. This correction replaces an 

incorrect docket number with the 

correct docket number for the public to 


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