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. [OFR--insert date 60 days after 

date of display in the Federal Register]. 

ADDRESSES: In commenting, please refer to file code CMS5507-NC. Because of staff and resource limitations, we 

cannot accept comments by facsimile (FAX) transmission. 
CMS-5507-NC 2 

 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 
CMS-5507-NC 3 

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 
CMS-5507-NC 4 

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. 
CMS-5507-NC 5 

I. Background 

The Medicare and Medicaid programs generally cover 

different populations, but an estimated 9.2 million lowincome 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 ill and costly individuals within both the 

Medicare and Medicaid populations. More than half of dual 

eligible beneficiaries have incomes below the poverty line3

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 nondual Medicare beneficiaries.5

 Approximately 1.5 percent of 

 

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. 

2

 CMS FFY 2007 MSIS Data; Medicare Payment Advisory Commission, Aligning Incentives (June 2010), 

Coordinating the Care of Dual-Eligible Beneficiaries, Chapter 5, 133. 

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 4

 Medicare 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

5

 Chronic 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. 
CMS-5507-NC 6 

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 spending8; 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 

 

7

 The 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 

8

 The 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 .
CMS-5507-NC 7 

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 1356310 (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 

 

10 See Exec. Order No. 13563, 76 Fed. Reg. 14 (Jan. 18, 2011). Available at: 

http://www.whitehouse.gov/the-press-office/2011/01/18/improving-regulation-and-regulatory-reviewexecutive-order (“Improving Regulation and Regulatory Review”).
CMS-5507-NC 8 

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 
CMS-5507-NC 9 

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 
CMS-5507-NC 10 

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 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 

 

11 See Memorandum for the Heads of Executive Departments and Agencies, 74 Fed. Reg. 15, 3825 (Jan. 

26, 2009). Available at: http://edocket.access.gpo.gov/2009/pdf/E9-1777.pdf (“Transparency and Open 

Government”).
CMS-5507-NC 11 

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 
CMS-5507-NC 12 

aim—better care for individuals, better health for 

populations and lower costs through improvement—the 

Medicare-Medicaid 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 
CMS-5507-NC 13 

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? 
CMS-5507-NC 14 

● 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? 
CMS-5507-NC 

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. 

BILLING CODE 4120-01-P 
CMS-5507-NC AS 05/05/2011 16

ADDENDUM 1: List of Alignment Opportunities 

(all regulatory references refer to 42 CFR) 

Acronyms used in Addendum 1 

ACO Accountable care organization ALJ Administrative Law Judge BBA Balanced Budget Act of 1997 (Pub. L. 105-33, enacted on August 5, 1997) CFR Code of Federal Regulations CMS Centers for Medicare & Medicaid Services CORF Comprehensive outpatient rehabilitation facility DME Durable medical equipment DRG Diagnosis-related group FFP Federal financial participation FFS Fee-for-service HCBS Home and Community-Based Services IRE Independent review entity LIS Low income subsidy MA Medicare Advantage MAC Medicare Appeals Council MCO Managed care organization MIPPA Medicare Improvement for Patients and Providers Act (Pub. L. 110-275, enacted on July 15, 200MSP * Medicare savings program NF Nursing facility PACE Program of All Inclusive Care for the Elderly PBP Plan benefit package PDP Prescription Drug Plan QI * Qualifying individual QIO Quality improvement organization QMB* Qualified Medicare beneficiary SLMB * Specified Low-income Medicare beneficiary SNF Skilled nursing facility SNP Special needs plan SSA Social Security Administration the Act the Social Security Act VTC Video teleconferencing 

* Under the Medicare Savings Programs (MSP), Medicaid pays for some or all of a low-income beneficiary's Medicare cost sharing. Inup to 100 percent FPL who meet the relevant resource test can qualify for QMB; in this program, Medicaid pays for their Medicare Pardeductibles, coinsurances, and copayments. Individuals with incomes under 120 percent FPL who meet the relevant resource test can qindividuals with incomes under 135 percent FPL who meet the relevant resource test can qualify for QI; in these two programs, Medicapremium only. 
CMS-5507-NC 17 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

Coordinated Care -- Enrollment 

Models already exist that integrate care for dual eligibles, but enrollment in these programs remains very low. 

Federal Medicaid requirements vary by type of coordinated care program. There may be additional State requirements. Medicaid may mandate enrollment into coordinated care programs; for dual eligibles mandatory enrollment applies to their Medicaid benefits only. 

Traditionally, there for Medicare to inccoordinated care. 

Coordinated Care -- Options 

Medicaid can cover care coordination in FFS as well as through capitated managed care organizations. Medicare primarily covers care coordination through capitated managed care organizations. New models for seamless care (for example, ACOs and health homes) do not necessarily have to coordinate care for dual eligibles across both benefits. 

FFS: Medicaid provides FFP for optional services related to care coordination in FFS. Examples include targeted case management, Primary Care Case Management programs, and health home programs. Under the Affordable Care Act, Medicaid now provides FFP for the optional services of health homes. States may not exclude dual eligibles. Managed Care: FFP is also available for capitated managed care (for example, MCOs for comprehensive services package, "carve outs" such as behavioral health). 

FFS: Medicare covwithin certain benephysician office vishealth), but doesn't coordination as a stthe Affordable Care share savings with Ademonstration authMedicare and MediMedicare continues payment approachehome services. Part C: Medicare Acoordinated care plcoordination servic

Coordinated Care -- MA Cost sharing information in standard Summary of Benefits 

CMS' model for the MA "Summary of Benefits" has information, including costsharing, that is presented at the plan level, not the beneficiary level. Dual eligible beneficiaries may not be aware that there is dual eligible-specific information in later sections of the Summary of Benefits. 

Medicaid generally pays for Medicare cost-sharing for QMBs and full benefit dual eligible beneficiaries in MA plans. 

CMS’ systems geneBenefits" that is appthan beneficiary levat www.Medicare.gSummary of Benefiarea to insert free focost-sharing specifieligible SNPs must Summary of Beneficomprehensive descost-sharing, as weMedicaid and Medithey are entitled. 
CMS-5507-NC 18 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

Coordinated Care -- MA -- Seamless conversion 

Medicare permits seamless conversion of Medicaid-only individuals enrolled in a Medicaid MCO into a MA plan offered by same organization when the person becomes Medicare eligible with the option for beneficiaries to opt out, but few plans avail themselves of this option. Plans may have difficulty identifying those in their Medicaid managed products who are about to become Medicare eligible. 

Medicaid programs have the option to offer managed care to dual eligibles, and to permit voluntary enrollment or mandate it for their Medicaid benefits. 

Medicare statute anseamless conversioout. 

Coordinated Care -- PACE -- External appeals 

While there is an integrated appeals process for internal appeals, dual eligible PACE participants may choose the Medicare or Medicaid managed care appeal processes for pursuing an external appeal (but not both). PACE organizations must inform the dual eligible beneficiary of his or her appeal rights under Medicare and Medicaid managed care, and assist the participant in choosing which to pursue and forward the appeal to the appropriate entity. §460.124. 

Some States provide access to Ombudsman or Independent Review Entities for those enrolled in managed care. All States must provide access to a State Fair Hearing to individuals entitled to a hearing under the Medicaid managed care rules. §460.124 and 42 CFR Part 438, subpart F; section 1932(b)(4) of the Act. 

Medicare beneficiaMedicare external aIndependent Review with CMS to resolvappeals. §460.124; 

Coordinated Care- -- Low income Medicare beneficiaries at risk of declining to point of qualifying for Medicaid 

For low income Medicare-only beneficiaries, Medicare FFS has limited flexibility to help prevent people from declining to a point where they need/qualify for Medicaid, particularly in instances where they may have been able to avoid nursing home care with appropriate community supports. 

State Medicaid programs can't receive FFP for services provided to people who are not eligible for full Medicaid benefits (that is, those who are only on Medicare Savings programs). 

Medicare FFS does coordination servic

Coordinated Care –Special Need Plans -- Current contracting issues 

The Federal Medicare and Medicaid programs stipulate contracting requirements, as do State Medicaid programs. These contracting requirements may conflict. For example, Medicare and Medicaid may have different reporting requirements. 

There are Federal contracting requirements for Medicaid managed care contracts. 42 CFR part 438 et. seq. provides general Federal guidance. State Medicaid requirements vary by State. These requirements would apply to a SNP that has a contract with a State Medicaid agency to cover Medicaid benefits. 

There are separate cfor MA. §422.504. 
CMS-5507-NC 19 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

Coordinated Care – Managed Care SNP -- Enrollment requirements 

Medicare and Medicaid both have requirements governing enrollment into managed care plans and these may conflict, including: ● When a beneficiary can enroll in and disenroll from plan. ● When and how often a beneficiary can change plans. ● Cutoff dates for requesting enrollment. ● Effective date of enrollment. ● Mandatory vs. voluntary enrollment in plans. ● Type of entity that can accept enrollment. 

● States are permitted to mandate enrollment and limit disenrollment to certain reasons. ● States may vary on cutoff for requesting enrollment and effective date of enrollment. ● States vary in entities they permit to accept enrollment (for example, enrollment broker; may not permit plans to directly accept). 

● Dual eligibles mplans at any time. ● Enrollments may themselves, or by cCutoff dates for eledate of that electionperiod applies. 

Coordinated Care -- SNP -- Future contracting issues 

Dual eligible SNPs must have a contract with State Medicaid agencies starting in 2010 (for expanding and new plans) and 2013 (for all dual eligible SNPs, including existing and new plans). 

States may selectively contract with managed care plans based on Statespecified criteria. 

Although plans wilcontract with the Stsection 164 of MIPsection 3205 of the Medicare cannot rewith SNPs. In limited instancesa single SNP in a mcrosses State lines. consider permitting to split a single plan need for different pdifferent States. 

Coordinated Care -- SNP -- Internal grievances and appeals 

Medicare and Medicaid differ in their requirements related to internal appeals and grievances for beneficiaries enrolled in managed care plans. Examples include: ● Grievances (complaints). ● Appeals (processes, timeframes). ● Continuation of services during appeal. ● External entity (State fair hearing versus Medicare independent review entity). ● Required notices. 

States may have varying requirements, on top of Federal Medicaid requirements. See appeals discussion, below. 

Medicare has its owappeals discussion, 
CMS-5507-NC 20 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

Coordinated Care -- SNP – Marketing 

Medicare and Medicaid both have requirements related to marketing. Examples include: ● Differing requirements related to the definition of what constitutes marketing. ● Content of marketing material. ● Process to approve marketing material. ● Standards for reading level, health literacy, and criteria prompting materials to be translated into other languages. 

Federal Medicaid requirements have more stringent readability/translation requirements; and define marketing more narrowly than Medicare. A given State may have its own, Statespecific requirements on reading level, translation, and approval process, in addition to Federal guidelines. 

There are a broad radocuments under thwhich apply generasome of which werSNPs. Model langudesigned for the Mewritten at a higher rplans may request alanguage at a lower Medicare requires Mspecific marketing language that is the more than 10 percearea. 

Coordinated Care -- SNP -- Quality requirements 

Medicare and Medicaid have different requirements for quality improvement efforts, types of quality data required to be submitted, and requirements for treatment plans or models of care. 

CMS Medicaid regulations at §438.240(d) include specific performance improvement program requirements. States may require additional performance measures, to be reported on State contracting cycles (which may differ from Federal cycles). States must contract with an External Quality Review Organization for each contract. Federal regulations require Medicaid MCOs to have treatment plans for enrollees with special health care needs. (§438.208). States have some discretion to waive these requirements for dual eligibles enrolled in an MA plan. 

MA regulations at §MA organizations cimprovement projeUnder §422.152(b)to measure performusing the measuremCMS, and report peThey must also prothat are reported as beneficiaries use to Under the Affordabbe approved by NCUnder the MA proghave a model of carrequirements for caaddition, the SNP imedication therapy the Part D benefit. 

Coordinated Care -- SNP -- Seamless delivery of services 

SNPs have different coverage limits and criteria. 

States’ Medicaid coverage of items and services varies. 

Medicare has its owcoverage of items a
CMS-5507-NC 21 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

FFS Benefits -- Behavioral health 

Medicaid and Medicare differ in coverage of behavioral health care providers and services. 

Some States may cover a broader range of behavioral health services, including community based behavioral services and providers, for example, Assertive Community Treatment for severe mental illness, intensive outpatient treatment and ambulatory detoxification for substance abuse treatment. Medicaid covers inpatient psychiatric hospital services only for individuals under age 21 and covers inpatient hospital services for persons age 65 or older with mental illness in institutions for mental diseases. Specialty inpatient psychiatric care is not covered for adults age 21-64. 

Medicare covers re“partial hospitalizatoutpatient and inpaprofessionals and p

FFS Benefits-- DME 

Medicare and Medicaid have different rules for qualifying for DME coverage for those receiving care in the community. In addition, each program may have different formularies governing what DME it covers. 

Medicaid covers DME in the home care context (§440.70). DME must be determined to be "medically necessary" and not experimental. There is no clear Federal definition of covered DME, so many but not all States have adopted some form of the Medicare definition. 

Medicare covers DM● Can withstand re● Is primarily and a medical purpose; ● Generally is not absence of an illnes● Is appropriate fo§410.38). See generally sectio§414.202. 

FFS Benefits -- Home health 

Medicare covers home health services for patients who have a skilled need. Specifically, the patient must need skilled nursing care on an intermittent basis or need skilled therapy services. Medicaid generally covers both acute and longer term needs. 

Medicaid covers skilled nursing/therapy/ home health aide services and/or personal care services. Certain services under the home health benefit are optional and may not be covered in certain States. The benefit is intermittent (that is less than 24 hours/day) and typically has limits, depending on the States. States may also offer HCBS services that provide additional home care, but these are usually targeted at particular populations. 

To qualify for the Mbenefit, a Medicare under the care of a intermittent need foneed physical or spto need occupationabeneficiary must be home health serviceapproved home heapays home health aadjusted episode bunursing, therapy, homedical social servroutine medical sup
CMS-5507-NC 22 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

FFS Benefits -- Nursing homehospital transfers 

Reimbursement policies between Medicare and Medicaid incentivize nursing homes to transfer dual eligibles to hospitals and vice versa. Nursing homes are reimbursed by Medicaid for custodial care, and may not have the staff to diagnose/treat more acute conditions in-house, especially after business hours. In addition, they are reimbursed at a higher rate by Medicare when the person is discharged from a hospital and qualifies for SNF level of care. Medicare reimburses hospitals on a per discharge basis, incentivizing them to discharge beneficiaries to nursing facilities. Inappropriate and/or avoidable hospital admission and readmissions put beneficiaries at risk of exposure to hospital-acquired conditions, fragmented care, medical errors, medication mismanagement, and poor follow-up care. 

Medicaid covers long term NF stays (that is, that don't meet SNF level of care), and generally pays with a FFS methodology (per day) that is generally lower than Medicare payment. There is an incentive to transfer dual eligibles with higher costs to hospitals, rather than manage them in-house, in order to requalify the individual for Medicare coverage. States also may pay for bed holds (meaning States continue to pay the reduced rate while the person is in hospital) so that the individual is guaranteed to be able to return to the facility. 

Medicare is generalhospital stays. Moshospitals are paid ounder the IPPS usinMedicare's post-acu(which reduces hospatients with certain patient is transferredesigned to avoid pa hospital to transfetheir stay to minimireceiving the fully pMS-DRG. Medicare generally SNF care in each bbeneficiaries who mrequirements. Genreimbursement for higher than MedicaNF stay. In order fSNF stay, the benefprior inpatient hospdays. 

FFS Benefits -- Skilled therapies 

Medicare and Medicaid differ in their provider definitions and qualifications for skilled therapies. 

Medicaid requirements at § 440.110 include requirements for Medicaid physical therapist credentials. 

Medicare amended physical therapy princreasing the numborganizations recogpurposes of reimbu

Prescription Drugs -- Access for new full duals 

States are required to submit data monthly to CMS to identify new dual eligibles. 

CMS requires States to submit dual eligible enrollment and eligibility data monthly, but States have discretion to submit more frequently. 

LI NET demonstratduals not yet auto-esale, that is, a pharmspecialized PDP avdemonstration and confirmation of payimmediate dispensi
CMS-5507-NC 23 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

Cost-sharing -- Crossover claims 

When Medicare pays a claim for certain dual eligible beneficiaries, it automatically sends it to Medicaid as a “crossover” claim to assist State Medicaid agencies in their obligation to pay any Medicare cost-sharing on those claims. 

Under section 1905(p)(3) of the Act, State Medicaid agencies are liable for QMB cost sharing. Medicaid is required to pay Medicare cost-sharing for dual eligibles who are QMBs, regardless of whether the service is normally covered under Medicaid, or whether the provider is enrolled as a Medicaid provider. In some States, where the provider is not enrolled as a Medicaid provider, the State's Medicaid claims processing system will reject the claims. Federal law permits States to cover the Medicare cost-sharing for QMBs up to the Medicaid payment rate. If the State's rate is equal or lower than the total reimbursement already received from the Medicare program, then the State is not required under current law to pay the Medicare cost-sharing. In these instances Federal guidance requires States to issue remittance advice. 

Medicare automaticclaims to State Medpurposes of paying eligible beneficiaryliability. Medicare State’s Medicaid Aremittance advice wfor cost-sharing, in report this on its Mreceive an adjustmesome of the loss. If remittance advice, tsuch an adjustment

Cost-sharing -- Balance billing for QMB 

Providers have difficulty identifying beneficiaries who are QMB. Medicare providers do not always understand they are not permitted to balance bill QMB beneficiaries. 

Medicaid providers must accept Medicaid payment as payment in full. §447.15 

Medicare generally pay applicable deduand/or copayments However, individuaeligibles or QMBs mproviders for Mediccopayments or deducovered items or se
CMS-5507-NC 24 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

Enrollment -- Medicare Part A buy-in 

States are required to pay Part A premiums for QMBs and may opt to pay for the Medicare Part A premium for other dual eligibles; States that do not, may be paying for services that could be billed to Medicare Part A. 

35 States and the District of Columbia have opted to buy in for Part A for nonQMBs, though not all necessarily enroll all eligible participants. 

Medicare Part A coincluding hospital, Beneficiaries who hof Medicare-coverehave a spouse who free Part A. Individworked 40 quarters by paying a monthlThe Qualified Disa(QDWI) program hpremiums for disabMedicare who have 

Enrollment -- Recertification requirements for Medicaid 

States may require in-person interviews or documentation at annual reviews to re-certify for Medicaid and/or MSP. 

States have the discretion to require in person interviews. Some States have removed the recertification interview from the process and reported administrative cost savings (Wisconsin, Louisiana, Arizona), and some States utilize passive or ex parte recertification. 

In general, people ware automatically enIndividuals have an enrollment in Part B become eligible for they are enrolled. Nare necessary. 

Enrollment -- Medicare Savings Program asset test 

Beneficiaries are often required to provide asset information and documentation as part of the Medicare Savings Programs application . 

Medicaid has limits on assets or resources for most individuals who are eligible on the basis of age or disability, for whom States are generally required under section 1902(a)(17) of the Act to apply the rules of the Supplemental Security Income program. State Medicaid agencies have discretion to disregard some or all assets for the Medicare Savings Programs under section 1902(r)(2) of the Act. 

There is no asset teprogram itself, thoulow income subsidy 
CMS-5507-NC 25 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

Appeals -- Timeframes for filing an appeal related to benefits 

Medicare and Medicaid (both in FFS and private health plans) have different timeframes for filing of initial and subsequent appeals. 

FFS: An individual has a right to request a fair hearing or appeal. The agency must provide a reasonable time to the applicant or recipient, not to exceed 90 days from the date the notice is mailed (as determined by the State). §431.221. Managed Care: Appeals may be filed via the State fair hearing process (sometimes after exhaustion of plan appeals) anywhere between 20 and 90 days (varies by States). §438.408. 

Parts A and B: Reqredetermination maof the date the party initial determinationreconsideration of tbe filed within 180 receives the notice Requests for ALJ, Mmust be filed within of the notice of the level of review. Parts C and D: App60 days. SubsequeMAC and Court) mdays. 

Appeals -- Access to State level or external review 

Medicare and Medicaid vary in the degree to which they allow a beneficiary to access a parallel external appeals process, separate and apart from the normal appeals system. 

All States must provide access to a State Fair Hearing, either directly or (if the State requires exhaustion of the health plan level of appeal) after an initial appeal to the health plan. §431.205 and §438.408; and section 1902(a)(3) of the Act. Some States provide access to Ombudsman or Independent Review Entities for those enrolled in managed care. 

Parts A and B: A QContractor is responreconsiderations. Ba Medicare Notice CORF, SNF, Home important message hospital, may accesmay conduct an ind§405.1200 et. seq. Parts C and D: Medin private health plaReview Entities, buan initial appeal to §422.592. Part C beopportunity to have termination or redu
CMS-5507-NC 26 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

Appeals -- Continuation of benefits pending appeal 

Medicare and Medicaid differ in terms of whether benefits continue to be provided while a coverage appeal is in process. 

Medicaid benefits generally continue and are covered pending a timely appeal (FFP is available for these costs), when the appeal is requested within a certain timeframe. States also may reinstate benefits if requested within 10 days of the date of action (although States may vary). §431.231. The basis of this rule is both regulatory and constitutional (due process clause), as interpreted by Supreme Court in Goldberg v. Kelly and its progeny. Section 1902(a)(3) of the Act; §431.205; §438.420 (managed care). The State may seek recovery against the beneficiary if he or she loses the appeal. 

Benefits generally dentire pendency of involving reduction services. 

Appeals -- Document notifying beneficiaries of appeal rights 

Medicare and Medicaid differ in the way in which documents provide notification of appeal rights. 

Various documents may be used to notify beneficiaries of their appeal rights depending upon the State. Regulations require that information about appeals be included at the time of application, with a notice of adverse action on a claim, at the time of transfer or discharge from a SNF. §431.206. Also there are requirements of providing notice to beneficiaries enrolled in managed care organizations during terminations, suspensions, reductions in service, denial of payment, among others. §438.404. 

Medicare Parts A aappeals -- “Medicarsent to beneficiaries appeal rights. For eMedicare Notice of important message beneficiaries of theMedicare Part C: A delivered to benefictheir appeal rights. Medicare Part D: A Medicare Prescriptidelivered to benefictheir appeal rights. 
CMS-5507-NC 27 

Topic Description Summary of Medicaid 

Requirements 

Summary of Me

Appeals -- Timeframes for resolution of an appeal related to benefits 

Medicare and Medicaid vary in the time that a payer has to make a decision once an appeal is received. 

FFS: Rules vary by State. Generally within 90 days of date of filing the appeal. §431.244. Managed Care: Standard appeals must generally be handled within 45 days, with extensions available in certain circumstances. Expedited appeals are to be handled within 3 working days, with extensions up to 14 calendar days in certain circumstances. §438.402, and §438.408. 

Parts A and B: For appeals, different pdepending upon the process. At the eargenerally have 60 dALJ/MAC Stage thdays, and failure to frame allows the pato the next higher leAct; §405.1000 et sexpedited appeals, tinitial stages are mogenerally not longe1869 of the Act; §4§405.1206. Parts C and D: Stanreconsiderations mudays (Part D) or 30 reviews are to be co

[FR Doc. 2011-11848 Filed 05/11/2011 at 11:15 am; Publication Date: 05/16/2011]