# 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

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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 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 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 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

7 

# The Lewin Group, Individuals Living in the Community with Chronic Conditions and Functional

Limitations: A Closer Look (Washington, DC: Office of the Assi stant 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 Medicar e 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 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

10 

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

http://www.whitehouse.gov/th e-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

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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/E 9-1777.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-PCMS-5507-NC AS 05/05/2011 16ADDENDUM 1: List of Alignment Opportunities(all regulatory references refer to 42 CFR)Acronyms used in Addendum 1ACOAccountable care organizationALJAdministrative Law JudgeBBABalanced Budget Act of 1997 (Pub. L. 105-33, enacted on August 5, 1997)CFRCode of Federal RegulationsCMSCenters for Medicare & Medicaid ServicesCORFComprehensive outpatient rehabilitation facilityDMEDurable medical equipmentDRGDiagnosis-related groupFFPFederal financial participationFFSFee-for-serviceHCBSHome and Community-Based ServicesIREIndependent review entityLISLow income subsidyMAMedicare AdvantageMACMedicare Appeals CouncilMCOManaged care organizationMIPPAMedicare Improvement for Patients and Providers Act (Pub. L. 110-275, enacted on July 15, 2008)MSP *Medicare savings programNFNursing facilityPACEProgram of All Inclusive Care for the ElderlyPBPPlan benefit packagePDPPrescription Drug PlanQI *Qualifying individualQIOQuality improvement organizationQMB*Qualified Medicare beneficiarySLMB *Specified Low-income Medicare beneficiarySNFSkilled nursing facilitySNPSpecial needs planSSASocial Security Administrationthe Actthe Social Security ActVTCVideo teleconferencing* Under the Medicare Savings Programs (MSP), Medicaid pays for some or all of a low-income beneficiary's Medicare cost sharing.Individuals with incomesup to 100 percent FPL who meet the relevant resource test can qualify for QMB; in this program, Medicaid pays for their Medicare Part A and B premium,deductibles, coinsurances, and copayments. Individuals with incomes under 120 percent FPL who meet the relevant resource testcan qualify for SLMB, andindividuals with incomes under 135 percent FPL who meet the relevant resource test can qualify for QI; in these two programs, Medicaid pays for the Part Bpremium only.CMS-5507-NC 17TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsCoordinated Care --EnrollmentModels already exist that integrate care fordual eligibles, but enrollment in theseprograms remains very low.Federal Medicaid requirements vary bytype of coordinated care program. Theremay be additional State requirements.Medicaid may mandate enrollment intocoordinated care programs; for dualeligibles mandatory enrollment appliesto their Medicaid benefits only.Traditionally, there have been few optionsfor Medicare to increase enrollment incoordinated care.Coordinated Care --OptionsMedicaid can cover care coordination in FFSas well as through capitated managed careorganizations. Medicare primarily coverscare coordination through capitated managedcare organizations. New models forseamless care (for example, ACOs andhealth homes) do not necessarily have tocoordinate care for dual eligibles across bothbenefits.FFS: Medicaid provides FFP foroptional services related to carecoordination in FFS.Examples includetargeted case management, Primary CareCase Management programs, and healthhome programs. Under the AffordableCare Act, Medicaid now provides FFPfor the optional services of healthhomes. States may not exclude dualeligibles.Managed Care: FFP is also available forcapitated managed care (for example,MCOs for comprehensive servicespackage, "carve outs" such as behavioralhealth).FFS: Medicare covers care coordinationwithin certain benefits(for example, hospital,physician office visits, hospice, and homehealth), but doesn't pay separately for carecoordination as a standalone benefit. Underthe Affordable Care Act, Medicare mayshare savings with ACOs. In addition, underdemonstration authority and the Center forMedicare and Medicaid Innovation,Medicare continues to test promisingpayment approaches, including medicalhome services.Part C: Medicare Advantage plans that arecoordinated care plans include carecoordination services.Coordinated Care --MA Cost sharinginformation instandard Summaryof BenefitsCMS' model for the MA "Summary ofBenefits" has information, including costsharing, that is presented at the plan level,not the beneficiary level. Dual eligiblebeneficiaries may not be aware that there isdual eligible-specific information in latersections of the Summary of Benefits.Medicaid generally pays for Medicarecost-sharing for QMBs and full benefitdual eligible beneficiaries in MA plans.CMS’ systems generate a "Summary ofBenefits" that is applicable at the plan ratherthan beneficiary level; these data also appearatwww.Medicare.gov. Section 3 of theSummary of Benefits provides a plan with anarea to insert free form text, for example,cost-sharing specific to dual eligibles. Dualeligible SNPs must use section 4 of theSummary of Benefits to provide acomprehensive description of dual-eligiblecost-sharing, as well as a description of bothMedicaid and Medicare benefits to whichthey are entitled.CMS-5507-NC 18TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsCoordinated Care --MA -- SeamlessconversionMedicare permits seamless conversion ofMedicaid-only individuals enrolled in aMedicaid MCO into a MA plan offered bysame organization when the person becomesMedicare eligible with the option forbeneficiaries to opt out, but few plans availthemselves of this option. Plans may havedifficulty identifying those in their Medicaidmanaged products who are about to becomeMedicare eligible.Medicaid programs have the option tooffer managed care to dual eligibles, andto permit voluntary enrollment ormandate it for their Medicaid benefits.Medicare statute and regulation permitseamless conversion with the option to optout.Coordinated Care --PACE -- ExternalappealsWhile there is an integrated appeals processfor internal appeals, dual eligible PACEparticipants may choose the Medicare orMedicaid managed care appeal processes forpursuing an external appeal (but not both).PACE organizations must inform the dualeligible beneficiary of his or her appealrights under Medicare and Medicaidmanaged care, and assist the participant inchoosing which to pursue and forward theappeal to the appropriate entity. §460.124.Some States provide access toOmbudsman or Independent ReviewEntities for those enrolled in managedcare. All States must provide access to aState Fair Hearing to individuals entitledto a hearing underthe Medicaidmanaged care rules. §460.124 and 42CFR Part 438, subpart F; section1932(b)(4) of the Act.Medicare beneficiaries have access to theMedicare external appeals route through theIndependent Review Entity that contractswith CMS to resolve Medicare Advantageappeals. §460.124; see also §422.592et seq.Coordinated Care- -- Low incomeMedicarebeneficiaries at riskof declining to pointof qualifying forMedicaidFor low income Medicare-only beneficiaries,Medicare FFS has limited flexibility to helpprevent people from declining to a pointwhere they need/qualify for Medicaid,particularly in instances where they mayhave been able to avoid nursing home carewith appropriate community supports.State Medicaid programs can't receiveFFP for services provided to people whoare not eligible for full Medicaidbenefits (that is, those who are only onMedicare Savings programs).Medicare FFS does not cover carecoordination services as a standalone benefit.Coordinated Care –Special Need Plans-- Currentcontracting issuesThe Federal Medicare and Medicaidprograms stipulate contracting requirements,as do State Medicaid programs. Thesecontracting requirements may conflict. Forexample, Medicare and Medicaid may havedifferent reporting requirements.There are Federal contractingrequirements for Medicaid managed carecontracts. 42 CFR part 438et. seq.provides general Federal guidance.State Medicaid requirements vary byState.These requirements would apply to aSNP that has a contract with a StateMedicaid agency to cover Medicaidbenefits.There are separate contracting requirementsfor MA. §422.504.CMS-5507-NC 19TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsCoordinated Care –Managed Care SNP-- EnrollmentrequirementsMedicare and Medicaid both haverequirements governing enrollment intomanaged care plans and these may conflict,including:●When a beneficiary can enroll in anddisenroll from plan.●When and how often a beneficiary canchange plans.●Cutoff dates for requesting enrollment.●Effective date of enrollment.●Mandatory vs. voluntary enrollment inplans.●Type of entity that can accept enrollment.●States are permitted to mandateenrollment and limit disenrollment tocertain reasons.●States may vary on cutoff forrequesting enrollment and effective dateof enrollment.●States vary in entities they permit toaccept enrollment (for example,enrollment broker; may not permit plansto directly accept).●Dual eligibles may change Part C and Dplans at any time.●Enrollments may be received by MA plansthemselves, or by calling 1-800-Medicare.Cutoff dates for electing a plan, and effectivedate of that election, vary by which electionperiod applies.Coordinated Care --SNP -- Futurecontracting issuesDual eligible SNPs must have a contract withState Medicaid agencies starting in 2010 (forexpanding and new plans) and 2013 (for alldual eligible SNPs, including existing andnew plans).States may selectively contract withmanaged care plans based on Statespecified criteria.Although plans will be required to have acontract with the State Medicaid agency persection 164 of MIPPA, as modified bysection 3205 of the Affordable Care Act,Medicare cannot require States to contractwith SNPs.In limited instances, MA organizations offera single SNP in a metropolitan area thatcrosses State lines. CMS has been asked toconsider permitting the SNP in this situationto split a single plan into two to support theneed for different plans to contract with twodifferent States.Coordinated Care --SNP -- Internalgrievances andappealsMedicare and Medicaid differ in theirrequirements related to internal appeals andgrievances for beneficiaries enrolled inmanaged care plans. Examples include:●Grievances (complaints).●Appeals (processes, timeframes).●Continuation of services during appeal.●External entity (State fair hearing versusMedicare independent review entity).●Required notices.States may have varying requirements,on top of Federal Medicaidrequirements. Seeappeals discussion,below.Medicare has its own regulations. Seeappeals discussion, below.CMS-5507-NC 20TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsCoordinated Care --SNP – MarketingMedicare and Medicaid both haverequirements related to marketing.Examples include:●Differing requirements related to thedefinition of what constitutes marketing.●Content of marketing material.●Process to approve marketing material.●Standards for reading level, healthliteracy, and criteria prompting materials tobe translated into other languages.Federal Medicaid requirements havemore stringent readability/translationrequirements; and define marketingmore narrowly than Medicare.A given State may have its own, Statespecific requirements on reading level,translation, and approval process, inaddition to Federal guidelines.There are a broad range of standard or modeldocuments under the MA program, some ofwhich apply generally to all MA plans, butsome of which were designed specifically forSNPs. Model language in documentsdesigned for the Medicare program may bewritten at a higher reading level. However,plans may request approval for alternatelanguage at a lower reading level.Medicare requires MA plans to makespecific marketing material available in anylanguage that is the primary language ofmore than 10 percent of the plan's servicearea.Coordinated Care --SNP -- QualityrequirementsMedicare and Medicaid have differentrequirements for quality improvementefforts, types of quality data required to besubmitted, and requirements for treatmentplans or models of care.CMS Medicaid regulations at§438.240(d) include specificperformance improvement programrequirements.States may require additionalperformance measures, to be reported onState contracting cycles (which maydiffer from Federal cycles).States must contract with an ExternalQuality Review Organization for eachcontract.Federal regulations require MedicaidMCOs to have treatment plans forenrollees with specialhealth care needs.(§438.208). States have some discretionto waive these requirements for dualeligibles enrolled in an MA plan.MA regulations at §422.152(b) require thatMA organizations conduct qualityimprovement projects.Under §422.152(b)(3), the SNPs are requiredto measure performance under the plan,using the measurement tools required byCMS, and report performance to CMS.They must also provide outcome measuresthat are reported as part of materialsbeneficiaries use to select plans.Under the Affordable Care Act, SNPs mustbe approved by NCQA beginning in 2012.Under the MA program, a SNP is required tohave a model of care, as well as standard MArequirements for carecoordination. Inaddition, the SNP is required to have amedication therapy management program forthe Part D benefit.Coordinated Care --SNP -- Seamlessdelivery of servicesSNPs have different coverage limits andcriteria.States’ Medicaid coverage of items andservices varies.Medicare has its own requirements forcoverage of items and services.CMS-5507-NC 21TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsFFS Benefits --Behavioral healthMedicaid and Medicare differ in coverage ofbehavioral health care providers andservices.Some States may cover a broader rangeof behavioral health services, includingcommunity based behavioral servicesand providers, for example, AssertiveCommunity Treatment for severe mentalillness, intensive outpatient treatmentand ambulatory detoxification forsubstance abuse treatment. Medicaidcovers inpatientpsychiatric hospitalservices only for individuals under age21 and covers inpatient hospital servicesfor persons age 65 or older with mentalillness in institutions for mental diseases.Specialty inpatient psychiatric care is notcovered for adults age 21-64.Medicare covers reasonable and necessary“partial hospitalizations,” traditionaloutpatient and inpatient visits to behavioralprofessionals and providers.FFS Benefits--DMEMedicare and Medicaid have different rulesfor qualifying for DME coverage for thosereceiving care in the community. Inaddition, each program may have differentformularies governing what DME it covers.Medicaid covers DME in the home carecontext (§440.70). DME must bedetermined to be "medically necessary"and not experimental. There is no clearFederal definition of covered DME, somany but not all States have adoptedsome form of the Medicare definition.Medicare covers DME that:●Can withstand repeated use;●Is primarily and customarily used to servea medical purpose;●Generally is not useful to a person in theabsence of an illness or injury; and●Is appropriate for use in the home (under§410.38).See generally section 1861(n) of the Act;§414.202.FFS Benefits --Home healthMedicare covers home health services forpatients who have a skilled need.Specifically, the patient must need skillednursing care on an intermittent basis or needskilled therapy services. Medicaid generallycovers both acute and longer term needs.Medicaid covers skilled nursing/therapy/home health aide services and/orpersonal care services. Certain servicesunder the home health benefit areoptional and may not be covered incertain States. The benefit isintermittent (that is less than 24hours/day) and typically has limits,depending on the States. States mayalso offer HCBS services that provideadditional home care, but these areusually targeted at particularpopulations.To qualify for the Medicare home healthbenefit, a Medicare beneficiary must beunder the care of a physician, and have anintermittent need for skilled nursing care,need physical or speech therapy, or continueto need occupational therapy. Thebeneficiary must behomebound and receivehome health services from a Medicareapproved home health agency. Medicarepays home health agencies a 60-day case mixadjusted episode bundled payment for allnursing, therapy, home health aide services,medical social services, and routine and nonroutine medical supplies.CMS-5507-NC 22TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsFFS Benefits --Nursing homehospital transfersReimbursement policies between Medicareand Medicaid incentivize nursing homes totransfer dual eligibles to hospitals and viceversa. Nursing homes are reimbursed byMedicaid for custodial care, and may nothave the staff to diagnose/treat more acuteconditions in-house, especially after businesshours. In addition, they are reimbursed at ahigher rate by Medicare when the person isdischarged from a hospital and qualifies forSNF level of care. Medicare reimburseshospitals on a per discharge basis,incentivizing them to discharge beneficiariesto nursing facilities. Inappropriate and/oravoidable hospital admission and readmissions put beneficiaries at risk ofexposure to hospital-acquired conditions,fragmented care, medicalerrors, medicationmismanagement, and poor follow-up care.Medicaid covers long term NF stays(that is, that don't meet SNF level ofcare), and generally pays with a FFSmethodology (per day) that is generallylower than Medicare payment. There isan incentive to transfer dual eligibleswith higher costs to hospitals, rather thanmanage them in-house, in order to requalify the individual for Medicarecoverage. States also may pay for bedholds (meaning States continue to paythe reduced rate while the person is inhospital) so that the individual isguaranteed to be able to return to thefacility.Medicare is generally the primary payer forhospital stays. Most short-term, acute carehospitals are paid on a per-discharge basisunder the IPPS using DRG payment rates.Medicare's post-acutecare transfer policy(which reduces hospital payments forpatients with certain diagnoses when thepatient is transferred relatively early) wasdesigned to avoid providing an incentive fora hospital to transfer certain patients early intheir stay to minimize costs while stillreceiving the fully payment for the specificMS-DRG.Medicare generally covers up to 100 days ofSNF care in each benefit period forbeneficiaries who meet coveragerequirements. Generally, Medicarereimbursement for a SNF level of care ishigher than Medicaid's reimbursement forNF stay. In order for Medicare to cover aSNF stay, the beneficiary must have had aprior inpatient hospitalization of at least 3days.FFS Benefits --Skilled therapiesMedicare and Medicaid differ in theirprovider definitions and qualifications forskilled therapies.Medicaid requirements at § 440.110include requirements for Medicaidphysical therapist credentials.Medicare amended §484.4 in 2008, revisingphysical therapy provider definitions andincreasing the number of credentialingorganizations recognized by Medicare forpurposes of reimbursement.Prescription Drugs -- Access for newfull dualsStates are required to submit data monthly toCMS to identify new dual eligibles.CMS requires States to submit dualeligible enrollment and eligibility datamonthly, but States have discretion tosubmit more frequently.LI NET demonstration will cover those newduals not yet auto-enrolled at the point ofsale, that is, a pharmacist can bill aspecialized PDP available under thedemonstration and get immediateconfirmation of payment, facilitatingimmediate dispensingof the drug.CMS-5507-NC 23TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsCost-sharing --Crossover claimsWhen Medicare pays a claim for certain dualeligible beneficiaries, it automatically sendsit to Medicaid as a “crossover” claim toassist State Medicaid agencies in theirobligation to pay any Medicare cost-sharingon those claims.Under section 1905(p)(3) of the Act,State Medicaid agencies are liable forQMB cost sharing. Medicaid is requiredto pay Medicare cost-sharing for dualeligibles who are QMBs, regardless ofwhether the service is normally coveredunder Medicaid, or whether the provideris enrolled as a Medicaid provider. Insome States, where the provider is notenrolled as a Medicaid provider, theState's Medicaid claims processingsystem will reject the claims.Federal law permits States to cover theMedicare cost-sharing for QMBs up tothe Medicaid payment rate. If the State'srate is equal or lower than the totalreimbursement already received fromthe Medicare program, then the State isnot required under current law to pay theMedicare cost-sharing. In theseinstances Federal guidance requiresStates to issue remittance advice.Medicare automatically sends “crossover”claims to State Medicaid agencies forpurposes of paying the provider for a dualeligible beneficiary’s Medicare cost-sharingliability. Medicare rules require that aState’s Medicaid Agency must issue aremittance advice with zero reimbursementfor cost-sharing, in order for a facility toreport this on its Medicare cost report andreceive an adjustment, providing offset ofsome of the loss. If the State does not issue aremittance advice, thefacility cannot receivesuch an adjustment.Cost-sharing --Balance billing forQMBProviders have difficulty identifyingbeneficiaries who are QMB. Medicareproviders do not always understand they arenot permitted to balance bill QMBbeneficiaries.Medicaid providers must acceptMedicaid payment as payment in full.§447.15Medicare generally requires beneficiaries topay applicable deductibles, coinsurance,and/or copayments for many of its services.However, individuals who are full dualeligibles or QMBs may not be billed byproviders for Medicare coinsurance,copayments or deductibles for Medicarecovered items or services.CMS-5507-NC 24TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsEnrollment --Medicare Part Abuy-inStates are required to pay Part A premiumsfor QMBs and may opt to pay for theMedicare Part A premium for other dualeligibles; States that do not, may be payingfor services that could be billed to MedicarePart A.35 States and the District of Columbiahave opted to buy in for Part A for nonQMBs, though not allnecessarily enrollall eligible participants.Medicare Part A covers inpatient services,including hospital, SNF, and hospice.Beneficiaries who have worked 40 quartersof Medicare-covered employment (or whohave a spouse who has) receive premiumfree Part A. Individuals who have notworked 40 quarters may "buy in" to Part Aby paying a monthly premium.The Qualified Disabled Working Individual(QDWI) program helps pay Medicare Part Apremiums for disabled individuals withMedicare who have returned to work.Enrollment -- Recertificationrequirements forMedicaidStates may require in-person interviews ordocumentation at annual reviews to re-certifyfor Medicaid and/or MSP.States have the discretion to require inperson interviews. Some States haveremoved the recertification interviewfrom the process and reportedadministrative cost savings (Wisconsin,Louisiana, Arizona), and some Statesutilize passive or ex parte recertification.In general, people who are entitled to Part Aare automatically enrolled in the program.Individuals have an opportunity to declineenrollment in Part B the first time theybecome eligible for it. If they do not decline,they are enrolled. No annual re-enrollmentsare necessary.Enrollment --Medicare SavingsProgram asset testBeneficiaries are often required to provideasset information and documentation as partof the Medicare Savings Programsapplication .Medicaid has limits on assets orresources for most individuals who areeligible on the basis of age or disability,for whom States are generally requiredunder section 1902(a)(17) of the Act toapply the rules of the SupplementalSecurity Income program. StateMedicaid agencies have discretion todisregard some or all assets for theMedicare Savings Programs undersection 1902(r)(2) of the Act.There is no asset test for the Medicareprogram itself, though there is one for thelow income subsidy in the Part D benefit.CMS-5507-NC 25TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsAppeals --Timeframes forfiling an appealrelated to benefitsMedicare and Medicaid (both in FFS andprivate health plans) have differenttimeframes for filing of initial andsubsequent appeals.FFS: An individual has a right to requesta fair hearing or appeal. The agencymust provide a reasonable time to theapplicant or recipient, not to exceed 90days from the date the notice is mailed(as determined by the State). §431.221.Managed Care: Appeals may be filed viathe State fair hearing process (sometimesafter exhaustion of plan appeals)anywhere between 20 and 90 days(varies by States). §438.408.Parts A and B: Requests for aredetermination may be filed within 120 daysof the date the party receives notice of theinitial determination. Requests forreconsideration of that redetermination mustbe filed within 180 days of the date the partyreceives the notice of the redetermination.Requests for ALJ, MAC and Court reviewsmust be filed within 60days after the receiptof the notice of the decision at the previouslevel of review.Parts C and D: Appeals must be filed within60 days. Subsequent appeals (to IRE, ALJ,MAC and Court) must also be filed within 60days.Appeals -- Accessto State level orexternal reviewMedicare and Medicaid vary in the degree towhich they allow a beneficiary to access aparallel external appeals process, separateand apart from the normal appeals system.All States must provide access to a StateFair Hearing, eitherdirectly or (if theState requires exhaustion of the healthplan level of appeal) after an initialappeal to the health plan. §431.205 and§438.408; and section 1902(a)(3) of theAct. Some States provide access toOmbudsman or Independent ReviewEntities for those enrolled in managedcare.Parts A and B: A Qualified IndependentContractor is responsible for Part A and Breconsiderations. Beneficiaries who receivea Medicare Notice of Non-Coverage in aCORF, SNF, Home Care or hospice, or animportant message from Medicare in ahospital, may access a Medicare QIO, whichmay conduct an independent review.§405.1200 et. seq.Parts C and D: Medicare allows beneficiariesin private health plans to access IndependentReview Entities, but only after the filing ofan initial appeal to a plan. §422.578 and§422.592. Part C beneficiaries also have theopportunity to have a QIO review atermination or reduction of servicesCMS-5507-NC 26TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsAppeals --Continuation ofbenefits pendingappealMedicare and Medicaid differ in terms ofwhether benefits continue to be providedwhile a coverage appeal is in process.Medicaid benefits generally continueand are covered pending a timely appeal(FFP is available for these costs), whenthe appeal is requested within a certaintimeframe. States also may reinstatebenefits if requested within 10 days ofthe date of action (although States mayvary). §431.231. The basis of this ruleis both regulatory and constitutional (dueprocess clause), as interpreted bySupreme Court in Goldberg v. Kellyandits progeny. Section 1902(a)(3) of theAct; §431.205; §438.420 (managedcare). The State may seek recoveryagainst the beneficiary if he or she losesthe appeal.Benefits generally do not continue during theentire pendency of a Medicare appealinvolving reduction or termination ofservices.Appeals --Document notifyingbeneficiaries ofappeal rightsMedicare and Medicaid differ in the way inwhich documents provide notification ofappeal rights.Various documents may be used tonotify beneficiaries of their appeal rightsdepending upon the State. Regulationsrequire that information about appeals beincluded at the time of application, witha notice of adverse action on a claim, atthe time of transfer or discharge from aSNF. §431.206. Also there arerequirements of providing notice tobeneficiaries enrolled in managed careorganizations during terminations,suspensions, reductions in service,denial of payment, among others.§438.404.Medicare Parts A and B: For standardappeals -- “Medicare Summary Notice” issent to beneficiaries to notify them of theirappeal rights. For expedited appeals --Medicare Notice of Non-Coverage orimportant message from Medicare notifiesbeneficiaries of their appeals rights.Medicare Part C: A notice of non-coverage isdelivered to beneficiaries to notify them oftheir appeal rights.Medicare Part D: A notice Denial ofMedicare Prescription Drug Coverage isdelivered to beneficiaries to notify them oftheir appeal rights.CMS-5507-NC 27TopicDescriptionSummary of MedicaidRequirementsSummary of Medicare RequirementsAppeals --Timeframes forresolution of anappeal related tobenefitsMedicare and Medicaid vary in the time thata payer has to make a decision once anappeal is received.FFS: Rules vary by State. Generallywithin 90 days of date of filing theappeal. §431.244.Managed Care: Standard appeals mustgenerally be handled within 45 days,with extensions available in certaincircumstances. Expedited appeals are tobe handled within 3 working days, withextensions up to 14 calendar days incertain circumstances. §438.402, and§438.408.Parts A and B: For standard, non-expeditedappeals, different periods of time applydepending upon the stage of the reviewprocess. At the earlystages, contractorsgenerally have 60 days for review. At theALJ/MAC Stage the review period is 90days, and failure to meet the required timeframe allows the party to escalate the appealto the next higher level. Section 1869 of theAct; §405.1000 et seq. For timely filedexpedited appeals, the time periods at theinitial stages are more abbreviated (andgenerally not longer than 72 hours). Section1869 of the Act; §405.1202, §405.1204, and§405.1206.Parts C and D: Standard planreconsiderations must be resolved within 7days (Part D) or 30 days (Part C). Expeditedreviews are to be conducted within 72 hours.[FR Doc. 2011-11848 Filed 05/11/2011 at 11:15 am; Publication Date: 05/16/2011]