Dual-eligible beneficiaries qualify for both Medicare and Medicaid, and may enroll in and receive benefits covered by each program. Individuals ages 65 or older can qualify for Medicare based on age, and individuals ages 18 to 64 can qualify for Medicare based on disability. Medicaid eligibility varies by state, but beneficiaries may qualify based on having a low level of income, a need for nursing home care, high medical expenses, or other criteria. For dual-eligible beneficiaries, Medicare is the primary payer for any benefits covered by both programs. As a result, Medicare is the primary payer for acute and post-acute care, such as physician services, hospitalizations, prescription drugs, and skilled nursing facility care. For many dual-eligible beneficiaries, Medicaid covers benefits not covered by Medicare. This includes long-term services and supports, which may include nursing home care, personal care services, or adult day care. Whether Medicaid covers these benefits varies between the two main categories of dual-eligible beneficiaries. Those in the first category are known as full-benefit, dual-eligible beneficiaries, because they may receive all Medicaid benefits, in addition to Medicare benefits. Medicaid also pays for their Medicare premiums and, in some cases, the cost- sharing for their Medicare benefits. Those in the second category are known as partial-benefit, dual-eligible beneficiaries, because Medicaid assistance is limited to payment of their Medicare premiums and, in some cases, the cost-sharing for their Medicare benefits. Partial-benefit, dual- eligible beneficiaries have limited income and assets, but their income and assets are not low enough to qualify them for full Medicaid benefits in their state. For Medicare, dual-eligible beneficiaries can choose to receive their Medicare services from either traditional Medicare or from MA plans. These options differ in key ways. For example, traditional Medicare may have a more extensive provider network than MA plans. However, MA plans may cover additional benefits, such as vision or dental care, which are generally not covered under traditional Medicare. If dual-eligible beneficiaries choose to enroll in MA plans, they may also have the choice between regular MA plans and D-SNPs, which offer certain services targeted at the needs of dual-eligible beneficiaries. For example, D-SNPs are required to perform health risk assessments, create individualized care plans, and provide an interdisciplinary care team for each beneficiary enrolled. They may also cover transportation services, home modifications, or other specialized services that are more likely to be used by dual-eligible beneficiaries. For Medicaid, states may allow or require Medicaid beneficiaries, including dual-eligible beneficiaries, to receive their Medicaid benefits through an MCO. In this managed care model, Medicaid MCOs are responsible for arranging for and paying providers’ claims for a specific set of Medicaid benefits provided to beneficiaries. More recently, some states have created new Medicaid managed care programs or expanded the benefits covered by existing Medicaid managed care programs in order to include additional populations previously covered through Medicaid fee-for-service. The new populations include seniors, persons with disabilities, and those who need long-term services and supports— many of whom may be dually eligible. A dual-eligible beneficiary may be able to enroll in a D-SNP and Medicaid MCO that are offered by the same or related companies, an arrangement known as aligned enrollment. In states with MLTSS, aligned enrollment means the same or related companies provide a beneficiary’s Medicare benefits, such as primary and acute care, through a D-SNP and Medicaid benefits, such as long-term services and supports, through a Medicaid MCO. State Medicaid agencies enter into contracts with both D-SNPs and Medicaid MCOs, and these contracts may include provisions to facilitate and encourage aligned enrollment. Since January 2013, all D-SNPs have been required to have an executed contract with the Medicaid agency in each state in which it operates. A state can enter into contracts with all, some, or none of the D-SNPs seeking to operate in the state, and any D- SNPs that the state declines to contract with cannot operate in the state. Each year, CMS reviews D-SNPs’ contracts with states to ensure that they include eight required elements, including the D-SNP’s responsibility for providing or arranging the provision of Medicaid benefits, among other things. According to CMS officials, in these reviews, CMS does not collect information regarding whether states are imposing requirements pertaining to aligned enrollment. States also have contracts with Medicaid MCOs, which can include requirements that could facilitate or encourage aligned enrollment. As shown in table 1, CMS’s Integrated Care Resource Center has identified five types of approaches that states can use to encourage aligned enrollment. For example, states can manage which D-SNPs operate in the state, such as only allowing D-SNPs with an aligned Medicaid MCO (that is, a MCO offered by the same company or a related company). This gives dual-eligible beneficiaries greater options for choosing aligned enrollment. As another example, states can allow the automatic assignment of certain dual-eligible beneficiaries to a D-SNP aligned with a Medicaid MCO, a process known as default enrollment. Default enrollment, which requires CMS approval, can directly increase the number of dual-eligible beneficiaries with aligned enrollment. In addition to D-SNPs with aligned enrollment, two other types of Medicare plans—Medicare-Medicaid plans and Program of All-Inclusive Care for the Elderly plans—exclusively or primarily serve dual-eligible beneficiaries and are responsible for both Medicare and Medicaid benefits. These three types of Medicare plans jointly served approximately 818,000 dual-eligible beneficiaries as of January 2019. Aligned enrollment in D-SNPs: As of January 2019, approximately 386,000 dual-eligible beneficiaries enrolled in D-SNPs had aligned enrollment, according to a report by the Medicare Payment Advisory Commission. This includes beneficiaries in a subset of D-SNPs that have been designated as fully integrated D-SNPs, which must meet additional specific requirements. For example, they must provide both Medicare and Medicaid benefits through a single managed care plan. In addition, the Medicaid benefits provided by the fully integrated D- SNPs must include long-term services and supports. Medicare-Medicaid plans: As of January 2019, approximately 388,000 dual-eligible beneficiaries in nine states were enrolled in these types of plans. These plans, which were established through CMS’s Financial Alignment Initiative, provide all Medicare benefits and all or almost all Medicaid benefits, and have some administrative processes that have been combined. In April 2019, CMS sent a letter to state Medicaid directors inviting additional states to express interest in the use of Medicare-Medicaid plans. Program of All-Inclusive Care for the Elderly plans: As of January 2019, approximately 44,000 beneficiaries in 31 states were enrolled in these types of plans. Most, but not all, are full-benefit, dual-eligible beneficiaries, and they are ages 55 or older and need the level of care provided in a nursing home. The plans are provider-sponsored and provide all Medicare and Medicaid benefits. In addition, each plan is required to have a physical site to provide adult day services. As of July 2019, of the 19 states with MLTSS and where aligned enrollment of dual-eligible beneficiaries in D-SNPs is possible, 16 have implemented at least one of the five approaches to encourage aligned enrollment identified by CMS’s Integrated Care Resource Center. (See fig. 1.) Of those 16 states, 11 managed which D-SNPs operate in the state, which is the foundation for promoting aligned enrollment, according to officials from the Integrated Care Resource Center. Of our seven selected states, all of them had implemented at least one of the five approaches to encourage aligned enrollment in 2019. The three most common approaches among our selected states were (1) managing which D-SNPs operate in the state; (2) limiting D-SNP enrollment to full- benefit, dual-eligible beneficiaries; and (3) encouraging D-SNP marketing to better support informed beneficiary decision-making. The details of the approaches implemented in each state varied widely. Managing which D-SNPs operate in the state. Five of the seven selected states (Arizona, New Jersey, Pennsylvania, Tennessee, and Virginia) managed which D-SNPs operated in 2019, but they varied in how they implemented this approach. For example, when Virginia established its Medicaid MLTSS program in 2017, only one D-SNP operated in the state, and Virginia required the companies with Medicaid MLTSS contracts to also start offering D-SNPs within 3 years. In contrast, when Pennsylvania and Tennessee implemented this approach, multiple D-SNPs already operated in each state. Pennsylvania and Tennessee required new D-SNPs to have aligned Medicaid MCOs, but allowed existing D-SNPs to continue operating. As a result, beneficiaries had the choice between D-SNPs that had aligned Medicaid MCOs and D-SNPs that did not have aligned Medicaid MCOs. Medicaid officials in these two states told us they chose not to cancel existing D-SNPs that did not have aligned Medicaid MCOs, as doing so could have disrupted beneficiary- provider relationships. As a result of the selected states’ differing approaches to managing which D-SNPs operated, the proportion of aligned to unaligned D-SNPs in each state varied. (See fig. 2.) Limiting D-SNP enrollment to full-benefit, dual-eligible beneficiaries. Five of the selected states (Arizona, Kansas, New Jersey, Pennsylvania, and Virginia) limited D-SNP enrollment in some or all of their D-SNPs to full-benefit, dual-eligible beneficiaries in 2019. In particular, Arizona and New Jersey Medicaid officials said that limiting D-SNP enrollment to full- benefit, dual-eligible beneficiaries allowed D-SNPs to provide a more straightforward benefit package. In turn, this can be more easily described in D-SNP materials and communications, which may help beneficiaries to make more informed decisions around aligned enrollment. Encouraging D-SNP marketing to better support informed beneficiary decision-making. Five of the selected states (Arizona, New Jersey, Pennsylvania, Tennessee, and Virginia) took steps to encourage D-SNP marketing to support informed beneficiary decision-making in 2019. For example, Arizona and Pennsylvania encouraged D-SNPs to directly market themselves to beneficiaries in the D-SNP’s aligned Medicaid MCO, in order to promote aligned enrollment. In addition, New Jersey Medicaid officials told us they review D-SNP marketing and work directly with D-SNPs to develop standard marketing language. In particular, the officials said some D-SNPs had marketed themselves as offering certain extra benefits, but those benefits were already a standard part of the state’s Medicaid package. The officials said they worked with the D-SNPs to correct the marketing, and they also developed standard language for marketing in the state. This can help reduce beneficiary confusion when making enrollment decisions. Automatically assigning certain beneficiaries to plans with aligned enrollment. Four selected states (Arizona, Florida, Pennsylvania, and Tennessee) allowed automatic assignment of certain beneficiaries to plans with aligned enrollment in 2019. For example, Arizona, Pennsylvania, and Tennessee allowed default enrollment by which certain Medicaid beneficiaries were automatically assigned to aligned D- SNPs. Under federal rules, beneficiaries have the opportunity to opt out prior to being default enrolled and select a different source of Medicare coverage; they also have the opportunity to disenroll within the first 90 days after default enrollment and select a different source of Medicare coverage. In addition, Florida and Pennsylvania automatically assigned certain dual- eligible beneficiaries to aligned Medicaid MCOs. For example, Florida law requires the state Medicaid agency to automatically assign certain D-SNP enrollees to aligned MLTSS plans when beneficiaries become eligible for long-term services and supports and have not voluntarily chosen an MLTSS plan. Engaging counselors to assist beneficiaries with aligned enrollment decisions. Two of the seven selected states (Arizona and Pennsylvania) engaged enrollment counselors to encourage aligned enrollment in 2019. For example, Arizona’s state Medicaid office works with the state’s Aging and Disability Resource Center and State Health Insurance Assistance Program counselors to increase beneficiary understanding of aligned enrollment and options to enroll in aligned plans. In 2019, Pennsylvania’s contracts with D-SNPs required collaboration between the D-SNPs and the state’s independent enrollment broker that assists beneficiaries with Medicaid enrollment. In addition to there being variation in the selected states’ use of approaches to encourage aligned enrollment, the proportion of D-SNP enrollees with aligned enrollment varied from 20 percent in Pennsylvania to 100 percent in New Jersey among the selected states that were able to provide data for 2019. (See fig. 3.) There can be multiple reasons for the varied levels of aligned enrollment between D-SNPs and MLTSS. For example, Arizona recently entered into new Medicaid MCO contracts, and this resulted in changes to the parts of the state served by each Medicaid MCO. According to state Medicaid officials, these new contracts somewhat reduced the extent of aligned enrollment. Medicaid officials in the seven selected states described various challenges with aligned enrollment. The most common challenge mentioned was difficulty using D-SNP data to implement and evaluate aligned enrollment policies. Medicaid officials in the selected states told us many of these challenges require ongoing monitoring and collaboration with CMS and the companies offering D-SNPs. Difficulty using data to implement and evaluate aligned enrollment. Medicaid officials in six of the selected states (Florida, Kansas, New Jersey, Pennsylvania, Tennessee, and Virginia) told us that using D-SNP and Medicare data to implement and evaluate aligned enrollment policies can be difficult. For example, Tennessee Medicaid officials told us that getting the data from CMS needed for default enrollment was a challenge. In particular, they said that, when the state was first starting to implement default enrollment, they had challenges with getting data from CMS in a timely fashion to identify which Medicaid beneficiaries were about to become dually eligible for Medicare, particularly those with eligibility due to disability. This meant that the state could not provide D-SNPs with the information needed by the D-SNPs to send notices to those beneficiaries in the required time frame. CMS officials also acknowledged that its data do not always identify individuals becoming eligible for Medicare early enough for D-SNPs to send notices in the required time frame. Tennessee Medicaid officials told us that CMS has worked with the state on this issue and it has now become easier for the state to receive the needed data. Furthermore, CMS and its Integrated Care Resource Center have also developed materials and, according to CMS officials, provided ongoing technical assistance for states on accessing data for default enrollment and other aspects of implementation of aligned enrollment. Medicaid officials in Virginia and New Jersey described related challenges with using D-SNP data to determine whether their policies work. Virginia Medicaid officials told us that it can be difficult to evaluate the health benefits of aligned enrollment, because data on quality measures can span multiple states. Specifically, one of the state’s D- SNPs operates in multiple states and therefore reports health outcome data to CMS for its entire service area. Virginia Medicaid officials told us they are not able to separate data for Virginia residents from those of other states. As a result, they said they currently cannot determine the effect of their aligned enrollment policies, and they plan to require the D- SNP to report Virginia-specific quality data in the future. New Jersey Medicaid officials described a challenge with receiving the relevant data to evaluate health outcomes for dual-eligible beneficiaries with aligned enrollment. The state has CMS approval to receive Medicare data directly from CMS. However, as of November 2019, the state’s data vendor was not in compliance with federal Medicare data security requirements for storing certain data, which meant that the state could not accept the Medicare data. The Bipartisan Budget Act of 2018 encourages CMS to require reporting of MA quality measures, including D-SNP quality measures, at the plan level. However, CMS has identified several challenges to developing such a requirement. One challenge CMS has identified is that about two- thirds to three-quarters of D-SNPs would not have reliable ratings, for example, because those plans had too few participants in the survey. Another challenge CMS has identified is the additional complexity and administrative burden for plans completing this reporting. As of December 2019, CMS officials told us they are continuing to work to determine the best reporting level for each quality measure. They also plan to collect additional feedback from stakeholders and a technical expert panel. Difficulties with information dual-eligible beneficiaries receive about Medicare enrollment choices. Medicaid officials in five of the selected states (Kansas, New Jersey, Pennsylvania, Tennessee, and Virginia) told us they have experienced challenges in ensuring that beneficiaries receive quality information about their Medicare enrollment choices. For example, in 2019, Pennsylvania’s contracts with D-SNPs required collaboration between the D-SNPs and the state’s independent enrollment broker that assists beneficiaries with Medicaid enrollment. However, Pennsylvania Medicaid officials told us the state’s independent enrollment broker did not have the capacity to provide this type of assistance in addition to its primary responsibility of assisting beneficiaries with Medicaid enrollment. As another example, Virginia Medicaid officials told us they have faced challenges using state D-SNP contracts to regulate D-SNP marketing. They told us that certain provisions in the state’s contracts with D-SNPs were intended to regulate the extent of D-SNP marketing in 2019. In particular, each D-SNP was supposed to only market to beneficiaries enrolled in that D-SNP’s aligned Medicaid MCO, which was intended to increase the extent of aligned enrollment in the state. However, state Medicaid officials told us that D-SNPs had different interpretations of the contract provisions, and one D-SNP had billboards and television advertisements available to the general public. Due to the difficulty of enforcement, among other reasons, Virginia Medicaid officials told us they chose to not include these provisions in the D-SNP contracts for 2020. Through the Integrated Care Resource Center, CMS has developed materials describing how states can regulate D-SNP marketing in their contracts with D-SNPs, and the agency reviews and may disapprove D- SNP marketing materials that do not follow federal requirements. CMS officials also told us they make themselves available to states to explain how to include marketing restrictions in the contracts that states have with D-SNPs. Limits of staff knowledge. Medicaid officials in four of the selected states (Florida, Kansas, New Jersey, and Pennsylvania) told us that limited staff knowledge of Medicare presents a challenge. For example, Medicaid officials in Kansas told us only one or two staff in the state’s Medicaid agency are knowledgeable about Medicare and would have the knowledge to implement aligned enrollment approaches. Similarly, Medicaid officials in Florida said they only recently learned about one of the approaches for encouraging aligned enrollment, which is that the state can decline to contract with certain D-SNPs. In addition, New Jersey and Pennsylvania Medicaid officials told us staff knowledge of Medicare is limited and that they would like to increase their level of knowledge as they continue to foster aligned enrollment. Competition from look-alike MA plans targeted to dual-eligible beneficiaries. Medicaid officials in four of our selected states (Arizona, Pennsylvania, Tennessee, and Virginia) identified certain MA plans that are so-called “look-alike” plans to the D-SNPs, which create a potential challenge to fostering aligned enrollment. According to CMS, look-alike plans are MA plans that are designed for and marketed exclusively to dual-eligible beneficiaries, but that are not D-SNPs. Therefore, look-alike plans do not need a contract with the state to operate and do not have to comply with state approaches that foster aligned enrollment. Medicaid officials from our selected states and the Medicare Payment Advisory Commission gave examples of the impact of look-alike plans. For example, Tennessee Medicaid officials told us that dual-eligible beneficiaries in look-alike plans do not receive care coordination between Medicare and Medicaid, in contrast with dual-eligible beneficiaries in D- SNPs, which are required to provide such coordination. In addition, Arizona Medicaid officials told us that look-alike plans have affected levels of aligned enrollment in the state. Similarly, according to the Medicare Payment Advisory Commission, look-alike plans can undermine states’ efforts to develop D-SNPs that integrate Medicare and Medicaid by encouraging dual-eligible beneficiaries to instead enroll in look-alike plans. CMS has also identified look-alike plans as a challenge and is considering some steps in response. In 2018, CMS revised its marketing guidelines to prohibit look-alike plans from marketing themselves as designed for dual-eligible beneficiaries and as having a relationship with the state Medicaid agency. In its April 2019 policy update for MA plans, CMS said that look-alike plans enable companies to offer plans that circumvent state and federal requirements for D-SNPs, which undermines efforts to improve the quality of care. In February 2020, CMS published a proposed rule that, if finalized, would prohibit the offering of MA plans whose enrollment of dual-eligible beneficiaries exceeds specific projected or actual enrollment thresholds in states with a D-SNP. According to CMS, this would prevent look-alikes from undermining the statutory and regulatory framework for D-SNPs. Extent of overlapping provider networks. Medicaid officials in two of our selected states (Pennsylvania and Tennessee) reported challenges with aligned D-SNPs and Medicaid MCOs that do not have completely overlapping networks of relevant providers. That is, even though the D- SNP and Medicaid MCO are offered by the same or related companies, certain providers may be in only the D-SNP network or only the Medicaid MCO network—but not both. For example, representatives from a beneficiary group in Pennsylvania told us that a dual-eligible beneficiary’s provider may be in the Medicaid MCO network, but not the D-SNP network. This can disrupt that beneficiary’s continuity of care if he or she is default enrolled into the D-SNP. There are no requirements for the state or D-SNP to ensure that a beneficiary’s primary care provider is in the D-SNP into which he or she is default enrolled. CMS’s model for the notice sent to beneficiaries identified for default enrollment suggests (but does not require) that the D-SNP include information on whether or not the beneficiary’s primary care provider is in the D-SNP’s network. CMS officials said they did not know of any complaints the agency has received on the issue. They also said they have not analyzed how the provider network of a D-SNP compares to the provider network of its aligned Medicaid MCO. Furthermore, in the preamble to the default enrollment final rule issued in April 2018, CMS said that it did not include any criteria related to provider networks, but that network adequacy requirements would apply and states can use their contracts with D-SNPs to create requirements for continuity of care. One state that does this is Tennessee, which specifically requires D-SNPs to develop provider networks that have substantial overlap with the provider network of their aligned Medicaid MCOs. The state also requires D-SNPs to ensure continuity of care for beneficiaries who have been default enrolled. For example, Tennessee Medicaid officials said that if a beneficiary who has been default enrolled has a long-standing primary care provider with the D-SNP’s aligned Medicaid MCO, the state requires the D-SNP to continue covering services by that provider for at least 30 days and to attempt to contract with the provider. CMS has assisted states with aligned enrollment. In particular, CMS has provided technical assistance to states on implementing the various approaches that encourage aligned enrollment. One way that CMS has done this is through its Integrated Care Resource Center, which has developed materials on how states can use their contracts with D-SNPs to align enrollment and promote integration. The Integrated Care Resource Center has also facilitated peer-to-peer assistance between states. For example, Integrated Care Resource Center officials said they facilitated conversations and assistance between state Medicaid officials in New Jersey and Pennsylvania on D-SNP marketing. Medicaid officials in six of our selected states said they had utilized CMS’s technical assistance, and they had overall positive views of CMS’s assistance. CMS reviews some aspects of the contracts between states and D-SNPs, including checking that the contracts include the eight required elements. According to CMS officials, in these reviews, CMS does not collect information regarding whether states are imposing requirements pertaining to aligned enrollment. CMS’s program audits of MA plans similarly do not include reviews of such state requirements pertaining to aligned enrollment. CMS has a direct role with one aspect of aligned enrollment: default enrollment. In particular, CMS approves D-SNPs to receive beneficiaries through default enrollment, and it processes the enrollment transactions of beneficiaries being default enrolled. D-SNPs’ approval for default enrollment: Before a D-SNP can receive beneficiaries through default enrollment, it must submit a proposal to CMS for approval. CMS reviews the D-SNP’s proposal and checks that the D-SNP meets an established list of requirements outlined in regulation. Among other requirements, the D-SNP must demonstrate it has the state’s support for default enrollment and that the required elements have been included in its template for the notice that is sent to beneficiaries identified for default enrollment. CMS also checks that the D-SNP is not facing any CMS enrollment sanctions and that the D-SNP has a quality rating of three or more stars. CMS grants approval for up to 5 years if it determines the D- SNP meets these requirements. Default enrollment transactions: CMS processes the enrollment transactions of dual-eligible beneficiaries being default enrolled, and it tracks these transactions in a monthly report. The monthly report lists the total number of beneficiaries identified for default enrollment for each applicable D-SNP, and the report lists numbers for certain subsets of beneficiaries who were ultimately not default enrolled. These subsets include beneficiaries who opted out prior to being default enrolled and beneficiaries whose default enrollment was not allowed by CMS for various reasons. Despite its direct role in default enrollment, CMS lacks quality information on the experiences of dual-eligible beneficiaries after they are default enrolled. This is inconsistent with federal internal control standards on information and communication, which state that management should use quality information to achieve the agency’s objectives. In particular, the monthly reports on enrollment transactions do not include data on the extent to which dual-eligible beneficiaries choose to disenroll after being default enrolled. Although the reports include data on the number of beneficiaries who opt out prior to being default enrolled (which CMS officials said was low), they do not include data on beneficiaries who choose to disenroll in the first 90 days after being default enrolled. This 90-day time frame for disenrollment is specified by federal regulation, and beneficiaries may choose to disenroll for various reasons. For example, one reason for disenrollment given by one beneficiary group we interviewed is that some beneficiaries may not realize they have been default enrolled into a D-SNP until they next see their provider, and that provider may not be in the D-SNP’s provider network. They said that beneficiaries may not have seen the notice or other information about being default enrolled, or they may not have understood the information. In addition, CMS cannot systematically review beneficiary complaints for trends or concerns related to default enrollment. Dual-eligible beneficiaries, like other Medicare beneficiaries, can submit complaints to CMS. These complaints are entered in the agency’s complaint tracking module, and D-SNP account managers, like other MA plan account managers, are responsible for monitoring complaints. CMS officials said that the D-SNP account managers have not identified any trends or concerns about default enrollment. However, CMS officials said default enrollment is not tracked as a distinct category in the complaint tracking module, and the guidance on monitoring complaints that is provided to the D-SNP account managers does not direct them to look for issues explicitly related to default enrollment. Quality information on the experiences of dual-eligible beneficiaries after they are default enrolled would allow CMS to better identify the extent to which these beneficiaries face challenges as a result of default enrollment and to determine how, if at all, to address the challenges. Future studies may provide CMS with additional information on beneficiaries in D-SNPs with aligned enrollment, but that information will not be available until 2022 or later. In particular, federal law directs the Medicare Payment Advisory Commission, in consultation with the Medicaid and CHIP Payment and Access Commission, to compare the quality of the different types of D-SNPs, including those with aligned enrollment, as well as comparing them to other types of plans. The commission is to develop an initial report by 2022 with subsequent reports afterward. Better care for dual-eligible beneficiaries is one of CMS’s strategic initiatives, and the agency has supported states’ decisions to encourage aligned enrollment in order to encourage better coordination of care. However, CMS lacks quality information on the experiences of beneficiaries who have aligned enrollment as the result of the use of default enrollment. For example, CMS’s monthly reports on default enrollment do not include data on beneficiaries who choose to disenroll after being default enrolled. CMS lacks this information even though selected states and others have reported challenges that could affect the care received by those beneficiaries. Quality information on the experiences of these dual-eligible beneficiaries would allow CMS to better identify the extent to which beneficiaries are facing challenges as a result of default enrollment and to determine how, if at all, to address those challenges. We are making the following recommendation to CMS: The Administrator of CMS should take steps to obtain quality information on the experiences of dual-eligible beneficiaries who have been default enrolled into D-SNPs, such as by obtaining information about the extent to which and reasons that beneficiaries disenroll from a D-SNP after being default enrolled. (Recommendation 1) We provided a draft of this report to the Department of Health and Human Services (HHS) for comment. In its comments, reproduced in appendix I, HHS concurred with our recommendation. HHS stated that it is committed to increasing the number of dual-eligible beneficiaries in integrated care and that it supports states with these efforts, such as the use of aligned enrollment. HHS also said that it has not identified any trends or areas of concern in its monitoring of beneficiaries who opted out prior to being default enrolled. In response to our recommendation, HHS stated it will evaluate opportunities to obtain more information on dual-eligible beneficiaries who disenroll from a D-SNP after being default enrolled. HHS also provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Administrator of the Centers for Medicare & Medicaid Services, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. In addition to the contact named above, Martin T. Gahart (Assistant Director), Corissa Kiyan-Fukumoto (Analyst-in-Charge), Jason Coates, Kelly Krinn, Virginia Lefever, Drew Long, Jennifer Rudisill, and Ethiene Salgado-Rodriguez made key contributions to this report. Medicare and Medicaid: Additional Oversight Needed of CMS’s Demonstration to Coordinate the Care of Dual-Eligible Beneficiaries. GAO-16-31. Washington, D.C.: December 18, 2015. Disabled Dual-Eligible Beneficiaries: Integration of Medicare and Medicaid Benefits May Not Lead to Expected Medicare Savings. GAO-14-523. Washington, D.C.: August 29, 2014. Medicare and Medicaid: Consumer Protection Requirements Affecting Dual-Eligible Beneficiaries Vary across Programs, Payment Systems, and States. GAO-13-100. Washington, D.C.: December 5, 2012. Medicare Special Needs Plans: CMS Should Improve Information Available about Dual-Eligible Plans’ Performance. GAO-12-864. Washington, D.C.: September 13, 2012. Medicare and Medicaid: Implementing State Demonstrations for Dual Eligibles Has Proven Challenging. GAO/HEHS-00-94. Washington, D.C.: August 18, 2000.

Summary: Congress authorized the establishment of D-SNPs in 2003 to address the unique needs of dual-eligible beneficiaries. For example, D-SNPs are required to provide certain specialized services targeted at the needs of dual-eligible beneficiaries, such as health risk assessments. D-SNPs must have approval of state Medicaid agencies to operate, and states can require D-SNPs to coordinate with Medicaid. Congress included a provision in statute for GAO to review D-SNPs’ integration with state Medicaid programs. This report, among other objectives, (1) describes what is known about selected states’ experiences with aligned enrollment in D-SNPs, and (2) examines CMS’s oversight of aligned enrollment. GAO reviewed relevant federal guidance and internal control standards. GAO also interviewed Medicaid officials in seven selected states and reviewed available documentation. The states (Arizona, Florida, Kansas, New Jersey, Pennsylvania, Tennessee, and Virginia) were selected, in part, for variation in experiences with aligned enrollment. GAO also interviewed officials from CMS, beneficiary groups, and companies that offered D-SNPs and Medicaid MCOs. Dual-eligible beneficiaries are Medicare beneficiaries who are also enrolled in the Medicaid program in their state. In certain states, they may receive both types of benefits through private managed care plans. As of January 2019, about 386,000 such individuals were enrolled in both a private Medicare plan known as a dual-eligible special needs plan (D-SNP) and a Medicaid managed care organization (MCO) that were offered by the same or related companies. This arrangement, known as aligned enrollment, may create opportunities for better coordination between Medicare's acute care services and Medicaid's long-term services and supports, such as nursing facility care or personal care services. Medicaid officials in seven selected states described challenges with aligned enrollment. One challenge cited by officials in six of the states was using D-SNP and Medicare data to implement and evaluate aligned enrollment. For example, officials in one state said they cannot separate D-SNP quality data for just their state, because some D-SNPs report data spanning multiple states to the Centers for Medicare & Medicaid Services (CMS). As of December 2019, CMS officials said they are determining the best way for D-SNPs to report these quality data. CMS has assisted states with aligned enrollment, but lacks quality information on the experiences of dual-eligible beneficiaries who have aligned enrollment through a process known as default enrollment. With default enrollment, states allow automatic assignment of beneficiaries who are enrolled in a Medicaid MCO and are about to become eligible for Medicare to the D-SNP aligned with that MCO. However, CMS's monthly reports on default enrollment do not include information on beneficiaries who choose to disenroll in the first 90 days after being default enrolled, a time frame specified in regulation. According to one beneficiary group, some beneficiaries may disenroll, because they did not realize they were default enrolled and their provider is not in the D-SNP's network. Quality information on the experiences of dual-eligible beneficiaries after default enrollment would allow CMS to better identify the extent to which beneficiaries face challenges and to determine how, if at all, to address the challenges. GAO recommends that CMS take steps to obtain quality information on the experiences of dual-eligible beneficiaries who have been default enrolled into D-SNPs. The Department of Health and Human Services concurred with the recommendation.