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The Affordable Care Act creates an office within the Centers for Medicare & Medicaid Services (CMS) whose focus is beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles).[1]  Specifically, the Federal Coordinated Health Care Office (CHCO) is created for the purposes of:

1. more effectively integrating benefits under Medicare and Medicaid for those dually eligible for both programs; and

2. improving coordination between the federal and State governments concerning both programs to ensure that such individuals get full access to the items and services to which they are entitled under titles XVIII and XIX of the Social Security Act. (Emphasis added.)[2]

Such an office – with a beneficiary-centered focus -- has promise for addressing long-standing issues that have plagued programs serving dual eligibles and that have likely contributed to such programs being under-subscribed by those who are eligible, as well as not providing full benefits for those who are enrolled.  These problems affect the roughly 80- 85% of dually eligible Medicare beneficiaries in traditional Medicare, as well as the 15 - 20% in Medicare Advantage plans.

The office also holds promise for evaluating myriad delivery systems, including but not limited to managed care programs, that have been developed over several decades to address policy and payment issues that may adversely affect dual eligibles' access to high quality care, and for promoting the use of systems that appear to be effective and replicable.

Beneficiary Advocacy for a Strong CHCO

Ten organizations[3] working on behalf of Medicare and Medicaid beneficiaries, including the Center for Medicare Advocacy, submitted recommendations for the work of the CHCO to the Directors of the Center for Medicare (Jonathan Blum), the Center for Medicaid, CHIP[4] and Survey & Certification (Cindy Mann) and the Center for Strategic Planning (Anthony Rodgers).  This Alert summarizes and highlights recommendations from that paper.[5]

The organizations assert that CHCO's agenda should start with a promise of real improvements in how care is delivered to dual eligibles, addressing longstanding access and eligibility issues that need to be remedied and deserve the full attention of the new office. The paper notes that the small percentage of dual eligibles in Medicare Advantage plans (and slightly larger percentage in Medicaid managed care) is evidence that most private plans have little experience with serving dual eligibles and that few dual eligibles have experience in managed care. It emphasizes that CHCO's efforts should not be limited to experimenting with new models for integrating and organizing care. 

The organizations identify specific priorities for CHCO:

1.  Increase Enrollment in the Medicare Savings Programs (MSP) and the Low Income Subsidy (LIS)

The CHCO should promote coordination of application pathways among federal health, nutrition and energy assistance programs.  This could begin with better oversight and enforcement of the provisions of the Medicare Improvements for Patients and Providers Act (MIPPA) that increase the level of protected assets for Medicare Savings Programs and require state Medicaid agencies to accept as an MSP application any data sent by the Social Security Administration (SSA) at a beneficiary's request.

The CHCO should encourage states to align their MSP eligibility criteria with those of the LIS.  This can be done through a provision in Medicaid law that allows states to use eligibility criteria that are more generous than those dictated by federal law for the Medicaid program. CHCO could also promote real time data exchanges between the states, CMS and SSA to increase the efficiency and speed of enrollments into MSP, LIS and Part D prescription drug plans.

2.  Develop and Test Integration and Coordination Models

CHCO should evaluate the effectiveness of current managed care plan models, and address problems with those models. For example, advocates have noted persistent problems with some Medicare Advantage Special Needs Plans for Dual Eligibles (D-SNPs) including insufficient networks of providers that accept both Medicaid and Medicare, provider billing issues (inappropriate billing of beneficiaries by providers), a lack of access to required "models of care" (not available on plan websites or even by request) and benefit packages that are not tailored to the needs of the target "special needs" population.

CHCO must recognize that a "one-size-fits-all" approach will not work.  CHCO should support managed care plan models that have a proven track record of improving outcomes.  CHCO should invest in systems that can be made available to duals outside of managed care delivery systems, such as medical homes and primary care case management.  Moreover, CHCO should recognize that not all successful models are replicable nationwide.

CHCO should assist states, and work with advocates, to promote access to long-term supports and services in the least restrictive and appropriate setting for functionally and cognitively impaired dual eligibles.

3.  Employ a Deliberative, Transparent Process for Implementing and Evaluating Models

Successful models, such as Programs of All Inclusive Care for the Elderly (PACE), have taken years to design at the local level with key input from beneficiaries and coordination between various branches of CMS.  Key elements of a transparent and inclusive process would include:

• Formal beneficiary input into the activities of the office.

• Clear procedures for considering, approving, implementing and evaluating models, pilots, demonstrations, and other experiments, with relevant materials available on-line.

• Coordination with the Medicaid waiver approval process and with the Center for Medicare and Medicaid Innovation.

• Coordination with the Part D/Medicare Advantage group at CMS.

4.  Adopt Appropriate Consumer Protections for All Delivery Systems

Such protections include:

• No reduction in benefits.  Where Medicare and Medicaid use different coverage standards for providing the same benefit, all delivery systems must ensure beneficiaries access under the more favorable standard.

• Access to the most favorable standard relating to notice and appeal rights.  For example, Medicaid beneficiaries are entitled to have their care continue pending an appeal, but most Medicare beneficiaries are not so entitled.  The right of continued care should apply.

• Enrollment rights that maintain beneficiaries' freedom of choice and provide opportunities to make enrollment changes as necessary.

• Transition protections that ensure access to providers and treatments as beneficiaries enroll and disenroll from integrated and coordinated care models.

• Linguistically and culturally appropriate information and care.

• Adequate provider networks and processes to seek exceptions to network requirements.

• Clear standards for care coordination and assessments to ensure that models purporting to provide such services actually deliver these important benefits.

5.  Ensure that All Integrated Models, as well as Traditional Medicaid and Medicare, Deliver the Full Benefits of Both Programs.  

Specific recommendations for addressing current issues that affect dual eligibles' access to care include:

• Enforce current rules and regulations regarding billing of dual eligibles. Providers (in both the traditional Medicare program and Medicare Advantage plans) need to know they are prohibited from billing Qualified Medicare Beneficiaries (QMB); they also need an easy way to bill Medicaid if they do not regularly participate in the Medicaid program. Such systems exist in a few states but are not widely used by states and are often not known by providers. CHCO should make sure states know they are supposed to have such systems and help the states set them up; CHCO should clearly communicate providers' responsibilities toward QMBs.  CHCO should ensure greater oversight by CMS of plans' provider networks and of improper billing of dual eligibles.
• Refine Part D auto-enrollment and deeming for dual eligibles.  Dual eligibles continue to face instability in the Part D program, struggling to transition both during the initial enrollment and annually as plan offerings change.  CHCO should join and expand existing efforts to study the feasibility and potential design of intelligent assignment, taking into account formulary coverage of drugs prescribed to new dual eligibles and other LIS beneficiaries who are auto-assigned to Part D plans.
• Resolve differences in Medicare and Medicaid benefits, coverage standards and appeal rights and prevent the creeping of more restrictive Medicare standards into the Medicaid program and vice versa.
• Examples of such differences include:
  • Home health care: Medicare requires beneficiaries to be "confined to the home" to receive home health services; Medicaid prohibits use of such a standard. CHCO should ensure that all states adhere to this prohibition.
  • Nursing home care: Medicare covers skilled nursing care; Medicaid covers both skilled nursing care and other nursing care.  CHCO should promote full certification for both programs of all certified nursing home beds.
  • Therapy caps: Medicare places a dollar limit on therapy services within a year; Medicaid has no such limit, but individual states may cap numbers of visits or require prior authorization.  CHCO should promote best practices for optimizing coverage under both programs to ensure that dual eligibles get the full range of therapy services available.
  • Aid Paid Pending: Medicaid law requires that services continue pending an appeal; Medicare does not.  Such protection is critical to low-income individuals.  CHCO should ensure that duals have such protections regardless of the delivery system through which they get care.
  • Increase dual eligibles' access to home and community based services by ensuring that integration/coordination efforts contain strong incentives toward the provision of home and community-based services.

6.  Learn More about Dual Eligibles and Current Access Problems. 

Before addressing any of the above, CHCO must obtain or develop good data about dual eligibles, which are not now generally available.  These data will provide an understanding of who dual eligibles are and the challenges they face and will provide a baseline for evaluating the success of various efforts undertaken by the office.  Data needed include:

• The number of dual eligibles and their categories;

• The extent to which duals are in Medicaid managed care, Medicare Advantage Special Needs Plans, other Medicare Advantage plans, PACE, etc;

• The percentage of providers in Medicare Advantage plans that are Medicaid providers and the percentage of providers in Medicaid managed care that are Medicare providers;

• Information on what benefits (both medical and non-medical) for full dual eligibles are not covered by Medicare, but are covered by state Medicaid programs;

• State-by-state provider rates in Medicaid compared to Medicare's rates for services provided to duals.

The ten organizations plan to further refine their recommendations by offering specific steps for action relating to the issues they have raised.