Apr 19, 2019
Today, over 12 million individuals are enrolled in both Medicaid and Medicare. These “dual eligible” individuals typically have high rates of chronic illness, many with multiple chronic conditions and/or social risk factors.
In a recent letter to state Medicaid directors, the Centers for Medicare and Medicaid services (CMS) outlined ten opportunities to better serve dual eligible populations. These opportunities are the result of new developments in managed care, Medicare data sharing, and reducing administrative burden for dual-eligibles and their providers.
CMS is encouraging states to take advantage of these opportunities to create more seamless experiences for dual-eligibles and to improve how both the Medicare and Medicaid programs work together.
In this edition of Episode Intelligence, Vicki Jessup, director of government relations for Change Healthcare, shares insights into what the opportunities outlined by CMS mean to states, health plans, and their members with Keslie Crichton, VP of sales for Change Healthcare’s member engagement and dual eligible solutions.
In today's show they discuss:
KESLIE CRICHTON: Hi everyone and welcome to this edition of Episode Intelligence. My name’s Keslie Crichton. I’m vice president of sales for Change Healthcare’s member engagement and dual eligible solutions. I’m here today with Vicki Jessup, director of government relations for Change Healthcare. She and the rest of the government relations team are responsible for maintaining relationships with state and federal offices, and driving member advocacy, helping to ensure that our Medicare Advantage health plan members get the benefits that they’re entitled to and often desperately need. Vicki came to us with more than 12 years of Medicaid experience in state and local government. She’s been working with CMS and state Medicaid offices as our government relations director for over seven years. Vicki, welcome to this edition of Episode Intelligence.
VICKI JESSUP: Thank you.
KESLIE: We’d like to talk with you today about the recent CMS letter to state Medicaid directors that outlined many opportunities to better serve dual eligible populations. I’m looking forward to hearing your perspective on the recommendations in the letter and how they can help improve care coordination, data sharing, and reduce the burdens for members, providers, and health plans associated with the administration of these services. First of all, my father told me never to assume anything, so can you tell our listeners exactly who CMS is and what their role is here?
VICKI: Absolutely. CMS is the Centers for Medicare and Medicaid Services. They are the federal agency that provides oversight to both the Medicare and the Medicaid program.
KESLIE: Right. So what is CMS introducing in this letter? And why is it generating such positive attention from not only states, but from our health plans as well?
VICKI: The letter outlines ten opportunities for states to better serve duals who are individuals eligible for both Medicare and Medicaid, and none of them require waivers or complex demonstrations. There are now more than 12 million duals and many have chronic illness and/or social risk factors and they also account for a disproportionate share of expenditures in both programs. So CMS is encouraging states to take advantage of these opportunities to create more seamless experiences for duals and improve how both the Medicare and Medicaid programs work together.
KESLIE: So how do these opportunities impact on Medicare Advantage plans and their members?
VICKI: Well the opportunities outlined in the letter are directed at states, but they’re intended to better serve duals through new developments and managed care using Medicare data to inform care coordination and reducing administrative burden for both members and the providers who serve them.
For example, states are encouraged to pursue what are known as NIPA contracts to promote integrated care. CMS wants to promote alignment between Medicare and Medicaid managed care so that members are getting their benefits through the same parent company. When that’s not possible, CMS wants to ensure plans have procedures in place to coordinate care and assist members to maintain their Medicaid coverage.
CMS highlighted a few examples of the states’ best practices, such as Florida is requiring D-SNP’s to help with annual redeterminations to keep their Medicaid. And there are requirements in Idaho, Minnesota, and New Jersey, and Massachusetts for D-SNP’s to only enroll members who are also in an affiliated Medicaid managed care product. States are also encouraged to approve the new default enrollment option which allows D-SNP’s to enroll a Medicaid managed care recipient into their affiliated D-SNP when they become newly eligible for Medicare.
KESLIE: So there’s a lot going on there. And some of it has caused confusion in the past when the demonstrations for the MMT’s first came out. Some states did some auto assignment into that. Not all states were doing the same thing. I think a lot of members found themselves thinking that they enrolled in one plan and ending up someplace else often because the plan of their choice didn’t also have a D-SNP or an MMT plan on file. So how is this going to roll out in the future? Do you think CMS is going to start auto-assigning more members as these states continue to file their demonstration plans or file for the health plans themselves file more D-SNP’s? Is that going to become more of a common practice?
VICKI: Hard to say. But it seems like they are definitely moving in that direction because they feel so strongly that care needs to be integrated within the same parent company. However, there always are beneficiary protections in place when they do these auto assignments so that if somebody isn’t satisfied with the plan selected for them, they do always have an option to select another plan or go back to fee-for-service Medicare.
KESLIE: One of them was about more frequent submissions of the MMA and the state buy-in files and how that could improve the beneficiary experience. Can you elaborate a little bit more on what that means? What’s an MMA file? And how does moving from a monthly to a weekly to a daily submission of that to CMS, how is that going to help everyone?
VICKI: Absolutely. So, from a member perspective, dual status on that MMA file prompts CMS to deem those individuals into a Medicare part D, low-income subsidy program and auto-enroll them into a Medicare prescription drug coverage back to the start of their dual status, which obviously reduces their cost sharing and improves access to their Medicare covered medications.
Lags in data from states to CMS can cause confusion for these QMB members because the Medicare summary notice they get shows they’re reliable and can be billed for services. So in the worst case scenario a member may limit the need for services because they perceive they may have a financial obligation to the provider. So for particularly or members who are newly dually eligible, the more frequent data exchange helps states facilitate enrollment into integrated products earlier.
Now from a provider and state perspective, data lags can also cause confusion on the ground about out-of-pocket obligations for QMB’s. So the sooner a dual transitioning from a Medicaid drug coverage to Medicare part B drug coverage gets enrolled into the Medicare drug plan, the fewer claims get paid erroneously by the state and the fewer they have to recoup from pharmacists who would then have the burden of reaching out to reconcile with a part B plan.
Finally, if there’s some data error such as transposed numbers and there’s back and forth needed between CMS and the state to straighten it out, there’s a better chance of getting it fixed before the start of the next month if there’s a more frequent transmission of these files. I did ask CMS about state frequency back in January and they told me that 13 states are currently submitting monthly. 24 states and DC submit weekly. And then 13 states are already submitting daily.
I do have the list of all of the states and their file submission frequencies, so if any of our listeners would like that detail for their state they can contact me. And I’d also like to note that on February 11th, CMS issued a proposed rule that would require all states to submit files daily. So, if these rules are finalized as written, those changes would take effect in April 2022.
KESLIE: Wow. So, if I under this correctly so something that we’ve been doing I think for low-income subsidies is a wonderful benefit for members. And historically I thought CMS was getting that approval out after we submit the application to social security administration. So, does that mean that this notification then from SSA to the state to CMS is going to all be moving faster so the benefits will actually get turned on and be able to be realized faster for that member?
VICKI: That’s exactly it. So when states inform CMS of somebody who’s dual, they run an overnight batch to deem that individual into the low-income subsidy. So in states that are transmitting this information daily that LIST deeming is occurring overnight. Whereas, if a state is submitting that information about duals monthly, it’s the deeming isn’t going to occur. You know there’s going to be a lag in that deeming. It wouldn’t occur until the night that they receive that. So that’s the reason CMS is really encouraging all states to submit as frequently as possible. And they’re proposing that all states be required to submit daily.
KESLIE: So one of the other points in the letter was around the Part A buy-in enrollment. And this is really interesting to me because I don’t think it’s widely known or widely taken advantage of, so can you tell us what a Part A buy-in means? And how that could produce savings for I don’t think so much the member but definitely for a health plan and for the state.
VICKI: Absolutely. So when a state has a Medicare buy-in agreement for Part A that’s going to facilitate the enrollment of the Medicare premiums by states on behalf of their Medicaid recipients. It removes enrollment period restrictions and late enrollment penalties. So the faster enrollment in Part A produces savings for the states and the plans because Medicare becomes the primary payer especially for expensive inpatient hospital and skilled nursing facility services.
KESLIE: So I’ve heard of also there’s quite a long list of states that don’t have a Part A buy-in. But I’ve also heard that members have gone to the state Medicaid office in a state with a buy-in agreement and the staff doesn’t necessarily know or isn’t familiar with the process or that they even have a buy-in agreement. Is there any advice that you could give for these health plans or how they could advise their members on how to get enrolled in this and how to push forward?
VICKI: I agree that it’s not a well-known process. I think that there isn’t a lot of knowledge of it at social security sometimes or within states. There is a lot of confusion. What’s the solution? It’s just education really I think.
KESLIE: So I again the buy-in enrollment could really produce some savings for a Medicaid plan. So if I understand this correctly, a Medicaid plan that’s receiving a managed Medicaid plan that’s receiving capitation from the state, for those members that have a Part A enrollment into Medicare the cost of those claims would be billed to fee-for-service Medicare. Right? And not come out of the capitation. Is this something that they can do themselves? How do they target members? Would be aging in and then is there state files that show members that could be potentially eligible for Part A?
VICKI: It’s my understanding that CMS is communicating that information to health plans in terms of upcoming Medicare enrollment. So, to the extent that these health plans can reach out to these members and help them with the process of getting signed up for Medicare Part A, particularly in states that have these buy-in agreements, because in states that don’t have these agreements they can only sign up for Medicare Part A during that annual, general enrollment period which is usually January through March. And then, even when they sign up during that GEP, the coverage begins July 1st. So, in the 36 states that have the buy-in agreement, they can enroll in Part A at any time and the coverage won’t wait to start until July 1st.
KESLIE: That’s awesome. I think we need to explore this more and how we can help plans and members to take advantage of this. So more coming up on that in another episode. Lastly, I think there’s one more point that would be important to talk about. So CMS is encouraging states to simplify eligibility and enrollment processes specifically for Medicare savings programs. Can you provide some examples of what states have done so far? Different reasons why states should not pursue this? Talk to us a little bit more about the policy.
VICKI: Sure. Historically, the Medicare savings programs have had low enrollment rates. The CBO estimated in 2004 that only one-third of eligible individuals were enrolled in QMB. And an even smaller percentage were enrolled in the SLMB, which is the specified low-income Medicare beneficiary program.
The difference between how income and assets are counted for, the low-income subsidy in the Medicare savings program makes it difficult for some states to act on the applications that they get for MSP from social security without requiring additional information and verification from applicants which is a step that requires a lot of additional work by states and can also present a barrier to enrollment for members. So aligning those methods for determining income and assets for the Medicare savings programs with those of the low-income subsidy is an option that’s currently available to all states.
But unfortunately, only a few states have used that flexibility. For example, Alabama, Mississippi, Vermont, and then DC they’ve eliminated the asset limit for the Medicare savings programs in their state and they also don’t count in kind income. So anyone who resides there and qualifies for the low-income subsidy will also automatically qualify for Medicare savings programs. However, in most states, there’s going to be differences between the income and asset rules for LIS and MSP. So even though somebody may qualify for LIS in some states, they’re not going to qualify for MSP because of those difference in the rules of how income and assets are counted between those programs. So CMS is encouraging in this letter states to align the requirements to the extent possible so that anyone who qualifies for LIS in that state will also qualify for MSP.
KESLIE: Do you think there’s any chance that CMS will just standardize eligibility requirements across all states?
VICKI: They really can’t. States have their own rules about income and assets and how they’re going to count it in their laws and in their Medicaid state plan. So CMS I don’t think has the authority to dictate them changing the rules. They can encourage it, but they can’t require it.
KESLIE: And do you think there will be any standardization for the recertification of these benefits especially as I consider that a lot of states more and more have access to third-party verification of income and assets? Do you see that becoming more prevalent and the use of it to have more of a passive recertification?
VICKI: Yes. States are definitely moving in that direction. And as you mentioned, especially to the extent that they implement asset verification systems, which they are required to do and many states have already implemented those systems. The rest of the states I think are in some process of implementing AVS’s. But yeah, they’re moving in the direction of electronic verification and to the extent that they can use these sources to confirm that somebody continues to qualify for the benefit will mean the less somebody has to do to prove that. It’ll significantly reduce the verification burden and the paperwork that has to go back and forth between states and members to complete the renewal process.
KESLIE: Well thank you. Vicki, thank you so much for your thoughts. We really appreciate your expertise. We hope that you’ll join us again. I think there’s a lot more to explore on this and you always have your kind of your ear to everything that’s going on at the state and federal level. So we really appreciate these updates. The policy changes, the important developments, they impact not only our members but our health plan partners as well. And so I think this is always useful information to everybody that might be listening.
That’s it for this edition of Episode Intelligence. Be on the lookout for other topics regarding dual eligibility, maternal health education, ways to boost member tenure, and improve quality and risk adjusted revenue. This is Keslie Crichton for Change Healthcare. Have a good day.