Working with Medicare Medicare 101 and 201: Key Issues for ... · Webinar Series • Designed for states: ... in Medicare managed care for at least part of the year, vs. 26 percent

The Integrated Care Resource Center, an initiative of the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination Office, provides technical assistance for states coordinated by Mathematica Policy Research and the Center for Health Care Strategies.

Working with Medicare Medicare 101 and 201:

Key Issues for States January 28, 2016

1:00-2:00 PM Eastern Time

Presenters

• Danielle Chelminsky • Ann Mary Philip • James Verdier

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Agenda

• Dually Eligible Beneficiaries: Characteristics, Service Use, and Spending

• Managed Care for Dually Eligible Beneficiaries • Selected Overlapping Payment and Coverage Issues

• Medicaid payment of Medicare beneficiary cost sharing

• Coordination of care for overlapping benefits

• Appendix: Key Medicare-Medicaid Resources • Questions and Answers

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The “Working with Medicare” Webinar Series • Designed for states:

• Implementing financial alignment demonstrations • Contracting with or interested in pursuing contracts with Medicare Advantage

(MA) Dual Eligible Special Needs Plans (D-SNPs) to coordinate care and services for dually eligible beneficiaries

• Pursuing another Medicare-Medicaid integrated care platform

• Webinars are repeated annually: • Winter – Medicare 101 and 201 • Spring – Medicare and Medicaid Nursing Facility Benefits • Summer – Coordination of Medicare & Medicaid Behavioral Health Benefits • Fall – Update on State Contracting with D-SNPs

• Supplemented by: • ICRC updates/e-alerts on important new Medicare information • ICRC technical assistance briefs on Medicare issues of importance to states

• Recordings available here: http://www.integratedcareresourcecenter.net/technicalassistance.aspx • Sign up and view past e-alerts here: http://www.integratedcareresourcecenter.net/subscribe.aspx

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Dually Eligible Beneficiaries: Characteristics, Service Use,

and Spending

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Profile of Dually Eligible Beneficiaries • In 2015, 10.2 million Americans were enrolled in both Medicare and

Medicaid (“dually eligible beneficiaries” or “Medicare-Medicaid enrollees”)

• 72% were full-benefit dual eligible (FBDE) enrollees, and the rest were partial-benefit (Medicaid paid only Medicare beneficiary premiums and/or cost sharing)

• Population characteristics in 2011: • 59% were age 65 or older and qualified as a result of age and low income/assets

• 41% were under age 65 and qualified as a result of physical and/or mental disabilities and chronic illnesses, as well as low income/assets

• Medical conditions and Alzheimer’s/dementia were more common in over-65 enrollees; behavioral health conditions and intellectual disabilities were more common in those under 65

• 44% of fee-for-service (FFS) FBDE enrollees used Medicaid long-term services and supports (LTSS)

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Sources: MMCO Analytic Reports and Data Resources, Medicare-Medicaid Enrollee State and County Enrollment Snapshots, March 2015; MedPAC-MACPAC Data Book, “Beneficiaries Dually Eligible for Medicare and Medicaid,” January 2016.

Dually Eligible Beneficiaries: Enrollment and Spending Trends • Enrollment: Trends between 2007 and 2014:

• Similar enrollment growth between all (full and partial) dually eligible beneficiaries (29%) and Medicare-only beneficiaries (21%)

• Larger enrollment growth in partial-benefit dually eligible beneficiaries (64%) compared to FBDE enrollees (19%)

• Larger enrollment growth for FBDE enrollees under age 65 (20%) compared to those over age 65 (8%)*

• Enrollment of FBDE enrollees in Medicare managed care grew from 8% to 20%.*

• Spending: In CY 2011, federal and state governments spent $294 billion on all dually eligible beneficiaries:

• 35% of total spending for Medicare, and 33% for Medicaid • Dually eligible beneficiaries accounted for 20% of Medicare enrollees

and 14% of Medicaid enrollees

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Sources: MMCO Analytic Reports and Data Resources, Medicare-Medicaid Enrollment and Snapshots (2007-2014), March 2015; MMCO Data Analysis Brief, “Medicare-Medicaid Dual Enrollment from 2006 through 2013,” December 2014; MedPAC-MACPAC Data Book, January 2016, Exhibits 3 and 4. * Enrollment trends from 2007-2013.

• Medicare eligibility requirements: • Age 65 and older with 10 years of Medicare-covered employment, or • Under age 65 and have a permanent disability (received SSDI benefits for at least two

years), or • Diagnosed with end stage renal disease (ESRD)

Pathways to Medicare Eligibility

Original Reason for Medicare Entitlement % of Medicare Beneficiaries (N)

Age 46.7% (3.6M)

Disability 40.8% (3.1M)

Unknown 11.3% (0.9M)

ESRD or Disability and Current ESRD 1.1% (0.1M)

Total 100% (7.7M)

Source: MMCO Data Analysis Brief. “Medicare-Medicaid Dual Enrollment from 2006 through 2013.” December 2014.

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• Medicaid eligibility requirements: • Must meet both categorical eligibility (for example, aged and/or disabled), and • Income and asset limits (determined by the state)

• In most cases, these limits are linked to the SSI program

Pathways to Medicaid Eligibility for FBDE Enrollees

Eligibility Group % of FBDE Enrollees (N)

QMB Plus 71.5% (5.5M)

Other FBDE Enrollees 24.8% (1.9M)

SLMB Plus 3.7% (0.3M)

Total 100% (7.7M)

QMB = Qualified Medicare Beneficiary SLMB = Specified Low-Income Medicare Beneficiary Source: MMCO Data Analysis Brief. “Medicare-Medicaid Dual Enrollment from 2006 through 2013.” December 2014. 10

• Medicaid eligibility requirements: • Must meet both categorical eligibility (for example, aged and/or disabled), and • Income and asset tests (determined by the state, with federal minimums)

• In most cases, these limits are linked to the SSI program

Pathways to Medicaid Eligibility for Partial-Benefit Dually Eligible Beneficiaries

Eligibility Group % of Partial-Benefit Dually Eligible Beneficiaries (N)

QMB-Only 47.0% (1.4M)

SLMB-Only 34.0% (1.0M)

Qualified Individuals 19.0% (0.6M)

Total 100% (3.0M)

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QMB = Qualified Medicare Beneficiary SLMB = Specified Low-Income Medicare Beneficiary Source: MMCO Data Analysis Brief. “Medicare-Medicaid Dual Enrollment from 2006 through 2013.” December 2014.

Medicare Coverage

Part A Part B Part C Part D

Benefits

Inpatient hospital stays, care in a skilled nursing facility, hospice care, some home health

Physician and outpatient services, medical supplies, preventive services

Medicare Advantage (Medicare managed care): includes Parts A, B, and D

Prescription Drugs

Costs

• Free, with 40 credits of Medicare-covered employment

• Deductible

• $121.80 premium (new enrollees in 2016)

• 20% co-insurance

• Part B premium • Plan premium • Cost sharing

• Premium • Deductible • Cost sharing • Coverage gap

For more details, refer to slides 41 and 42 for links to these resources: • July 2013 ICRC “Medicare Basics” TA brief, Table 1 and Appendix A. • January 2016 MedPAC-MACPAC Data Book, Tables 2 and 3

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Distribution of Spending For Medicare –Medicaid Enrollees by Service, CY 2011

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Percent Using Service and Per-User Spending, CY 2011 FBDE Enrollees in FFS

* Payments to limited-benefit managed care plans for behavioral health, transportation, and/or dental services. Source: MedPAC–MACPAC Dual Eligible Data Book, January 2016, Exhibits 14 and 15.

Medicare Medicaid

Service % Using Service $ Per User Service % Using Service $ Per User

Inpatient Hospital 28% $18,708 Inpatient Hospital 14% $2,115

Other Outpatient 94% $5,904 Outpatient 87% $2,390

Skilled Nursing Facility 11% $19,467 Institutional LTSS 21% $41,789

Home Health 14%

$5,906

HCBS Waiver 14% $29,511

HCBS State Plan 14% $10,020

Part D Drugs 92% $4,976 Drugs 50% $277

- - - Managed Care Capitation* 32% $2,391

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Condition Percent of FFS Dually Eligible Beneficiaries Under age 65 Age 65 and older

COGNITIVE IMPAIRMENT Alzheimer’s disease or related dementia 3 23

Intellectual disabilities and related conditions 8 1

MEDICAL CONDITIONS Diabetes 22 35

Heart failure 8 23

Hypertension 39 66

Ischemic heart disease 14 34

BEHAVIORAL HEALTH CONDITIONS Anxiety disorders 21 12

Bipolar disorder 14 3

Depression 31 21

Schizophrenia and other psychotic disorders 13 7

FFS Dually Eligible Beneficiaries With Selected Conditions, CY 2011

Source: MedPAC–MACPAC Dual Eligible Data Book, January 2016, Exhibit 8.

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Managed Care for Dually

Eligible Beneficiaries

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Type of Medicare Enrollment

Percent of Dually Eligible Beneficiaries Enrolled Non-Dual Medicare

beneficiaries All Under age 65

Age 65 and older

Full benefit

Partial benefit

FFS only 78 84 74 82 68 74

MA only 18 12 22 14 28 25

Both FFS and MA 4 4 4 4 4 1

Medicare Fee-For-Service and Managed Care Enrollment, CY 2011

Note: Includes all dually eligible and non-dually eligible beneficiaries. Percentages may not sum to 100 due to rounding.

Source: MedPAC-MACPAC Data Book, “Beneficiaries Dually Eligible For Medicare and Medicaid:,” January 2016 Exhibit 11.

In 2011, 22 percent of dually eligible beneficiaries were enrolled in Medicare managed care for at least part of the year, vs. 26 percent of other Medicare beneficiaries.

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Type of Medicaid Enrollment

Percent of Dually Eligible Beneficiaries Enrolled Non-Dual Medicaid

Beneficiaries (disabled,

under age 65) All

Under age 65

Age 65 and older

Full benefit

Partial benefit

FFS only 58 58 59 45 94 27

FFS and limited-benefit managed care only 28 28 28 37 4 28

At least one month of comprehensive managed care

14 15 13 18 2 45

Medicaid Fee-For-Service and Managed Care Enrollment, CY 2011

Note: Includes all dually eligible beneficiaries. The non-dual Medicaid beneficiary category excludes nondisabled Medicaid beneficiaries under age 65 and Medicaid beneficiaries age 65 and older who do not have Medicare coverage. Percentages may not sum to 100 due to rounding.

Source: MedPAC-MACPAC Data Book, “Beneficiaries Dually Eligible For Medicare and Medicaid,” January 2016, Exhibit 12.

In 2011, 14 percent of dually eligible beneficiaries were in comprehensive Medicaid managed care for at least one month, as compared to 45 percent of other Medicaid beneficiaries with disabilities or over age 65.

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• MA plans • Usually combined with Part D prescription drug coverage (MA-PD

plans)

• MA SNPs for specified populations: • Beneficiaries with specified severe and disabling chronic conditions

(C-SNPs) • Beneficiaries who live in long-term care institutions or who have an

institutional level of care need (I-SNPs) • Beneficiaries dually eligible for Medicare and Medicaid (D-SNPs)

• Medicare-Medicaid Plans (MMPs): • Operate in states participating in the CMS Financial Alignment

Initiative capitated model (CA, IL, MA, MI, NY, OH, RI, SC, TX, and VA)

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Medicare Managed Care Options for Dually Eligible Beneficiaries

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Level of Integration of MA Plans MA* D-SNP MMP**

State Contracting Involvement None

Must have a contract with the state that includes minimum Medicare Improvements

for Patients and Providers Act (MIPPA) requirements

3-way contract between plan, CMS, and state

Medicaid Benefits Covered None

Capitated coverage not required. At state option, coverage can range from Medicare

cost sharing and wrap-around Medicaid benefits to all Medicaid covered benefits

including LTSS and behavioral health

Medicare cost sharing, wrap-around Medicaid benefits, and LTSS; may include behavioral

health

Level of Medicare and Medicaid

Alignment None

Minimum responsibility to coordinate delivery of Medicare and Medicaid services; may include option for beneficiaries to enroll

in aligned D-SNPs and Medicaid plans operated by the same company, and

coordination of enrollment, materials, appeals, etc.

Extensive, including unique joint state and federal

oversight and financing

* As of January 2016, there were 485 MA and MA-PD contracts with 16.9 million enrollees. ** As of January 2016, there were 60 MMP contracts with 382,705 enrollees. MMP operation is limited to areas covered under CMS-approved financial alignment demonstrations.

Note: There were also 72 stand-alone prescription drug plan (PDP) contracts as of January 2016, with 24.3 million enrollees. PDPs provide drug coverage when Medicare beneficiaries are in Original Medicare.

• D-SNPs are required by federal law (MIPPA) to have contracts with states: • Contracts must contain some specific features, but states can add others (42 CFR

§422.107) • Minimum requirements include D-SNP responsibility to provide or arrange for Medicaid

benefits, beneficiary cost sharing protections, information sharing, eligibility verification, service area covered, and contract period

• ICRC prepared a technical assistance (TA) tool in February 2015 that analyzed 2014 D-SNP contracts in selected states (AZ, FL, HI, MA, MN, NJ, NM, OR, PA, TN, TX, and WI): http://www.chcs.org/media/ICRC-Issues-and-Options-in-Contracting-with-D-SNPs-FINAL.pdf

• November 2015 ICRC Working with Medicare webinar titled “Update on State Contracting with D-SNPs” provides a summary and update of the February TA tool: http://www.integratedcareresourcecenter.com/PDFs/ICRC%20-%20WWM%20D-SNP%20Contracting%20Slides.pdf

• ICRC is currently preparing a full update of the February 2015 TA tool

• For contract year 2016, there are 350 D-SNPs with total national enrollment in January of 1.73 million

• D-SNPs operate in 38 states and the District of Columbia and Puerto Rico, but three-quarters of January enrollment was in 11 states (FL, CA, NY, TX, PA, AZ, TN, AL, GA, MN, and MA)

• 16% of total enrollment was in PR

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State Medicaid Agency Contracts with D-SNPs

21 Source: CMS SNP Comprehensive Report, January 2016.

State Number of D-SNP Plans Total D-SNP Enrollment

Puerto Rico 14 273,084 Florida 58 228,580 New York 36 195,012 California 32 148,041 Texas 25 126,975 Pennsylvania 11 109,406 Arizona 21 79,642 Tennessee 7 78,851 Alabama 4 50,815 Georgia 9 49,873 Massachusetts 7 37,469 Minnesota 9 36,891 Louisiana 9 30,503 Washington 6 23,627 South Carolina 3 23,428 Oregon 7 22,409 Wisconsin 13 21,175 Hawaii 6 19,921 North Carolina 7 19,392 Ohio 11 15,545 Mississippi 4 14,320

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D-SNP Enrollment by State, January 2016

Source: CMS SNP Comprehensive Report, January 2016. 22

State Number of D-SNP Plans Total D-SNP Enrollment

Arkansas 4 13,570 New Jersey 4 13,364 New Mexico 4 12,900 Connecticut 2 12,382 Michigan 4 11,608 Illinois 5 11,307 Missouri 3 10,586 Colorado 4 9,025 Utah 2 8,168 Kentucky 8 5,917 Washington DC 3 5,532 Maryland 3 2,884 Maine 2 2,443 Delaware 1 1,996 Idaho 1 1,936 Virginia 2 1,751 Indiana 3 1,476 West Virginia 1 251 Montana 1 36 TOTAL1 356 1,732,088

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D-SNP Enrollment by State, January 2016

Source: CMS SNP Comprehensive Report, January 2016.

1 Five Plans spanned across multiple states. In this table, we divided the number of enrollees in those plans evenly across the states and added the plan to each state’s total number of D-SNP. The total excludes 35 enrollees in plans with fewer than 11 enrollees.

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• Medicare Advantage enrollment periods: • Open Enrollment Period: October 15 to December 7

(coverage begins January 1) • Special Enrollment Period:

• Available all year for dually eligible beneficiaries; can enroll or disenroll at any time

• Also available if a person moves out of a plan’s service area, if enrollee’s plan leaves the Medicare program, and in other special situations

• For more details on all Medicare enrollment periods, including initial enrollment, Original (FFS) Medicare, and Part D, see July 2013 ICRC “Medicare Basics” TA brief (Table 2). Available at: http://www.integratedcareresourcecenter.net/PDFs/ICRC%20Medicare%20Basics.pdf

Medicare Advantage Enrollment Periods

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Key Medicare Advantage Dates (Important dates for states are shown in bold)

* MIPPA = Medicare Improvements for Patients and Providers Act

January February March April May June

• Jan 1st enrollment effective date

• Annual LIS Medicare Part D reassignment occurs

• Release of Medicare Advantage (MA) plan applications

• MA applications due to CMS (e.g., due Feb 17, 2016 for CY 2017)

• CMS release of Advance Notice of MA payment policies and draft Call Letter

• MedPAC and MACPAC release reports to Congress

• CMS release of Final Call Letter and MA capitation rates

• CMS launches the plan benefit package (PBP) module

• Mid-year Medicare Star ratings released (annually each Spring)

• Deadline for MA organizations to submit bid and PBP for upcoming year

• MA organizations not renewing MA contracts must notify CMS in writing

July August September October November December

• MA organizations must submit MIPPA* D-SNP contracts to CMS by July 1

• D-SNPs work with CMS and states to address deficiencies in State Medicaid Agency (SMA) contracts

• D-SNP approval letters sent by CMS

• Annual notice of change/ evidence of coverage due to current enrollees

• Start of Medicare Annual Election Period (Oct 15th)

• Final Medicare Stars ratings for upcoming year go live on Medicare.gov

• Notice of intent to apply from D-SNP applicants (NOIA) due to CMS (e.g., due in Nov 2016-Jan 2017 for CY 2018)

• End of Medicare Annual Election Period (Dec 7th)

Selected Overlapping Payment and Coverage Issues

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• Similar to private insurance with deductibles, coinsurance, and copayments

• Amounts specified each year for Original (FFS) Medicare: • Part A deductible ($1,288 in 2016) and coinsurance for inpatient stays • Part B deductible ($166 in 2016) and coinsurance of 20% of Medicare-

approved amount for most services

• MA plans may charge less

• Medicare Savings Programs (MSPs) • Low-income Medicare beneficiaries who meet state

Medicaid income and asset requirements may have some or all of their Medicare premiums and cost sharing paid by Medicaid through MSPs

Medicare Beneficiary Cost Sharing

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Cost Sharing Varies by Full or Partial Benefit Category Category Eligibility % Dually Eligible

Beneficiaries in 2015*

Medicaid Benefit

Full-benefit dual eligible (FBDE) enrollees

Varies by state 72% All Medicaid benefits and Medicare beneficiary premiums, cost sharing

Partial Benefit Categories: Medicare Savings Program

Qualified Medicare Beneficiaries (QMB)

(<=100% FPL) 14% Part A and B premiums and cost sharing

Specified low-income Medicare beneficiaries (SLMB)

(101% - 120% FPL) 9% Part B premiums

Qualified individuals (QI) (121% - 135% FPL) 5% Part B premiums

Qualified disabled and working individuals

(<= 200% FPL) <1% Part A premiums

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For more details, see Table 1, pp. 4-5, in January 2016 MedPAC-MACPAC Dual Eligibles Data Book. *Source: MMCO Analytic Reports and Data Resources, Medicare-Medicaid Enrollment and Snapshots, March 2015. 28

• Cost sharing is covered by Medicaid for dually eligible beneficiaries, but not always up to the full Medicare-approved amount

• Beneficiaries cannot be billed for the balance, so the difference must be absorbed by providers

• Crossover claims for deductibles and coinsurance • Medicare is primary payer, so providers must bill Medicare first • Claims then “cross over” to Medicaid for payment of beneficiary cost sharing and for

services Medicare does not cover but Medicaid may • States may choose to cover:

• The full amount of Medicare deductibles and co-insurance; or

• The difference between the Medicaid rate and the amount already paid by Medicare (i.e., “lesser-of” payment policies)

• For more information, see MACPAC March 2013 Report to Congress, Chapter 4 (“Medicaid Coverage of Premiums and Cost Sharing for Low-Income Medicare Beneficiaries”)

• https://www.macpac.gov/publication/ch-4-medicaid-coverage-of-premiums-and-cost-sharing-for-low-income-medicare-beneficiaries/

Medicaid Payment of Medicare Cost Sharing

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Physician visit* FFS Full Payment Policy FFS Lesser-of Policy

Provider charge $125 $125

Medicare-approved amount $100 $100

Medicaid payment rate $90 $90

Medicare payment (e.g., 80% Medicare approved amount less deductible)

(80% of $100)-$0 = $80 (80% of $100)-$0 = $80

Medicare cost sharing (billed to Medicaid as a crossover claim) $20 $20

Medicaid payment to provider $20

• Lesser of Medicare cost sharing, ($20) OR

• Medicaid rate minus Medicare payment ($90-$80 = $10)

Total provider payment $100 $90

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Crossover Claims Example

*Example assumes full Medicare deductible has been met Source: MACPAC March 2013 Report to the Congress on Medicaid and CHIP.

If one managed care plan covers both Medicare and Medicaid services, all payments may be handled within the plan:

• May reduce burden on providers, beneficiaries, and Medicaid agency • Amounts payable for crossover claims may be outlined in state contract with plans and/or plan

contracts with providers • If plans are responsible for paying Medicaid cost sharing payments to providers, state makes

capitated payments to plans to cover projected amounts

How Providers Bill Services for Dually Eligible Beneficiaries

Crossover Claims in Managed Care

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Beneficiary Medicare & Medicaid Status

Medicare Physician Service Claim

Crossover Claim

Medicare Advantage (MA) & FFS Medicaid Bill MA Organization Bill CMS or State directly

MA and Managed Medicaid Bill MA Organization Bill Medicaid MCO

FFS Medicare and Medicaid Bill CMS directly Bill CMS or State directly

FFS Medicare and Managed Medicaid Bill CMS directly Bill Medicaid MCO

Financial Alignment Demonstration (MMPs) Bill MMP regardless of services Providers submit one claim

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• Both Medicare and Medicaid provide coverage for home health, nursing facility services, hospice, durable medical equipment (DME), behavioral health, and transportation for dually eligible beneficiaries

• Which program covers what, when, and under what circumstances is complicated and confusing for providers, beneficiaries, and payers, especially in the FFS system

• Making one managed care plan responsible for both Medicare and Medicaid services provides an opportunity for greater coordination, simplicity, and efficiency

• Some issues may still remain with encounter data reporting, grievances and appeals, and program integrity monitoring

• April 2014 ICRC technical assistance brief has more details on home health and DME overlaps and coordination opportunities, http://www.integratedcareresourcecenter.com/PDFs/ICRC%20-%20Improving%20Coordination%20of%20HH%20and%20DME%20-%204-29-14%20(2).pdf

Coordination of Care for Medicare and Medicaid Overlapping Benefits

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• Home health • Medicare requires beneficiaries to be homebound, but

Medicaid does not • Medicare consolidates provider payment into 60-day

episodes of care, while most Medicaid programs pay by service or by visit

• No Medicare counterpart for other in-home benefits covered under many Medicaid programs, e.g.:

• Personal care assistance is a separate Medicaid state plan benefit in about two-thirds of states

• Medicaid HCBS waivers also cover home health, personal care assistance, and other community LTSS

Differences Between Medicare and Medicaid Home Health Benefits

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• Nursing facility services • Medicare pays for short-term post-acute skilled care, while Medicaid

pays for longer-term custodial care • ICRC April 2015 WWM webinar covers coordination opportunities

• http://www.chcs.org/media/ICRC_WWM_SNF_NF_Overlap_4-30-15.pdf

• Hospice • Medicare is primary payer, but Medicaid may “wrap around” if Medicaid

coverage is more generous than Medicare’s • While over 60 percent of Medicare hospice care is provided in the

home, more than a quarter is provided in nursing facilities • Medicaid is required to pay hospice providers an amount equal to at least

95 percent of the “room and board” portion of the Medicaid per diem nursing facility rate for dually eligible beneficiaries in nursing facilities, while Medicare pays other hospice costs

• Can result in overlapping or duplicate payments if Medicaid payment includes nursing and other staff costs

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Overlapping Nursing Facility and Hospice Services

Opportunities for Better Coordination of Medicare and Medicaid DME • Medicare spent $7.7 billion on DME in 2014 and Medicaid $6.1 billion

(30 percent of all national DME expenditures) • Medicare requires DME to be used primarily in the home, while

Medicaid programs generally allow broader use • Since Medicare is the primary payer, most states require a Medicare

denial before Medicaid will pay for DME for dually eligible beneficiaries • Some states seek to minimize the burden of required Medicare denials in FFS by

developing lists of DME that Medicare will almost never cover, but that Medicaid may or will

• New Medicare DME rule may make coordination easier by allowing Medicare prior authorization for more items earlier in the process

• Federal Register, December 30, 2015, pp. 81674-81707

• When managed care plans cover both Medicare and Medicaid DME for dually eligible enrollees (MMPs and some D-SNPs), the plan is the payer for all DME

• Plan can handle Medicare “denial” as largely an internal administrative matter, minimizing burden on providers and beneficiaries

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• Medicare sets state-specific fee schedules or uses competitive bidding, while Medicaid uses a variety of payment methods, with Medicare payment often used as a ceiling

• Medicare competitive bidding program began in 2009; gradually being expanded across geographic areas and to more items

• For more detail on the program, including geographic areas covered, see http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/DMEPOSCompBidProg.pdf

• States and health plans should consider revising/updating their DME payment schedules to reflect Medicare competitive bidding results

• New federal law (Consolidated Appropriations Act of 2016, H.R. 2029) will limit state Medicaid DME reimbursement to Medicare FFS rates beginning January 1, 2019

• See Section 503 in Division O. Includes Medicare FFS rates established under competitive bidding

Competitive Bidding for Medicare DME and Implications for Medicaid

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Medicare Behavioral Health (BH) Covered Benefits

Covered Medicare Mental Health Services

Psychiatric diagnostic interviews and neuropsychological tests Psychotherapy (individual, interactive, family, group)

Psychoanalysis

Medication management

Electroconvulsive therapy (ECT)

Narcosynthesis

Biofeedback therapy

Individual activity therapy (if part of a partial hospitalization program (PHP)) Screening, Brief Intervention, and Referral to Treatment (SBIRT)

• Part A covers inpatient care in a general hospital (standard coinsurance amounts apply, which Medicaid covers)

• Part B covers services provided by approved health care professionals (standard 20% coinsurance before deductible is met applies, which Medicaid covers)

• Part D covers prescription drugs (including BH drugs)

For more details, see CMS Medicare Learning Network, “Mental Health Services.” (January 2015). Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Mental-Health-Services-Booklet-ICN903195.pdf

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Medicare BH Benefits Are Generally More Limited Than Those in Medicaid

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• Medicare coverage of behavioral health services • Must generally be provided by a medical professional • Inpatient psychiatric care in a free-standing psychiatric hospital is limited to 190

days in a lifetime • Medicare pays for some services Medicaid does not

• Services in an institution for mental disease (IMD) for disabled beneficiaries between ages 21 and 65

• Medicaid coverage of behavioral health services • Mandatory covered services include inpatient and outpatient hospital services,

and physician services • Most states cover several optional mental health services, including non-medical

support services • Rx drugs for Medicaid-only beneficiaries

• ICRC August 2015 WWM webinar has more details on coordinating Medicare and Medicaid behavioral health benefits

• http://www.integratedcareresourcecenter.com/PDFs/WWM%20BH%20Slides%20FINAL.pdf

Comparison of Medicare and Medicaid Behavioral Health Benefits

38 Source: Kaiser Family Foundation “Mental Health Financing in the United States,” April 2011. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8182.pdf

Service Medicare Medicaid

Screening for alcohol misuse or illicit drug use a b

Screening for suicide risk b

Diagnostic tests, psychological testing

Outpatient mental health/substance abuse psychotherapy

Inpatient MH/SA psychotherapy c

Inpatient and outpatient detoxification

Pharmacological therapies and medication management

Opioid addiction treatment

Short- and long-term MH/SA residential care

Case management/intensive case management for MH/SA

Crisis intervention for MH/SA

Non-emergency transportation services

Peer support services

Family support services

Home-based support services a Covered for Medicare Screening, Brief Intervention and Referral for Treatment services. b Service covered for children under Medicaid’s EPSDT benefit; a minority of states cover screening for adults. c Excludes services in an institution for mental health diseases (IMD) for those ages 21-64.

Non-Emergency Medical Transportation (NEMT) Benefits

• Medicare generally covers only emergency ambulance transportation to a hospital or skilled nursing facility if it is medically necessary

• In limited circumstances, Medicare will cover non-emergency ambulance transportation if a doctor states in writing that it is medically necessary

• Medicaid coverage of NEMT is much broader • Covers travel expenses for medical exams and treatment by any

medical provider by ambulance, taxi, common carrier, “or other appropriate means”

• 42 CFR § 440.170 • Medicaid NEMT benefit can be difficult for states to manage in FFS

• States commonly contract with transportation brokers to manage NEMT • Managed care plans covering both Medicare and Medicaid benefits for

dually eligible beneficiaries may be able to coordinate transportation with medical services more effectively than in FFS

• Since managing transportation requires significant administrative resources, most managed care plans also contract with transportation brokers

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Appendix:

Key Medicare-Medicaid Resources

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• Call Letter – Medicare Advantage guidance document that accompanies advance notice and announcement of Medicare Advantage capitated rates; issued each year by CMS in draft form in February and final form in April.

• Cost-sharing – Costs incurred by the enrollee that may include deductibles, coinsurance, and copayments.

• Crossover Claim – A claim submitted for payment first to Medicare that is then submitted for Medicaid payment. The crossover is the transfer of processed claim data from Medicare operations to Medicaid (or state) agencies. Medicaid agencies can delegate responsibility for processing of crossover claims to contracted health plans.

• Dual Eligible Special Needs Plan (D-SNP) – Dual Eligible Special Needs Plans (D-SNPs) are SNPs that enroll beneficiaries who are entitled to both Title XVIII (Medicare) and Medical Assistance from a State/Territorial plan under Title XIX (Medicaid) of the Social Security Act (the Act).

• Low Income Subsidy (LIS) Medicare Part D Reassignment – Annual movement of Medicare beneficiaries from their current Medicare Prescription Drug Plan (PDP) or terminating Medicare Advantage Prescription Drug Plan (MA-PD) to another PDP if necessary to maintain the option of minimum beneficiary cost sharing.

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Key Medicare Terms

• Medicare Advantage (MA) Plan – Health benefits coverage offered under a policy or contract by a MA organization that includes a specific package of health benefits offered at a uniform premium and uniform level of cost-sharing to all Medicare beneficiaries residing in the service area (or segment of the service area) of the MA plan.

• Medicare Advantage-Prescription Drug Plan (MA-PD Plan) – A MA plan that provides qualified prescription drug coverage, as defined at 42 CFR 423.100 and in section 20.1 of Chapter 5 of the Prescription Drug Benefit Manual, under Part D of the Social Security Act.

• Medicare-Medicaid Plan (MMP) – A MA plan that has entered into a three-way contract with CMS and a state participating in the CMS Financial Alignment Initiative capitated model to provide comprehensive Medicare and Medicaid benefits to individuals dually eligible for Medicare and Medicaid (“Medicare-Medicaid enrollees”).

• Notice of Intent to Apply (NOIA) – CMS requires notification from all interested plans in November of each year for all new contracts, contract extensions, or service area expansions planned for the next full MA plan cycle (e.g., Nov 2014 NOIAs are for the CY 2016 plan cycle).

• State Medicaid Agency Contract (SMAC) or MIPPA Contract – Interchangeable terms for required state contracts that D-SNP applicants must submit to CMS by July 1st of each year to receive approval from CMS to operate a D-SNP product in a state in the upcoming year.

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Key Medicare Terms (Cont.)

Additional Resources • CMS Medicare-Medicaid Coordination Office

• http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/index.html

• Integrated Care Resource Center • Contains resources, including briefs and practical tools to help address

implementation, design, and policy challenges • http://www.integratedcareresourcecenter.com

• CHCS: “Medicare-Medicaid Integration Toolkit” • Contains policy resources and tools to help advance integrated care

models http://www.chcs.org/resource/medicare-medicaid-integration-online-toolkit/

• Mathematica Policy Research: “Managing the Care of Dual Eligible Beneficiaries: A Review of Selected State Programs and Special Needs Plans,” June 2011

• http://www.mathematica-mpr.com/~/media/publications/PDFs/health/managingdualeligibles.pdf

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About ICRC

• Established by CMS to advance integrated care models for dually eligible beneficiaries

• ICRC provides technical assistance (TA) to states, coordinated by Mathematica Policy Research and the Center for Health Care Strategies

• Visit http://www.integratedcareresourcecenter.com to submit a TA request and/or download resources, including briefs and practical tools to help address implementation, design, and policy challenges

• Send additional questions to: [email protected]

Questions and Answers

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• Medicare-Medicaid Coordination Office (MMCO). Data Analysis Brief “Medicare-Medicaid Dual Enrollment from 2006 through 2013.” December 2014: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/DualEnrollment20062013.pdf

• Integrated Care Resource Center. “State Contracting with Medicare Advantage Dual Eligible Special Needs Plans: Issues and Options.” February 2015: http://www.chcs.org/media/ICRC-Issues-and-Options-in-Contracting-with-D-SNPs-FINAL.pdf

• Medicare Payment Advisory Commission (MedPAC) and Medicaid and CHIP Payment and Access Commission (MACPAC). Data Book. “Beneficiaries Dually Eligible for Medicare and Medicaid.” January 2016: http://www.medpac.gov/documents/publications/january-2016-medpac-and-macpac-data-book-beneficiaries-dually-eligible-for-medicare-and-medicaid.pdf?sfvrsn=0

• Integrated Care Resource Center. “Medicare Basics: An Overview for States Seeking to Integrate Care for Medicare-Medicaid Enrollees.” July 2013: http://www.integratedcareresourcecenter.com/pdfs/ICRC%20Medicare%20Basics.pdf

• CMS SNP Comprehensive Reports • Monthly reports of enrollment in three SNP types, by state and by plan

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/Special-Needs-Plan-SNP-Data.html

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Links to Main Sources Cited

• MMCO/ICRC goal is to help states improve

integration of services for dually eligible beneficiaries

• Tell us what Medicare issues you would like more information on

• Send additional questions to:

[email protected]

Next Steps

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