On March 13, 2014, CMS issued the FY 2013 Medicare-Medicaid Coordination Office (“the Office”) Report to Congress.  In the Report, CMS provided a review of FY 2013 demonstrations, improvements and other initiatives to improve the experience of Medicare-Medicaid beneficiaries. Additionally, CMS made three legislative recommendations and specified two areas of interest to Congress. These recommendations and areas of interest are briefly described below.

First, CMS asked Congress for legislative authority to implement a streamlined, integrated appeals-process system to serve the Medicare-Medicaid (“dual”) eligible population. According to the Report, different provisions of the Social Security Act (“SSA”) govern the Medicare and Medicaid programs’ appeals process—including time frames and limits, amounts in controversy, and levels of appeals. Additionally, the Medicare appeals process varies depending on the Medicare Part (i.e. A, B, C or D) the claim involves. The Office asserted that for dual eligible individuals, who are generally the disabled or chronically ill elderly, the differing rules for appeals “may be barriers to seamless delivery of benefits and services.” CMS offered that Medicare-Medicaid Financial Alignment Demonstrations are underway to fully integrate the service delivery and financing of the programs.

Second, CMS asked Congress to make permanent the Demonstration for Retroactive and Point of Sale Coverage for Certain Low-Income Beneficiaries program (“LI NET Demonstration”).  According to the Report,  LI NET Demonstration was established to eliminate gaps in prescription drug coverage by having Medicare pay for a specialized PDP [prescription drug program] using an alternative payment mechanism to provide retroactive coverage and limited prospective coverage for LIS [low income subsidy]-eligible enrollees during these gaps. Through this program, CMS auto-enrolls or facilitates enrollment to register all applicable LIS-eligible beneficiaries into a Medicare Part D PDP that has a premium at or below the low-income premium benchmark. The LI NET Demonstration is scheduled to expire at the end of Calendar Year 2014.

The report notes that the requests for authority to implement the integrated Medicare-Medicaid appeals process and for the LI NET Demonstration program to become permanent were also included in theCoordination Office’s FY 2012 Report to Congress and in President Obama’s proposed FY 2014 budget.

Third, CMS asked Congress to amend the SSA to provide the agency with authority to launch a new pilot under which the Program for All-Inclusive Care for the Elderly (PACE) eligibility would be extended to individuals over age 21 in qualifying states. Currently, PACE serves individuals 55 and older, who meet a nursing-home-level of care. The Office seeks to extend the program to individuals older than 21 in certain states to “enhance existing person-centered, integrated care models.” By extending this program, CMS argued it could assess whether the PACE model of care would be successful in promoting community services, supporting self-determination and achieving better health outcomes.

Fourth, CMS identified coverage standards for dual enrollees as an area of interest the Office is currently examining. At present, Medicare coverage policies vary by region and Medicaid policies vary by state. Therefore, varying threshold standards may be applied to dual eligibles for items and services applicable, which may result in confusion for states, providers, and the Medicare-Medicaid enrollees. Varying coverage rules also may create conflicting incentives that could result in cost-shifting between programs and additional administrative expenses.  According to the Report, CMS conducted a demonstration from 2000-2010 to review state-initiated home health appeals; the evaluation is pending.

Fifth, CMS stated the Office is interested in learning about the extent to which cost-sharing is not reimbursed to the states when state Medicaid programs pay Medicare cost sharing (coinsurance and deductibles) for dual eligibles in the qualified Medicare beneficiaries program; and whether this impacts beneficiaries’ access to services and payments to providers.  According to the report, complexities of the existing financing often result in that cost-sharing not being reimbursed to states.

The Medicare-Medicaid Coordination Office, formally the Federal Coordinated Health Care Office, is in its third year of existence and was created under Section 2602 of the Affordable Care Act. The purpose of the Office is to “bring together Medicare and Medicaid in order to more effectively integrate benefits, and improve the coordination between the Federal Government and states to ensure access to quality services for individuals who are enrolled in both programs.” Among its responsibilities, the Office is mandated to submit a Report to Congress annually.

Read the full report here.

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