Centers for Medicare and Medicaid Studies Issue Guidance to States on Service

The Centers for Medicare & Medicaid Services (CMS) recently released a “Dear State Medicaid Director” letter highlighting ten opportunities for states to better serve individuals dually eligible for Medicare both and Medicaid. The letter states that these these opportunities are newly available to states through Medicare rulemaking or other CMS burden reduction efforts and can be used to help better the lives of an estimated 12 million Americans dually eligible for Medicare and Medicaid.


Medicaid is an important source of medical coverage for individuals dually qualified Medicare beneficiaries as the former covers services the latter does not, such as long term care in nursing homes or assisted living facilities. Additionally, Medicaid aids in cost reduction for Medicare by helping pay Medicare premiums and cost-sharing, which may be high for low income individuals.


The outlines in the letter include new developments in managed care, using Medicare data to inform care coordination and program integrity initiatives, and reducing administrative burden for dually eligible individuals and the providers who serve them. Many advocacy groups have welcomed CMS’s efforts to forge closer ties with state administrators to improve the Medicare Part A Buy-in Program and simplify the eligibility and enrollment processes for Medicare Savings Programs.


Among the other opportunities outlined in the letter are default enrollment of Medicare beneficiaries into Medicaid to maintain continuity of Medicaid managed services, known as Dual Eligible Special Needs Plans (D-SNP). Through default enrollment, Medicaid beneficiaries in capitated managed care may be automatically enrolled into a D-SNP affiliated with the individuals’ Medicaid managed care organization (MCO).


Even with the enrollment, beneficiaries still retain the ability to opt out of default enrollment to instead receive their Medicare services through Medicare Fee-For-Service (FFS), Programs of All-inclusive Care for the Elderly (PACE), or another Medicare Advantage plan. The letter states that states can use these default enrollment plans to facilitate enrollment into managed care arrangements in which these dually eligible beneficiaries are able to receive all their Medicare and Medicaid benefits through the same organization.


In an effort to promote integrated care, continuity of care, and partnership with states, CMS recently codified a new, limited expansion of its regulatory authority to conduct passive enrollment in the Final Parts C and D Rule for 2019. While enrollment in a Medicare Advantage or standalone Part D plan is generally initiated by beneficiaries, in certain limited instances CMS may passively enroll individuals into Medicare health or drug plans.

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