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Medicare
and Medicaid Dual Eligibility The Medicare
program has two basic types of coverage
-- Part A, which pays for hospitalization
costs; and Part B, which pays for outpatient
and physician services. Beneficiaries
are automatically eligible for Part
A coverage, but Part B coverage is optional.
Part B coverage may be purchased, or
beneficiaries may choose not to purchase
it. In addition there are at least 8
million low-income Medicare beneficiaries
who are estimated to be eligible for
some level of Medicaid benefits and
subsidies. Based on state income requirements,
Medicare beneficiaries may be eligible
for full Medicaid benefits. In addition,
Federal Medicaid legislation requires
Medicaid payment of Medicare deductibles,
copayments, and Part B premiums for
certain beneficiaries. Enclosure 1 describes
the categories of dual eligibility.
The Families USA Foundation has recently
estimated that about 3.5 million of
the Medicare beneficiaries who are eligible
for Medicaid coverage are not enrolled
for those benefits or subsidies. A state-by-state
breakdown of this analysis is presented
as Enclosure 2.
This finding highlights an opportunity
for Bureau-supported sites to expand
their role in assisting with Medicaid
enrollment and providing care for this
population. Since Medicaid most often
subsidizes all or part of the optional
Part B premiums, unenrolled beneficiaries
are likely to be uninsured for services
provided by health centers and NHSC
sites.
Improving enrollment among this population
should therefore improve reimbursements
for Bureau sites that serve this population
and enhance their ability to provide
comprehensive care. Nationally about
8 percent, or 800,000 of health centers_
patients are elderly, and about 5 percent
of total health center revenue comes
from the
Medicare program.
Medicare Managed Care
The opportunities for Bureau supported
sites to increase revenues and expand
services
to the Medicare population will be impacted
by the expected growth in Medicare managed
care enrollment.
Through the Balanced Budget Act of 1997,
Congress created the Medicare+Choice
program to increase the range of
managed care entities that could enroll
Medicare beneficiaries. In 1998, 14
percent of all Medicare beneficiaries
are enrolled in managed care. That proportion
is projected to rise under Medicare+Choice
to 25 percent by 2002. A description
of the Medicare+Choice program is included
as Enclosure 3. While most of the dual
eligibles will generally not be enrolled
in managed care, health centers and
NHSC sites in some markets may have
opportunities to expand their services
to other Medicare beneficiaries by contracting
with Medicare managed care plans in
their areas.
STRATEGY FOR EXPANDING ACCESS AND IMPROVING
REIMBURSEMENT
The strategy for assisting Bureau-supported
sites to expand their provision of services
to the low-income elderly has two parts:
(1) a state based strategy and (2) a
technical assistance and training strategy.
(1) State Based Strategy
Through expansion of the Outstationed
Eligibility Worker Demonstration Program,
State Primary Care Associations
(PCAs) will be funded to work with their
state Medicaid agencies and the Bureau-supported
sites in their state to
improve implementation of the dual eligibility
programs. A letter describing this funding
opportunity was released
to PCAs and Primary Care Offices on
October 20, 1998.
Through Memorandums of Agreement with
state Medicaid agencies, PCAs would
work with states to assess their
policies around dual eligible enrollment
and to improve implementation of subsidies
for all categories of eligible
low-income elderly. The PCAs would also
work with health centers and NHSC sites
in their state to expand the
function of outstationed Medicaid eligibility
worker programs to include this population.
The PCAs would also
be expected to work with the centers
to develop programs for reaching out
to the elderly and encouraging their
use
of primary care services.
Building on the market assessments that
have been conducted by the PCAs, they
may also work with the Bureau supported
sites in their state to evaluate their
opportunities for expanding service
capacity for the elderly. Where appropriate,
the PCAs would work with the Bureau
to coordinate technical assistance and
training for
developing the capacity for expanded
services to the elderly.
For additional information on this program,
please contact Lynn Spector at 301-594-6014.
(2) Technical Assistance and
Training Strategy
The Bureau will offer a workshop to
PCAs, health centers, and NHSC sites
on expanding coverage and access to
services for the low-income elderly.
The workshop will cover the structure
of Medicare and Medicaid dual
eligibility programs, outreach and enrollment
strategies targeted to the elderly,
and capacity expansion and
delivery system design. This workshop
will be offered beginning in January
of 1999.
In addition, in response to the expected
growth in Medicare managed care enrollment
under the Medicare+Choice program, the
Bureau of Primary Health Care (BPHC)
is also offering a workshop on Medicare
managed care. The course covers Medicare
benefits and contracting issues, reimbursement
and financial issues, and utilization
and risk management for the Medicare
population. This workshop is currently
available.
Both of these workshops can be scheduled
by contacting Ron Farhood at BPHC (301-594-4060)
or Deloris Campbell at the National
Association of Community Health Centers
(202-659-8008).
Finally, the Bureau is developing a
resource manual for health centers and
NHSC sites on reaching out to and
serving the elderly that will highlight
successful strategies and programs that
have already been developed
by centers. The manual will be completed
and distributed to health centers in
the Spring 1999.
If you have any questions about these
activities or the information provided
in the enclosures, please contact Julia
Tillman at 301-594-4060.
Sincerely yours,
Marilyn
H. Gaston, M.D.
Assistant Surgeon General
Associate Administrator
Director
MEDICARE AND MEDICAID
DUAL ELIGIBILITY PROGRAMS
The dual eligible programs, which have
been in effect since 1988, were designed
to protect low-income seniors from the
growing costs of receiving Medicare coverage.
The programs provide varying levels of
Medicaid coverage to Medicare beneficiaries
who are up to 120 percent of the Federal
Poverty Level. The Balanced Budget Act
of 1997 created two new categories of
Medicare and Medicaid dual eligibility
that extends the threshold for some level
of coverage up to 175 percent of the Federal
Poverty Level.
The following
describes each of the categories of
individuals who are known as dual eligibles.
Medicare has two basic coverages: Part
A, which pays for hospitalization costs;
and Part B, which pays for physician
services, lab and x-ray services, durable
medical equipment, and outpatient and
other services. Dual eligibles are individuals
who are entitled to Medicare Part A
and Part B and are eligible for some
form of Medicaid benefit.
Category |
Eligibility Criteria
|
Benefit |
Qualified Medicare
Beneficiaries (QMBs)
without other Medicaid
(QMB Only) |
come of 100% of the federal
verty level (FPL) or less
esources that do not exceed
ce the limit for SSI eligibility
re not otherwise eligible for
Medicaid |
Medicaid payment of
Medicare Part A
premiums, if any
Medicare Part B premiums
Medicare deductibles and
coinsurance for Medicare
services provided by
Medicare providers |
with full Medicaid (QMB |
come of 100% FPL or less
esources that do not exceed
ce the limit for SSI eligibility
re eligible for State
dicaid benefits |
Medicaid payment of
Medicare Part A
premiums, if any
Medicare Part B premiums
Medicare deductibles and
coinsurance
ull Medicaid benefits |
Specified Low-Income
Medicare Beneficiaries
(SLMBs) without other |
_. Income of 100 _120 %
of FPL
_. Resources that do not
_. Medicaid payment of
Medicare Part B
premiums
Medicaid (SLMB Only) exceed twice
the limit
for SSI eligibility
_. Are not otherwise
eligible for Medicaid |
|
SLMBs with full Medicaid
(SLMB Plus) |
_. Income of 100 _ 120%
FPL
_. Resources that do not
in exceed twice the limit
for SSI eligibility
_. Are eligible for State
Medicaid benefits |
_. Medicaid payment of
Medicare Part B
premiums
_. Full Medicaid benefits |
Qualifying Individuals (1)
(QI-Is)
_. This group is effective
1/1/98 - 12/31/02
_. There is an annual cap
on the amount of money
available, which may
limit the number of
individuals in the group |
Income of 120 _
135% FPL
_. Resources that do
not exceed twice the
limit for SSI eligibility
_. Are not otherwise
eligible for Medicaid |
_. Medicaid payment of
Medicare Part B
premiums |
Qualifying Individuals (2)
(QI-2s)
_. This group is effective
1/1/98 - 12/31/02
_. There is an annual cap
on the amount of money
available, which may
limit the number of
individuals in the group |
_. Income of 135 - 175%
FPL
_. Resources that do not
exceed twice the limit
for SSI eligibility
_. Are not otherwise
eligible for Medicaid |
_. Medicaid payment of a
portion of Medicare Part
B premiums |
Medicaid Only Dual
Eligibles (Non QMB,
SLMB, QI-1, or QI-2) |
re eligible for full Medicaid
nefits
re not eligible for Medicaid
a QMB, SLMB, QI-l, or QI-2 |
ull Medicaid benefits
ayment for Medicaid
rvices provided by Medicaid
oviders |
|
ypically, these beneficiaries
into a Medicaid eligibility
verty group that exceeds the
its for those categories) |
Medicaid payment of
edicare cost-sharing
Medicaid payment of
edicare Part B premiums is
State option |
STATE ESTIMATES
FOR NON-COVERED DUAL ELIGIBLES
[The following are estimates from a
report by the Families USA Foundation]
State |
Number
of QMB and SLMB Eligibles |
Percentage
Not Enrolled |
Alabama |
209,000 |
44% - 48% |
Arizona |
118,000 |
60% - 63% |
Arkansas |
139,000 |
47% - 53% |
California |
826,000 |
9% - 12% |
Colorado |
52,000 |
9% - 21% |
Connecticut |
63,000 |
29% - 43% |
Delaware |
21,000 |
62% - 67% |
District of Columbia |
32,000 |
57% - 60% |
Florida |
547,000 |
46% - 50% |
Georgia |
249,000 |
35% - 41% |
Hawaii |
32,000 |
44% - 49% |
Idaho |
22,000 |
38% - 45% |
Illinois |
325,000 |
61% - 70% |
Indiana |
156,000 |
56% - 65% |
Iowa |
43,000 |
15% |
Kansas |
69,000 |
50% - 60% |
Kentucky |
149,000 |
33% - 39% |
Louisiana |
176,000 |
40% - 48% |
Maine |
48,000 |
37% - 44% |
Maryland |
127,000 |
57% - 64% |
Massachusetts |
218,000 |
43% - 52% |
Michigan |
226,000 |
45% - 52% |
Minnesota |
86,000 |
42% - 54% |
Mississippi
|
111,000 |
9% - 15% |
Missouri |
144,000 |
50% - 59% |
Montana |
24,000 |
55% - 63% |
Nebraska |
39,000 |
60% - 68% |
Nevada |
43,000 |
63% - 66% |
New Hampshire |
17,000 |
69% - 75% |
New Jersey |
195,000 |
36% - 44% |
New Mexico |
70,000 |
54% - 57% |
New York |
476,000 |
31% - 40% |
North
Carolina |
270,000 |
26% - 32% |
North
Dakota |
20,000 |
75% - 80% |
Ohio |
393,000 |
59% - 67% |
Oklahoma |
125,000 |
54% - 61% |
Oregon |
88,000 |
45% - 49% |
Pennsylvania |
356,000 |
57% - 65% |
Rhode
Island |
43,000 |
65% - 72% |
South
Carolina |
152,000 |
34% - 36% |
South
Dakota |
22,000 |
49% - 59% |
Tennessee |
176,000 |
11% - 19% |
Texas |
684,000 |
54% - 59% |
Utah |
22,000 |
39% - 47% |
Vermont
|
19,000 |
34% - 40% |
Virginia |
224,000 |
54% - 58% |
Washington |
181,000 |
55% - 59% |
West
Virginia |
99,000 |
60% - 63% |
Wisconsin |
109,000 |
40% - 52% |
Wyoming |
9,000 |
44% - 53% |
TOTAL |
8,044,000 |
42% - 48% |
MEDICARE+CHOICE PROGRAM OVERVIEW
The Balanced Budget Act of 1997 (BBA)
introduced a new Part C of the Medicare
program, Medicare+Choice (M+C). Medicare+Choice
expands the choices
available to beneficiaries by allowing
them to select among several health
delivery
systems, including traditional Medicare
fee-for-service, coordinated care plans,
private fee-for-service plans, or medical
savings accounts.
While entirely new options are introduced
for the Medicare population, the law
also
makes certain changes in payment policy,
contracting requirements, and other
aspects of Medicare law that are intended
both to facilitate the introduction
of new
options and to expand the availability
of current Medicare managed care options.
Regulations published in June 1998 implement
the statutory provisions of the M+C
program. This regulation establishes
the requirement for organizations that
contract
with Health Care Financial Administration
(HCFA) to provide health care services
to
Medicare beneficiaries. Requirements
include, but are not limited to eligibility,
election, and enrollment; benefits and
beneficiary protections; quality assurance;
provider relationships; payments, premiums,
and cost sharing; and grievance and
appeals procedures.
New Coverage Options
Prior to the BBA, Medicare beneficiaries
could choose to receive their care through
original fee-for-service Medicare or
through health maintenance organizations
(HMOs). The M+C introduces several new
health plan options for Medicare
beneficiaries.
Coordinated care plan options that are
available to beneficiaries are no longer
limited
to traditional HMOs. Under the BBA,
the Medicare program can contract with
HMOs,
preferred provider organizations, and
provider sponsored organizations. The
HMOs
participating in the Medicare program
may also now offer point-of-service
options.
In addition, the BBA allows HCFA to
enter contracts with private fee-for-service
plans.
These plans would reimburse participating
providers on a fee-for-service basis,
and
enrollees would not be limited to network
providers.
Beneficiary choice among health plans
may be further increased by the elimination
of
the enrollment composition requirement
for health plans. Prior to the BBA,
Medicare
contracting health plans were required
to have enrollment of at least 50 percent
non-
Medicare members. This requirement has
been eliminated.
Payment Changes and Risk Adjustment
The BBA introduced several changes in
how Medicare risk contractors will be
paid
beginning in 1998. Payments across geographic
areas will not be subject to as wide
a level of variation as under the prior
methodology. The prior methodology based
Medicare capitation payments on historical
fee-for-service costs in the geographic
area. This resulted in wide variation
across counties. The new payment methodology
made a number of changes that will even
out these differences and may serve
to
increase the availability of managed
care options in rural areas.
The BBA also made payment policy changes
to address the issue of selection bias
among Medicare risk plans. Beginning
in 2000, payments to M+C plans will
be
adjusted for the health status of individual
enrollees. To make these adjustments,
HCFA is requiring M+C plans to submit
patient data on their enrollees beginning
in
1998.
Quality and Consumer Protection
The implementing regulations for the
M+C program require contracting health
plans to
measure and report on plan performance,
meet minimum performance standards,
and undertake performance improvement
activities that lead to improvements
in both
clinical and non-clinical areas.
The HCFA is required by the BBA to provide
beneficiaries with information on health
plan quality and performance, disenrollment
rates, satisfaction levels, and health
outcomes.
The regulation also establishes requirements
for enrollee access to care under M+C
and requires that M+C networks maintain
a network with sufficient numbers and
appropriate types of providers. Plans
are also required to provide services
in a
culturally competent manner.
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