By Elena Eyber, J.D.
The GAO’s report describes what is known about selected states’ experiences with aligned enrollment in D-SNPs and examines CMS’s oversight of aligned enrollment.
The Government Accountability Office (GAO) reviewed dual-eligible special needs plans (D-SNPs) integration with state Medicaid programs. The GAO’s report (1) describes what is known about the extent to which states have encouraged aligned enrollment of dual-eligible beneficiaries in D-SNPs; (2) describes what is known about selected states’ experiences with aligned enrollment; and (3) examines CMS’s role in and oversight of states’ use of aligned enrollment (GAO Report, GAO-20-319, March 13, 2020).
Aligned enrollment. Dual-eligible beneficiaries are Medicare beneficiaries who are also enrolled in the Medicaid program in their state. In certain states, they may receive both types of benefits through private managed care plans. As of January 2019, about 386,000 individuals were enrolled in both a private Medicare plan known as a dual-eligible special needs plan (D-SNP) and a Medicaid managed care organization (MCO) that were offered by the same or related companies. This arrangement, known as aligned enrollment, may create opportunities for better coordination between Medicare’s acute care services and Medicaid’s long-term services and supports, such as nursing facility care or personal care services.
Challenges with aligned enrollment. Medicaid officials in seven selected states described challenges with aligned enrollment. One challenge cited by six of the states was using D-SNP and Medicare data to implement and evaluate aligned enrollment. For example, one state stated it cannot separate D-SNP quality data for just the state because some D-SNPs report data spanning multiple states to CMS. As of December 2019, CMS stated it is determining the best way for D-SNPs to report these quality data.
Default enrollment. CMS has assisted states with aligned enrollment, but lacks quality information on the experiences of dual-eligible beneficiaries who have aligned enrollment through a process known as default enrollment. With default enrollment, states allow automatic assignment of beneficiaries who are enrolled in a Medicaid MCO and are about to become eligible for Medicare to the D-SNP aligned with that MCO. However, CMS’s monthly reports on default enrollment do not include information on beneficiaries who choose to disenroll in the first 90 days after being default enrolled, a time frame specified in regulation. According to one beneficiary group, some beneficiaries may disenroll because they did not realize they were default enrolled and their provider is not in the D-SNP’s network. Quality information on the experiences of dual-eligible beneficiaries after default enrollment would allow CMS to better identify the extent to which beneficiaries face challenges and to determine how to address the challenges.
GAO’s recommendation. GAO recommended that CMS take steps to obtain quality information on the experiences of dual-eligible beneficiaries who have been default enrolled into D-SNPs, such as by obtaining information about the extent to which and reasons that beneficiaries disenroll from a D-SNP after being default enrolled.
HHS comments. HHS concurred with the recommendation. HHS stated it will evaluate opportunities to obtain more information on dual-eligible beneficiaries who disenroll from a D-SNP after being default enrolled.
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