This blog is part of our Medicaid Access and Managed Care Rules for HCBS series, which examines the implications of the new rules on home and community-based programs and provides states with suggestions to improve data, quality reporting, and oversight.
The final rule on Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality (Managed Care Rule) published by the Centers for Medicare & Medicaid Services (CMS) in May 2024 is just the latest in a series of rules and guidance that demonstrate CMS’ expectation that states collect and analyze Medicare data for their dually eligible individuals and include these populations in publicly reported quality measures and quality rating systems. It is critical for states to build their capacity to collect and use Medicare data to comply with these new requirements, support care coordination, and monitor access and quality for the almost 13 million people who are dually eligible for Medicare and Medicaid, a disproportionate share of whom—27 percent—use home and community-based services (HCBS).
Dually eligible individuals have complex care needs and often experience fragmented care
As the name implies, dually eligible individuals qualify for both Medicare and Medicaid. They have more complex care needs than the Medicare-only population, including higher rates of chronic conditions, a greater need for behavioral health services and long-term services and supports, poorer self-rated health, and are more racially and ethnically diverse than the Medicare only population. Medicare and Medicaid have different covered benefits, rules, and provider networks. Most people who need long-term services and supports prefer to receive them at home via HCBS, and HCBS make up a large share of Medicaid spending for dually eligible individuals.
Dually eligible individuals experience uncoordinated and fragmented care when Medicare and Medicaid operate in silos, which can create barriers to accessing care and lead to poor health outcomes. Although there are a few different types of integrated programs that combine Medicare and Medicaid benefits, payments, and data collection, only a small share of dually eligible individuals (roughly 9 percent) are enrolled in programs that fully align Medicare and Medicaid under a single organization. Across the country, states have drastically different landscapes of Medicare and Medicaid coverage arrangements for dually eligible individuals.
Medicare data can help support care coordination, quality, and experience of care for dually eligible HCBS users
When states or their contracted Medicaid managed care plans don’t have access to Medicare data, it can result in issues with care coordination and quality for dually eligible individuals. For example, a person’s Medicaid-paid personal care aide might not be aware of a hospital admission (where Medicare is the primary payer) or an imminent hospital discharge. As a result, the individual might not receive support from their case manager in discharge planning or get timely support after leaving the hospital. This could put them at risk for poor outcomes, including readmission. Siloed Medicare and Medicaid systems can also make it harder to get insurance to cover medications due to confusion about payer responsibility and prior authorization rules. From a state perspective, if Medicaid managed care plan reports don’t incorporate Medicare data (for example, to report on measures of diabetes medication management, management of chronic conditions, or avoidable rehospitalizations), the quality or experience of care measures they submit to the state won’t represent the full experience of care for dually eligible individuals, let alone dually eligible individuals who use HCBS. This would make it challenging to hold plans accountable to quality and access standards for this population.
Recent federal rules require states to collect and analyze Medicare data for dually eligible individuals
As noted, a host of recent changes at the federal level mean that states must start collecting and analyzing Medicare data for dually eligible individuals if they are not already doing so.
- The Managed Care Rule requires states to establish a quality rating system for Medicaid and CHIP managed care plans (Medicaid and CHIP Quality Rating System or MAC QRS) which will allow Medicaid beneficiaries to compare and choose among Medicaid managed care plans. The rule also specified that QRS measures must include dually eligible individuals and stratify rates by dual eligible status, so beneficiaries and other interested parties can determine the plans and measures under which dually eligible individuals seem to fare better or worse than other Medicaid beneficiaries.
- As mentioned in a prior blog in this series, the May 2024 Access Rule created a requirement for states to report several measures in the HCBS Quality Measure Set. States will need Medicare data to report three of these required measures. (These measures capture the following information on people using HCBS: admission to a facility, length of stay, and successful transition after a long-term facility stay.)
- The August 2023 Medicaid and Children’s Health Insurance final rule established the mandatory reporting of the behavioral health Adult Core Set measures and the Child Core Set, which must include dually eligible individuals beginning in measurement year 2025.
Tips for obtaining and using Medicare data
States already have access to Medicaid fee-for-service (FFS) and managed care utilization data through their managed care plans and their own Medicaid management information systems, but they may need additional support to receive and use Medicare data. Given the diverse landscape of Medicare and Medicaid coverage arrangements referenced above, states will need to collect and use both Medicare FFS claims and Medicare Advantage (MA) encounter data. States can obtain these data as follows:
- Medicare FFS data. States can request FFS Medicare data through the CMS State Data Resource Center (SDRC). Although all states may receive FFS Medicare data via SDRC, only 29 currently do.
- Medicare Advantage encounter data. Currently, states can receive data directly from MA dual eligible special needs plans (D-SNPs), which are the most common source of integrated care for dually eligible individuals, and are available in 45 states and the District of Columbia (though the degree of integration varies based on the D-SNP type, among other factors). To operate in a state, D-SNPs must have a state Medicaid agency contract (SMAC) with the state Medicaid agency. States can use SMACs to require D-SNPs to submit MA encounter data to the state and to specify the timing, format, and content of data submissions. Example contract language and other state approaches are included in several technical assistance tools posted on the Integrated Care Resource Center website.
A chapter on SMACs in the Medicaid and CHIP Payment and Access Commission (MACPAC) June 2024 Report to Congress—informed by a Mathematica-led study— recommends that states utilize SMACs in this way to facilitate oversight and monitoring of care coordination and quality of care. It also notes that states may need to update their information technology systems and seek additional guidance to build their capacity for receiving and using Medicare data.
In the future, states will be able to request MA data directly from CMS (similar to how they can request FFS data), as noted in the Calendar Year 2025 MA Part D final rule.
What’s next on the road ahead?
As each blog in this four-part series has shown, states have a long road ahead in building their data and analytic capacity to comply with the Managed Care and Access rules. The challenge of capturing data on dually eligible HCBS users is even more nuanced. The silver lining is that, as noted in the Managed Care Rule responses to public comments, CMS plans to provide technical assistance and additional guidance to states about how to collect Medicare data (among other topics). Further, mission-driven, data-informed organizations like Mathematica are poised to help states navigate compliance with these new rules and improve public well-being. For more information or help with the topics raised in this blog series, reach out to HCBSPractice@mathematica-mpr.com.
