CMS Coordinated Care Office Streamlining State Medicaid Access To Part D Rx Data

CMS announces initiatives to improve care for Medicare/Medicaid dual eligibles, including data sharing with states and an "Alignment Initiative" to start eliminating regulatory conflicts between the programs.

CMS will begin providing state Medicaid programs with Medicare patient data they need to better coordinate care for beneficiaries enrolled in both programs, known as dual eligibles, the agency announced May 11.

In the same announcement, CMS said it is launching an "Alignment Initiative" through the Federal Coordinated Health Care Office and is seeking comment on how to more effectively integrate benefits under the two reimbursement programs in six main areas, including prescription drugs. CMS believes better coordination will result in better care for individuals, but also lower program costs. The coordinated care office was established through the Affordable Care Act (Also see "CMS Coordinated Care Office Setting Priorities; Rx Management Is Of Interest" - Pink Sheet, 29 Nov, 2010.).

For dual eligibles, Medicare covers basic acute health care services and drugs and Medicaid covers supplemental benefits such as long-term care supports and services. Medicaid also helps cover Medicare premiums and cost-sharing for those who need additional financial assistance.

There are 9.2 million dual eligibles, and they account for a disproportionate share of spending in the programs. In recent years, dual eligibles accounted for 16% of Medicare enrollees but 27% of Medicare spending and 15% of Medicaid enrollees but 39% of Medicaid spending. Dual eligibles tend to be not only poorer than the average Medicare enrollee, but also older, sicker and chronically ill.

During a press call, HHS Secretary Kathleen Sebelius said that until now, states were "dealing with a very opaque system from the state level to try and figure out what in the world was going on." So to help states better understand the care dual eligibles are receiving, they will now have access to data from Medicare Parts A, B and D. Sebelius said CMS also is creating a technical assistance center to answer states' questions and share best practices.

Sebelius has experience with the state perspective, having served previously as the governor and insurance commissioner for Kansas.

Coordinated care office Director Melanie Bella specifically addressed how states will access Part D data. "States will be able to request those data directly ... from CMS," she said. "We will work with a contractor, ResDAC [Research Data Assistance Center], who currently helps with practice data requests, but we set up a special streamlined process to work with states to review the requests for the Part D data and then to make those data available, and those data will be made available to states at no charge." CMS said it will post a bulletin on its website with details on how states can request data.

Sebelius gave an example of how access to the information will help improve care.

"When a complicated patient gets out of the hospital, one of the questions is did they fill their prescription? Right now [states have] no way of tracking that or following that," she said. "That information will be available. They can make the call to say, 'Oh, by the way, Mrs. Jones, you need to fill the prescription and take the prescription so your blood pressure doesn't go back up.' Things like that that just are not possible without the full record."

Alignment Initiative Request For Comments

CMS outlined the related Alignment Initiative in a request for comments posted on the Federal Register website May 11.

It includes a list of six main "alignment opportunities," which CMS describes as "areas in which the Medicare and Medicaid programs have conflicting requirements that prevent dual eligible individuals from receiving seamless, high quality care."

The areas are: 1) coordinated care; 2) fee-for-service benefits; 3) prescription drugs; 4) cost sharing; 5) enrollment; and 6) appeals.

Specifically, CMS is seeking information on how to ensure dual eligibles get full access to program benefits, how to simplify processes for them to access products and services, opportunities to eliminate regulatory conflicts between rules in the two programs, how CMS can work to improve care continuity and ensure safe and effective care transitions, and how to eliminate cost-shifting between the programs and related health care providers.

Comments are due July 11.

-Scott Steinke ([email protected])