Industry: No MA Ratings for Plans Covering Dual Eligibles

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By Mindy Yochelson

Aug. 12 — States shouldn't be permitted to use the Medicare Advantage (MA) five-star quality system to rate health plans that just serve beneficiaries dually eligible for both Medicare and Medicaid, industry officials told the CMS.

Although commenters on a proposed rule on managed care for Medicaid beneficiaries agreed that the state-centered program should be aligned with Medicare managed care, there were strenuous objections to applying MA's star rating system to Medicaid plans.

America's Health Insurance Plans (AHIP), the lead health plan lobbying group, told the Centers for Medicare & Medicaid Services that it strongly opposes the states using the MA rating system for plans that serve dual eligibles or other Medicaid-eligible populations.

“Considerable data demonstrates the [MA] Star Ratings System systematically disadvantages plans focusing on low-income populations despite plans’ best efforts to serve the unique needs of these individuals,” AHIP said. Adopting the MA star ratings “is therefore inappropriate for dual eligibles and other Medicaid populations until CMS makes changes to address this issue.”

The proposal (RIN 0938-AS25, CMS-2390-P), which would overhaul the Medicaid managed care delivery system, was published in the June 1 Federal Register (80 Fed. Reg. 31,097) and comments were due July 27.

Aligning Coverage

An overall goal of the proposed rule is to align provisions related to Medicaid managed care plans with other health insurance coverage, including MA and qualified health plans (QHPs) in the insurance exchanges.

The proposal requires development of a Medicaid managed care quality rating system (QRS) in each state that would report plans' performance information.

However, states would be given the option to use the MA five-star rating for plans that serve only dual eligibles, in lieu of the Medicaid QRS.

Plans that serve only dual eligibles are Medicare Advantage special needs plans for dual eligibles called D-SNPs and Medicare-Medicaid Plans (MMPs) that are part of the CMS's financial alignment demonstration.

“To avoid duplication of effort,” the agency said, “we propose providing states with the option to default to the MA five-star rating system for those plans that serve dual eligible beneficiaries only.”

Different System

AHIP's words were echoed by another group, the Association for Community Affiliated Plans (ACAP), which also said that states shouldn't be permitted to use MA star ratings for plans exclusively serving dual eligibles.

“First, it would result in [a] different system for plans only serving dual eligible compared to plans serving dual eligible and other populations,” according to ACAP, an association of 59 nonprofit and community-based safety-net health plans.

More importantly, ACAP continued, the CMS has acknowledged that the MA star rating program doesn't accurately measure quality of care for dual eligibles and is evaluating changes to the program to address this issue.

Allowing states to use the MA five-star program for dual eligible plans “would further institutionalize a flawed quality rating system,” ACAP said.

Similarly, Centene Corp., which has health plans serving Medicaid, Medicare and the exchanges, said it's against using the MA five-star rating system for dual eligibles. It is widely accepted that this system, as it currently exists, doesn't capture that dual eligibles “have worse health outcomes that cannot be attributed to a health plan's quality of service.”

Failure of Five-Star System

The SNP Alliance, a national organization of D-SNPs and MMPs, said the MA star rating system doesn't “adequately account for social determinants of health.”

The alliance said “it fails to account for a broad spectrum of psycho-socio, environmental, cultural, educational, behavioral and economic conditions that affect the health and health outcomes for people in poverty.”

Instead, the CMS should conduct a review of Medicare and Medicaid measures as applied to integrated programs serving duals. The goal would be to identify “a more limited but more relevant set of priorities for measurement across both programs” and address gaps in measures for subsets of these beneficiaries, such as those dealing with behavioral health needs.

Increase Efficiencies

However, the objection wasn't universal.

The Alliance of Community Health Plans (ACHP) praised the use of a Medicaid quality rating system consistent in format and scope with those in MA and the exchanges. Consistency will make it easier for beneficiaries, especially those transitioning among these programs, to understand the quality ratings of their health plan options.

ACHP, a group of community-based and regional health plans and provider organizations, also supported CMS's proposed “flexibilities” in allowing states to use the MA quality rating system for plans that serve duals.

“Aligning quality standards across plans will increase the operational efficiency for plans that participate in both programs and will avoid duplication of effort,” ACHP said.

Thumbs Up on Benefit Coordination

On another issue impacting dual eligibles, providers were supportive of a requirement that Medicaid plans enter into a “Coordination of Benefits Agreement” with Medicare and participate in an automated “claims crossover” process administered by Medicare.

Under the process, when a provider submits a claim to Medicare, there is an automatic crossover to the state for whatever Medicaid would owe. The process is intended to reduce administrative burdens and ensure more efficient provision of benefits to enrollees.

The Medical Group Management Association said it supports the proposal for “the growing population” of duals. “As more managed care plans are contractually responsible for Medicare deductibles and co-insurance, providers face a much more complex set of processes,” according to MGMA, which represents medical administrators.

The American Hospital Association said it supports the proposal because it alleviates the administrative burden hospitals face in having to submit separate bills for their dually eligible patients.

The Medicare Rights Center said that, without such a process, “providers can face complicated and cumbersome billing requirements,” which could lead to their rejecting dual patients.

CMS's Laissez-Faire on Network Adequacy

Unlike a crossover claims process, some beneficiary and provider groups expressed a lack of enthusiasm for the CMS's proposed decision to be less involved in Medicaid network adequacy requirements than it has been in MA.

For the MA program, the CMS has set standards that include the minimum number of providers, maximum travel time and maximum travel distance per county for all provider types covered under the MA organization contract.

But in the existing rules for Medicaid managed care and the rules finalized for marketplaces, “we did not establish detailed and specific time and distance standards or provider to enrollee ratios but deferred to each Marketplace or state to develop specific standards,” the CMS said.

The agency's regulatory framework instead “relies heavily on attestations and certifications from the applicable health plan, with supporting documentation, about the adequacy of the network.”

Less Prescriptive

The CMS said it prefers that system for the state-run Medicaid managed care.

“Consistent with the primary role of states in this, we intend to keep that general approach for the Medicaid program, rather than taking the more detailed approach used in the MA program,” the proposal said.

At a minimum, states should establish time and distance standards, which present a more accurate measure of the enrollee’s ability to have timely access to covered services than do provider-to-enrollee ratios, the agency said.

Advocates' Objection

The Center for Medicare Advocacy objected to the lighter oversight role for Medicaid than for Medicare and said that network problems in MA could be “magnified in Medicaid.”

MA enrollees can leave their plans for fee-for-service Medicare if they are negatively affected by plans' provider terminations, according to the advocacy center.

However, “many enrollees in Medicaid MCOs [managed care organizations] do not have similar options” because they are in jurisdictions with mandatory Medicaid managed care enrollment and “have neither a default to Traditional Medicaid, nor do they have significant plan options,” the center said.

This underscores the need for increased federal oversight for Medicaid MCOs rather than increased state discretion as outlined in the proposed regulation, the center added.

Provider Groups

Provider groups also urged following the MA system in this area.

“At least initially, we urge CMS to take a central role in the establishment and application of network adequacy standards” by Medicaid managed care plans, the American Osteopathic Association (AOA) said.

The establishment and maintenance of “stable physician-patient relationships is critical and that attention should be directed not only to the accessibility of provider networks, but to their stability,” the AOA said.

“For this reason, we urge CMS to include a requirement that MMC [Medicare managed care] plans provide periodic reports of provider turnover to the state and to submit appropriate remedial plans in the event of excessive provider turnover.”

Hospitals Want MA Standards

Likewise, the Federation of American Hospitals said the CMS should “take a more directive role with regard to setting appropriate parameters” for Medicaid plans.

Although initially the agency deferred to MA plans regarding network adequacy, the FAH said, “CMS’s experience over time led to a change to a more detailed and standards-based framework.”

The hospital group recommended that the CMS “adopt the MA network adequacy standards for Medicaid managed care.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Janey Cohen at


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