Helping states develop integrated programs for individuals who are dually eligible for Medicare and Medicaid

March 13, 2020

Spotlight: New Interoperability and Patient Access Rule Will Affect Dually Eligible Individuals

On March 9, the Centers for Medicare & Medicaid Services (CMS) issued the Interoperability and Patient Access final rule (CMS-9115-F), which is designed to improve patient access to their health information, improve interoperability and encourage innovation, while reducing burden on payers and providers. Two provisions will specifically affect dually eligible individuals (see Section VII, Improving the Medicare-Medicaid Dually Eligible Experience by Increasing the Frequency of Federal-State Data Exchanges, and final changes to regulatory text in Parts 406, 407, and 423).

1.      Daily Exchange of Buy-In Files: The rule requires daily state-CMS data exchange to identify Medicare enrollees as well as which party – Medicare or Medicaid – is liable for paying each beneficiary’s Parts A and B premiums (commonly referred to as “buy-in” files). The table below lists the current frequency of buy-in file exchange in each state. For CMS technical assistance to help shift to daily submission of buy-in files, state staff should contact the CMS Office of Information Technology (xxxxxx@cms.hhs.gov) and copy (xxxxxx@cms.hhs.gov).

2.      Daily Exchange of MMA Files: The rule also requires daily state submission of Medicare Modernization Act (MMA) files, which identify all full-benefit and partial-benefit dually eligible beneficiaries. States and CMS currently may exchange these data as infrequently as monthly. Moving to daily data exchange will expedite enrollment status changes, improve customer experiences, and reduce the volume of payment inaccuracies and recoupments. Improving the accuracy and timeliness of data on dual eligibility status is an important step in improving how Medicare and Medicaid work together for beneficiaries, providers, and payers. The table below lists the current frequency of MMA file exchange in each state. States should visit the State Data Resource Center website for more information on MMA files and to request technical assistance in shifting to daily file submission.

Frequency of Buy-In and MMA File Exchange with CMS by State

Both file exchange provisions will take effect April 1, 2022, but states can initiate the process at any time. CMS is encouraging states to make the transition as early as possible and to contact CMS with any questions. For more information, please contact the State Data Resource Center at xxxxxx@EconometricaInc.com or (877) 657-9889. 

ABOUT THE INTEGRATED CARE RESOURCE CENTER

The Integrated Care Resource Center is a national initiative of the Centers for Medicare & Medicaid Services to help states improve the quality and cost-effectiveness of care for individuals dually eligible for Medicare and Medicaid. The state technical assistance activities are coordinated by Mathematica and the Center for Health Care Strategies. For more information, visit https://protect2.fireeye.com/url?k=23e3f835-7fb6f126-23e3c90a-0cc47adb5650-5e15700ae6aef33b&u=http://www.integratedcareresourcecenter.com/.

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