States must operate their Medicaid programs within broad federal  parameters. states may obtain the authority to enroll Medicaid beneficiaries, including  dual-eligible beneficiaries, into managed care through the approval of two  types of Medicaid waivers:
Section 1115 of the Social Security Act provides the Secretary of  Health and Human Services with the authority to grant states waivers  of certain federal Medicaid requirements and allow costs that would  not otherwise be eligible for federal funds for the purpose of  demonstrating alternative approaches to service delivery. In 2010,  about 9.3 percent of dual-eligible beneficiaries were enrolled in Medicaid  managed care plans. Selected Consumer Protection Requirements

Medicare and Medicaid have a number of requirements intended to  protect the rights of beneficiaries, some of which are of particular  importance to dual-eligible beneficiaries. Programs to Integrate Medicare and Medicaid for Dual-Eligible Beneficiaries

Both Medicare and Medicaid have standard appeals processes and expedited appeals  processes in cases of urgent need. Medicare and Medicaid Consumer Protection Requirements Vary across Programs, Payment Systems, and States

There are key differences in enrollment choice requirements across the  Medicare and Medicaid programs, the FFS and managed care payment  systems and the selected states. SNPs, including D-SNPs, have been reauthorized  several times since their establishment was first authorized in 2003.

		Notable Differences Exist in Requirements for Enrollment Choice across the Programs, Payment Systems, and Selected States

Within Medicare, enrollment in managed care is always voluntary,  whereas state Medicaid programs can require enrollment in managed  care in certain situations. Under the Geographic Managed Care program, dual-
Minnesota: Dually eligible seniors in Minnesota must enroll in one of  two managed care programs, and dual-eligible beneficiaries who  became eligible on the basis of their disabilities can choose whether  to enroll in a managed care program. North Carolina: According to North Carolina Medicaid officials, all  Medicaid beneficiaries, including dual-eligible beneficiaries, are in  FFS, and the majority of dual-eligible beneficiaries are in a primary  care case management program, where primary care providers are  paid on a FFS basis, in addition to receiving a monthly fee to perform  certain care coordination activities. Certain Requirements for Continuity and Coordination of Care, Provider Networks, and Marketing Materials Are Unique to Managed Care

			Continuity and Coordination of Care

In general, federal law and regulations do not specifically require MA  plans or Medicaid managed care plans to cover services provided by a  beneficiary’s previous providers if that provider is not in the plan’s network  when a beneficiary first enrolls in a plan or switches plans. However, states determine to what  extent Medicaid managed care plans must provide beneficiaries with  access to a person or entity primarily responsible for coordinating health  services on the basis of the services the plan must cover. Medicare and state Medicaid programs require managed care plans to  meet certain provider network standards. For example, MA plans  operating in rural counties must have at least one full-time equivalent  (FTE) primary care provider per 1,000 beneficiaries. Medicare has five levels of appeals for managed care and FFS. 1. States can structure their Medicaid appeals processes within the  parameters of federal requirements. Beneficiaries in  Medicaid managed care plans must have the ability to appeal a  termination, suspension, or reduction of a benefit to the plan as well as  have access to a state fair hearing. For example, Arizona requires beneficiaries to  first appeal to their managed care plan before requesting a state fair  hearing. CMS and States Used a Range of Actions to Help Ensure Organizations Comply with Medicare and Medicaid Consumer Protection Requirements

CMS and states used compliance and enforcement actions that ranged  from informal written notices to contract terminations in order to help  ensure MA organizations and Medicaid managed care plans complied  with consumer protection requirements. CMS Took Compliance and Enforcement Actions against Medicare Advantage Organizations

CMS used both compliance and enforcement actions to bring  noncompliant MA organizations into compliance with federal  requirements. Between January 1, 2010, and June 30, 2012, CMS took 546 compliance  actions generally related to consumer protection requirements of  importance to dual-eligible beneficiaries. Between January 1,  2010, and June 30, 2012, the three states reported they took a total of  157 compliance actions against their Medicaid managed care plans. California and  Minnesota identified noncompliance with the appeals and grievance  process that required corrective actions.take corrective actions to ensure beneficiaries were able to access  appropriate translation services. The department noted that the report was an accurate  assessment of the programs we reviewed, and added that the Medicare- Medicaid Coordination Office has already made some progress aligning  the requirements between the two programs in the area of appeals. Appendix II: Description of Selected Federal and State Requirements

Table 3 describes selected consumer protection requirements for  Medicare and Medicaid fee-for-service (FFS), and table 4 describes  selected consumer protection requirements for Medicare Advantage (MA)  and Medicaid managed care.
Why GAO Did This Study

Dual-eligible beneficiaries are low-income seniors and individuals with disabilities enrolled in Medicare and Medicaid. In 2010, there were about 9.9 million dual-eligible beneficiaries. Both programs have requirements to protect the rights of beneficiaries. These requirements are particularly important to dual-eligible beneficiaries, who must navigate the rules of both programs and generally have poorer health status.
To help inform efforts to better integrate the financing and care for dual-eligible beneficiaries, GAO (1) compared selected consumer protection requirements within Medicare FFS and Medicare Advantage, and Medicaid FFS and managed care, and (2) described related compliance and enforcement actions taken by CMS and selected states against managed care plans.
GAO identified consumer protections of particular importance to dual-eligible beneficiaries on the basis of expert interviews and literature, including protections related to enrollment, provider networks, and appeals. GAO reviewed relevant federal and state statutes, regulations, and policy statements, and interviewed officials from CMS and four states selected on the basis of their share of dual-eligible beneficiaries and use of managed care (Arizona, California, Minnesota, and North Carolina). GAO analyzed data on compliance and enforcement actions in Medicare Advantage and Medicaid managed care from January 1, 2010, through June 30, 2012.

What GAO Found

Medicare and Medicaid consumer protection requirements vary across programs, payment systems--either fee-for-service (FFS) or managed care--and states. Within Medicare, enrollment in managed care through the Medicare Advantage (MA) program must always be voluntary, whereas state Medicaid programs can require enrollment in managed care in certain situations. For example, Arizona requires nearly all beneficiaries, including dual-eligible beneficiaries, to enroll in managed care, but in North Carolina all beneficiaries are in FFS. In addition, Medicare and state Medicaid programs require managed care plans to meet certain provider network requirements to ensure beneficiaries have adequate access to covered services. For example, MA plans in rural counties must have at least one primary care provider per 1,000 beneficiaries. Subject to federal parameters, states establish network requirements for their Medicaid programs. For example, in California every plan must have at least one primary care provider per 2,000 beneficiaries. Finally, Medicare and Medicaid also have different appeals processes that do not align with each other. The Medicare appeals process has up to five levels of review for decisions to deny, reduce, or terminate services, with certain differences between FFS and MA. In Medicaid, states can structure appeals processes within federal parameters. States must establish a Medicaid appeals process that provides access to a state fair hearing and Medicaid managed care plans must provide beneficiaries with the right to appeal to the plan, though states can determine the sequence of these appeals. For example, Arizona requires beneficiaries to appeal to the managed care plan first, while a beneficiary in Minnesota may go directly to a state fair hearing without an initial appeal to the managed care plan.
Both the Centers for Medicare & Medicaid Services (CMS), the agency that administers the Medicare program and oversees states' operation of Medicaid programs, and states took a range of compliance and enforcement actions to help ensure that MA and Medicaid managed care organizations complied with their consumer protection requirements. Between January 1, 2010, and June 30, 2012, CMS took 546 compliance actions against MA organizations on the issues GAO identified as generally related to consumer protections of particular importance to dual-eligible beneficiaries. Compliance actions included notices, warning letters, and requests for corrective action plans (CAP). During the same period, CMS took 22 enforcement actions against MA organizations, including the imposition of 17 civil money penalties--nearly all for late or inaccurate marketing materials. For five serious violations, CMS suspended enrollment into the MA plan and suspended the MA plan's ability to market to beneficiaries. Similarly, states used notices, letters, fines, and CAPs to improve Medicaid managed care plan compliance with Medicaid consumer protection requirements. During the same period, Arizona, California, and Minnesota required managed care plans to undertake 91 corrective action plans, 52 percent of which related to problems with plans' appeals and grievances processes.
In commenting on a draft of the report, the Department of Health and Human Services noted that the report was an accurate assessment of the programs we reviewed.