New evidence of state variation in Medicaid payment policies for dual Medicare‐Medicaid enrollees

Abstract

Objective: To develop the first longitudinal database of state Medicaid policies for paying the cost sharing in Medicare Part B for services provided to dual Medicare-Medicaid enrollees ("duals") and an index summarizing the impact of these policies on payments for physician office services. Data sources: Medicaid policy data collected from electronic sources and inquiries with states. Study design: We constructed a national database of Medicaid payment policies for the period 2004-2018, consolidating information from online Medicaid policy documents, state laws, and policy data reported to us by state Medicaid programs. Using this database and state Medicaid fee schedules, we constructed a Medicaid payment index for duals. This index represented the proportion of the Medicare allowed amount that physicians would expect to be paid from Medicare and Medicaid for a subset of physician office services (evaluation and management services) based on annual state payment policies and Medicaid fee schedules. Principal findings: In 2018, 42 states had policies to limit Medicaid payments of Medicare cost sharing when Medicaid's fee schedule was lower than Medicare's-an increase from 36 such states in 2004. In the preponderance of states with these policies, combined Medicare and Medicaid payments for evaluation and management services provided to duals averaged 78 percent of the Medicare allowed amount for these services, reflecting relatively low Medicaid fee schedules in these states. In 2013 and 2014, physicians who qualified for the Affordable Care Act's Medicaid "fee bump" were paid 100 percent of the Medicare allowed amount for these services. Conclusions: Medicaid programs vary across states and over time in their payments of cost sharing for physician office services provided to duals. Our database and index can facilitate monitoring of these policies and research on the consequences of policy changes for duals.

Assessment of the Patient Protection and Affordable Care Act’s Increase in Fees for Primary Care and Access to Care for Dual-Eligible Beneficiaries

“…At the same time, there have been ongoing changes in payment policy for dual-eligible patients, with more states capping reimbursement. 9 In contrast to our study, a prior study 32 found a positive association between full vs lesser-of reimbursement policy and the likelihood that dual-eligible patients had an outpatient visit. Practitioners could be more likely to change their behavior in response to state changes in dual payment policy if these are viewed as less temporary in nature than the ACA fee bump.…”

“…6 , 8 A recent analysis found that the number of states capping dual reimbursement increased from 36 to 42 between 2004 and 2018. 9 Federal law prohibits health care practitioners from directly billing dual-eligible beneficiaries for the uncovered coinsurance amount, although some improper billing occurs, which can further impede access to care for these patients. 10…”

“…6,8 A recent analysis found that the number of states capping dual reimbursement increased from 36 to 42 between 2004 and 2018. 9 Federal law prohibits health care practitioners from directly billing dualeligible beneficiaries for the uncovered coinsurance amount, although some improper billing occurs, which can further impede access to care for these patients. 10 The ACA fee bump temporarily increased primary care Medicaid payments to 100% of the Medicare rate to address potential barriers to care associated with low Medicaid fees, which are often identified by physicians as a deterrent to accepting Medicaid patients.…”

Does Medicaid coverage of Medicare cost sharing affect physician care for dual‐eligible Medicare beneficiaries?

“…These payment rules are termed "lesser-of" policies, because Medicaid's payment equals the lesser of two amounts: (a) Medicare's cost sharing, and (b) the difference between Medicaid's fee schedule and Medicare's payment, net of cost sharing. 4 In states with lesser-of policies and low Medicaid fee schedules, Medicare and Medicaid's combined payment rate for duals can be much lower than the amount providers receive for other Medicare beneficiaries, who are responsible for paying Medicare's cost sharing out-of-pocket or with private supplemental insurance. 4 This payment differential has raised concern that providers may avoid duals, limiting access to care in a population with substantial health risks because of its low socioeconomic status and disproportionate burden of chronic and disabling health conditions.…”

“…4 In states with lesser-of policies and low Medicaid fee schedules, Medicare and Medicaid's combined payment rate for duals can be much lower than the amount providers receive for other Medicare beneficiaries, who are responsible for paying Medicare's cost sharing out-of-pocket or with private supplemental insurance. 4 This payment differential has raised concern that providers may avoid duals, limiting access to care in a population with substantial health risks because of its low socioeconomic status and disproportionate burden of chronic and disabling health conditions. 5 However, little research has examined whether requiring Medicaid to pay Medicare's cost sharing in full would increase the provision of care to this population.…”