Since January 1, 2006, all dual-eligible beneficiaries--individuals with both Medicare and Medicaid coverage--must receive their drug benefit through Medicare's new Part D prescription drug plans (PDP) rather than from state Medicaid programs. GAO analyzed (1) current challenges in identifying and enrolling new dual-eligible beneficiaries in PDPs, (2) the Centers for Medicare & Medicaid Services' (CMS) efforts to address challenges, and (3) federal and state approaches to assigning dual-eligible beneficiaries to PDPs. GAO reviewed federal law, CMS regulations and guidance and interviewed CMS and PDP officials, among others. GAO also made site visits to six states to learn about the enrollment of dual-eligible beneficiaries from the state perspective.
Recommendations for Executive Action
|Centers for Medicare and Medicaid Services||1. To help ensure that dual-eligible beneficiaries are receiving Part D benefits, the Administrator of CMS should require PDP sponsors to notify new dual-eligible beneficiaries of their right to reimbursement for costs incurred during retroactive coverage periods.|
|Centers for Medicare and Medicaid Services||2. To determine the magnitude of Medicare payments made to PDPs under its retroactive coverage policy, the Administrator of CMS should track how many of the new dual-eligible beneficiaries it enrolls each month receive retroactive drug benefits and how many months of retroactive coverage the agency is providing them.|
|Centers for Medicare and Medicaid Services||3. To determine the impact of its retroactive coverage policy, the Administrator of CMS should monitor PDP reimbursements to dual-eligible beneficiaries, and those that paid on their behalf, for costs incurred during retroactive periods through an examination of the prescription utilization data reported by PDP sponsors.|
|Centers for Medicare and Medicaid Services||4. To mitigate the risks associated with implementing Part D information systems changes, especially in light of initial systems issues caused by the lack of adequate testing, the Administrator of CMS should work with key partners to plan, prioritize, and execute end-to-end testing.|
|Centers for Medicare and Medicaid Services||5. To help ensure new dual-eligible beneficiaries are enrolled in PDPs that serve the geographic area where they live, the Administrator of CMS should assign dual-eligible beneficiaries with representative payees to a PDP serving the state that submits the individual's information on their dual-eligible file.|
|Centers for Medicare and Medicaid Services||6. To support states with the relevant authority that want to use alternative enrollment methods to reassign dual-eligible beneficiaries to PDPs, the Administrator of CMS should facilitate the sharing of data between PDPs and states.|