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How California’s Dual-Eligibles Project Compares With Five Other States’ Plans

Officials in six states designing programs to coordinate benefits and services for people who qualify for both Medicare and Medicaid are finding one of the most difficult issues to resolve is creating an integrated appeals process.

That’s the summary finding of a new analysis released last week by the National Senior Citizens Law Center, a not-for-profit senior advocacy and research group.

“The appeals systems for Medicare and Medicaid have developed separately with different required timeframes, different appeal procedures and different consumer protections,” the report said. “Achieving the twin goals of maintaining existing beneficiary protections while also simplifying the beneficiary experience has been a challenge.”

The six states furthest along in their dual-eligibles projects include California, which hopes to launch the Cal MediConnect program in April 2014. The other five states are Illinois, Massachusetts, New York, Ohio and Virginia.

The report examined four primary appeals criteria:

  • The levels of appeal offered;
  • Timeframes of those appeals;
  • How overlapping services are handled; and
  • Aid paid while appeals are in the process, or whether beneficiaries continue to receive services while an appeal is being heard.

Four states have a 60-day timetable for appeals and one state set 90 days for the appeal process. During its preliminary demonstration project, California will retain the current 60-day Medicare appeal timeframe as well as the 90-day timeframe for Medi-Cal, California’s Medicaid program. California officials plan to shift all appeals to the 90-day timetable in future years.

California and Ohio are the only two states to allow direct access to a fair hearing, rather than requiring all internal appeals to finish first. However, neither Ohio nor California provides clarity on how overlapping services will be handled, the report said.

The biggest difference in California is the position on aid paid pending appeal in its memorandum of understanding with federal officials, the report said.

“All of the [states], except California, provide for [aid paid pending] for all services — whether Medicare or Medicaid — during the internal plan appeal,” the report said. “Currently it is unclear whether California will offer [aid paid pending] during plan-level appeals of Medicare services.”

The other difference in California, the report said, is in integration of appeals, citing California’s “approach of waiting until the demonstration has begun to identify opportunities for additional integration.”

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