This week’s newsletter covers the NAMD Spring meeting the release of VPB Issue Brief and a letter on FLSA. Other topics include HCBS, eligibility and enrollment, Zika, Congressional action, and HHS OIG 2016 work plan update.
NAMD Holds Annual State-Only Spring Meeting in Nashville
Last week, NAMD convened Medicaid Directors and senior staff for our annual state-only Spring Meeting in Nashville, Tennessee. NAMD provided Directors with the opportunity to network with and learn from their peers, discuss key federal regulatory issues, provide updates on initiatives in their states, and engage in productive discussion with federal partners at the Centers for Medicare and Medicaid Services (CMS). Topics discussed included NAMD’s work on Medicaid value-based purchasing, the final Medicaid managed care rule, the home and community-based services settings rule, and the access monitoring rule.
For the first time, this year’s Spring Meeting featured a full day of Medicaid leadership development, focused on articulating visions and translating that vision into effectively leading through change.
NAMD Welcomes New Staff
We would like to welcome and introduce you to the newest NAMD staff member, Cornelia Lluberes. Cornelia joins NAMD as a policy and data analyst and one of her duties is working on the NAMD Operations Survey that will be coming out soon. Before NAMD, Cornelia worked for the ONE Campaign’s health policy team, managing policy content for the Global Fund to Fight AIDS, TB, and Malaria’s replenishment campaign for 2017-2019 while providing analytic support for several issues including health systems strengthening, pandemic preparedness, and donor transition policies.
Cornelia received her B.A. from Princeton University’s Woodrow Wilson School of Public Policy and International Affairs in 2014. During her time at Princeton, she participated and later advised a mock taskforce on the role of states in implementing the Affordable Care Act for the Medicaid and CHIP Payment and Access Commission (MACPAC). Under the guidance of Heather Howard, her senior thesis focused on coverage of obesity-related treatments in Maryland’s and Virginia’s public and private markets.
New NAMD Issue Brief Examines Multi-Payer Alignment in VBP On June 13, NAMD released a new issue brief, with support from The Commonwealth Fund, that examines the importance of including Medicaid state-led work in national conversations on value-based purchasing (VBP). This new resource builds on NAMD’s comprehensive report released earlier this year on the landscape of VBP in Medicaid, and it explores the opportunities for state and federal alignment in the development of VBP in order to maximize its effectiveness. Key issues examined in this resource include:
What is driving Medicaid VBP and how states are building these models;
Federally-led efforts to drive value in health care purchasing, such as MACRA and the Health Care Payment Learning and Action Network; and
Opportunities for furthering Medicare and Medicaid alignment in this work, such as around key federal programs (i.e., CPCI) and around the tools that underpin value-based purchasing (i.e., quality measurement).
For more information on NAMD’s payment and delivery system reform work, please contact Lindsey Browning.
NAMD, Sister State Agency Associations Weigh in on FLSA White Collar Exemption Rule
On June 3, NAMD joined with sister state agencies representing state mental health programs, state aging and physical disability programs, and state developmental disability programs to send a letter to the Department of Labor (DOL) regarding its recent final rule on the Fair Labor Standards Act (FLSA) and the “white collar” exemptions. Specifically, we articulate concerns around the DOL’s non-enforcement policy, which exempts new wage thresholds for employees at providers of Medicaid-funded services for individuals with intellectual or developmental disabilities in residential homes and facilities with fewer than 15 beds.
The letter states that the DOL policy fundamentally misunderstands the nature of long-term services and supports in the Medicaid program, does not clearly articulate entities impacted by the non-enforcement policy, discriminates against some Medicaid populations receiving home and community-based services, and may limit access to such services. To alleviate these concerns, the state associations request that DOL expand the non-enforcement policy to all government-funded HCBS services, delay the effective date until after the end of the next state legislative session, and provide support for HCBS providers against the threat of litigation or other private action.
NAMD President Tom Betlach Named to CBO Panel of Health Advisers
NAMD wishes to congratulate Arizona Medicaid Director and NAMD President Tom Betlach on his selection to the Congressional Budget Office (CBO)’s panel of health advisers. We are pleased that Tom will be lending his expertise to inform CBO’s analysis of legislation impacting the Medicaid program and the overall national healthcare system.
CMS Offers Initial Approval of HCBS STPs to Kentucky and Ohio
On June 2, the Centers for Medicare and Medicaid Services (CMS) sent letters indicating initial approval of both Kentucky and Ohio’s statewide transition plans (STPs) required under the home and community-based services (HCBS) settings rule. These initial approvals are based on the states’ systemic assessments of their regulations, certifications, policies, and procedures, plans to remediate any findings of non-compliance with the HCBS settings rule in those procedures, and the outlining of milestones to complete remediation activities.
To view these STPs and see the status of all state STPs, visit CMS’s HCBS website here.
Louisiana Implements First-in-the-Nation Approach to Eligibility and Enrollment
Beginning June 1, Louisiana residents with a household income below 138% of the federal poverty level are eligible to obtain health coverage through the state’s Medicaid program. Led by Governor John Bel Edwards and Medicaid Director Jen Steele, Louisiana’s expansion brings the total number of states that have expanded Medicaid to 31 (including the District of Columbia), meaning that now more than half of uninsured individuals who could obtain coverage from Medicaid expansion live in states that have expanded the program. In an unprecedented move, Louisiana will utilize information from the Supplemental Nutrition Assistance Program (SNAP) to determine eligibility for Medicaid enrollment. It is estimated that under the expansion, 375,000 new adults will enroll in coverage; nearly 30,000 fewer people will be crippled by burdensome medical costs; and $200 million in uncompensated care costs will be saved annually.
On June 1, the Centers for Medicaid and CHIP Services (CMCS) published an informational bulletin providing information on how Medicaid programs can utilize various services and authorities to provide options for the prevention, detection, and treatment of the Zika virus. The guidance notes several options states have for providing Zika-related services, including:
Claiming FFP for over-the-counter mosquito repellants prescribed by an authorized health professional;
Using 90% match family planning services to educate beneficiaries about the Zika virus and providing access to contraceptives;
Coverage of diagnostic services to detect Zika via the diagnostic services benefit, the screening services benefit, other preventive services benefit, or other laboratory and x-ray services benefit;
Coverage of Zika-related treatment services via targeted case management, physical therapy and related services, prescribed drugs, long-term services and supports, and other authorities.
On May 31, the Centers for Medicaid and CHIP Services (CMCS) published an informational bulletin updating the spousal impoverishment standards for married individuals seeking certain long-term services and supports services. This update reflects annual adjustments reflecting changes in the Supplemental Security Income (SSI) benefit rate and the Consumer Price Index (CPI).
The bulletin describing these changes is available here. A chart detailing the 2016 SSI and spousal impoverishment standards is available here.
CMS Publishes Final Rule on Medicare ACOs with Focus on Performance-Based Risk Arrangements
On June 6, the Centers for Medicare and Medicaid Services (CMS) published a final rule detailing how regional Medicare FFS spending will be incorporated into the Medicare Shared Savings Program’s Medicare Accountable Care Organization (ACO) benchmarking updates for those ACOs choosing to continue program participation beyond the initial 3-year agreement. The rule also provides incentives for ACOs to begin transitioning to a performance-based risk arrangement. The new benchmarking methodology is aimed at assessing ACO performance in comparison to other providers in the ACO’s regional market.
A fact sheet providing more information about this rule is available.
Recently, the Center for Medicare and Medicaid Innovation (CMMI) issued an updated FAQ document on its Comprehensive Primary Care Plus (CPC+) model, which details changes to CPC+ eligibility requirements to allow participation by primary care practices which are also participating in an Accountable Care Organization (ACO) under the Medicare Shared Savings Program. Specifically, the changes allow up to 1,500 eligible primary care practices currently participating in or applying to participate in Tracks 1, 2, or 3 of the Medicare ACO program as of January 1, 2017, to also participate in CPC+.
The full FAQ document detailing this change and other CPC+ information is available here.
CMS Acting Administrator Elevates Role of Silicon Valley in Medicaid IT
On May 25, CMS Acting Administrator Andy Slavitt wrote a blog post discussing CMS’s work to link software and technology innovation companies to the Medicaid IT space. In the post, he discusses a CMS meeting which took place in Silicon Valley last week to bring together states, tech companies, and senior CMS staff to explore how to enhance collaboration among these actors and leverage technology opportunities to enhance the Medicaid program. The blog notes the Software as a Service model as a means to meet Medicaid’s IT needs, as well as the availability of enhanced federal match to support state work in this area. The blog also highlights CMS’s work to create a one-stop web portal for open state Medicaid IT Requests for Proposal, the ability for software vendors to receive CMS pre-certification of their products for Medicaid purposes, and CMS’s desire to recruit an entrepreneur-in-residence to further support its work.
Senate Subcommittee Approves Investments in Opioid Abuse Prevention and Mental Health
On June 7, the Senate Appropriations Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS) Subcommittee passed a FY 2017 appropriations bill providing $161.9 billion in discretionary spending, a $270 million reduction from FY 2016 and $2 billion less than the President’s budget request. The bill makes $126 million in additional federal investments (total of $261 million) to combat opioid abuse, with targeted investments of $28 million in CDC prescription drug overdose programs, $49 million SAMHSA treatment and prevention programs, and $50 million for community health centers to expand treatment and prevention services. The bill also increases federal funding for mental health by $80 million compared to FY 2016 (total of $541.5 million), with an additional $30 million to the Mental Health Block Grant program and $50 million for community health centers to expand mental health treatment services.
House Committee Poised to Mark Up Mental Health Bill
This week, the House Energy and Commerce Committee (E&C) is scheduled to hold a full committee markup of H.R. 2646, the Helping Families in Mental Health Crisis Act. The bill would create an Assistant Secretary for Mental Health and Substance Use Disorders, significantly reform SAMHSA grant programs, reform statutory limits around the sharing of mental health diagnosis information, and set in statute the “in lieu of” Medicaid IMD services provided by managed care organizations recently finalized in the Medicaid managed care final rule, among other provisions.
NAMD requested that policymakers consider the connection between mental health and substance use disorder programs and the wide array of state-driven initiatives and demonstrations currently underway in the Medicaid program which impact similar populations. These include but are not limited to those approved and subject to evaluation by the Center for Medicare and Medicaid Innovation (CMMI). NAMD also noted that several states are exploring integration models (e.g. behavioral health homes) and others have a key focus on mental health delivery models within their State Innovation Model (SIM) program. NAMD stated that policymakers should ensure there is a clear expectation for strategic coordination and communication with CMS and state Medicaid agencies given Medicaid’s dominate role as a payor for mental health and substance use disorder services and the work underway to integrate and transform delivery systems that serve individuals with MH or SUD conditions.
Bipartisan Senate Letter Requests Lifting of Restrictions on MAT
On June 1, a bipartisan group of 22 Senators sent a letter to HHS Secretary Sylvia Burwell requesting that the cap of 100 patients per provider for medication assisted therapy (MAT) via buprenorphine be lifted. The letter notes that in light of the ongoing opioid abuse epidemic, access to a broad range of evidence-based treatments, including MAT, is necessary. The Senators state that a proposed rule to lift the cap to 200 patients per provider will not be sufficient, and asks for a cap of 500 patients per provider in the final rule.
Senators Convene Mental Health Summit, Prepare for Mental Health Vote This Summer
Work in the Senate on mental health reform legislation continues, with Senate Health, Education, Labor, and Pensions (HELP) Committee Chairman Lamar Alexander (R-TN) indicating that Senate Majority Leader Mitch McConnell (R-KY) anticipates the bill would be introduced in the summer. His comments came during a “Senate Mental Health Summit” hosted by Sens. Chris Murphy (D-CT) and Bill Cassidy (R-LA) hosted. The event brought together a range of experts in the field to discuss the latest research, needed federal policy changes and to press for passage of the Mental Health Reform Act ( S. 2680).
Remaining issues that must be resolved before a vote can occur include whether and how the legislation would impact gun rights and how the legislation’s costs would be offset. Senators continue to negotiate the whether the chamber will take up policies addressing the Medicaid IMD payment exclusion. For the latter, an expansion of the IMD demonstration program rather than a full repeal of the policy may be a potential path forward, according to Sen. Chris Murphy (D-CT).
RECAP: House E&C Hearing on Medicare, Medicaid Improper Payments
On May 24, the House Energy and Commerce (E&C) Subcommittee on Oversight and Investigations held a hearing titled “Medicare and Medicaid Program Integrity: Combatting Improper Payments and Ineligible Providers.” A recording of the hearing, full witness list, and submitted testimony are available on E&C’s website.
The hearing focused primarily on exploring reports from the Health and Human Services Office of the Inspector General (HHS OIG) on Medicaid provider ownership and enrollment, Medicare provider enrollment records, and Medicaid provider enrollment screening. A report from the Government Accountability Office on the Provider Enrollment, Chain and Ownership System (PECOS) was also discussed. E&C members focused on CMS’s delay in implementing recommendations in these reports and prior OIG and GAO reports, with Subcommittee Chairman Tim Murphy (R-PA) noting OIG’s estimated $89 billion in fraud and improper payments from the two programs. OIG’s testimony reiterated the need for getting provider enrollment right, while GAO focused on the ongoing need to improve address verification. CMS’s Center for Program Integrity testified regarding its efforts to improve state access to federal databases for provider screening purposes, but noted that more work remains to be done in this space.
In the News
Oklahoma Budget Deal Nixes Expansion, Sidesteps Large Rate Cuts
Recently, Congressional Quarterly covered a budget the Oklahoma legislature passed on May 27 to address a $1.3 billion state funding shortfall, in the process avoiding a proposed 25 percent reduction in Medicaid reimbursements and associated negative impacts on access to covered Medicaid services. The budget deal did not include passage of a proposed cigarette tax, which was intended to fund a Medicaid expansion to cover 175,000 uninsured adults.
NAMD Executive Director Matt Salo is quoted in the CQ article on the political dynamics impacting the expansion debate. “It’s predictably difficult to get a lot done in the run up to an election cycle, because maybe things will be different after the election,” he said. “At the state level once you get through the election and primary season, which is generally more important, that frees up state legislatures to openly and publicly engage on these issues.”
Georgia Reports on Extension of Settlement Agreement with DOJ
On May 18, the State of Georgia and the United States Department of Justice agreed to an Extension of Settlement Agreement modifying the original terms of the 2010 Americans with Disabilities Act Settlement. The decision follows findings that Georgia has been in “substantial compliance” with virtually all of the behavioral health obligations set forth in the original 2010 settlement and has achieved significant progress in transforming its intellectual and developmental disability service system. Containing work in areas such as supported housing, risk management, quality reviews, and community-based care, the agreement carries pivotal implications for Georgia’s Medicaid program.
Government Technology Reports on New CMS Medicaid IT Procurement Portal
In January of this year, CMS launched the State Medicaid IT Procurement Opportunities portal, signifying an important change in how the federal government manages private-sector vendors and large state technology projects. Fostering open cooperation with competitive vendors, the portal will function as a “one stop shop” for connecting private sector actors with state projects; it will run alongside a pre-certification program, which will allow vendors to create and advertise software modules against additional vetted options, thereby assuring states of the options’ legitimacy and operability.
Moreover, the portal will encourage iterative development by enabling vendors to certify their initiatives via incremental steps so that states are not stuck with large but monopolizing (and sometimes dysfunctional) systems. To assist with the portal’s development, CMS is currently interviewing for an “entrepreneur-in-residence” who will help the agency understand what vendors need to know to optimize their engagement with the portal.
The Times-Picayune reports on Medicaid coverage of bug repellant to combat Zika
On June 1, CMS offered basic guidelines to help states prevent, detect and respond to the threat of Zika as summer approaches, articulating how Medicaid programs may pay for prescription mosquito repellent. Likely to be one of the states most impacted by the virus, Louisiana has begun taking proactive measures to follow CMS guidance and protect its citizens, including computerized tomography scans, magnetic resource imaging, ultrasounds and blood tests, and family planning coverage, which can prevent sexual transmission of Zika. Louisiana Medicaid Director Jen Steele said her office will base its coverage criteria on recommendations from the U.S. Centers for Disease Control and Prevention. Still, there is concern that New Orleans and other cities with high proportions of people in poverty will have difficulty securing universal access to bug repellants, window screens, and/or air conditioners.
Federal Court Judge Prohibits Limitations on Access to Hepatitis C Drugs
On May 28, the Seattle Times published an article titled, “Judge orders Washington Medicaid to provide lifesaving hepatitis C drugs for all.” The article cites U.S. District Court Judge John C. Coughenour’s recent injunction, mandating that Washington’s Medicaid provider suspend a 2015 policy restricting access to hepatitis C drugs according to individuals’ fibrosis score (a proxy for”level” of sickness) and adjust for state- and federal-level inconsistencies. The injunction represents a response to a class-action lawsuit filed in February on behalf of two patients who were denied a prescribed hepatitis C drug (Harvoni) due to its cost. It is not yet clear how soon Medicaid patients with hepatitis C may begin filling prescriptions for Harvoni and other direct-acting antiviral drugs, but the associated costs are expected to rise dramatically: Washington’s state Medicaid director, MaryAnne Lindeblad, has estimated that paying for hepatitis C treatment for all Washington Medicaid clients could triple the agency’s current $1 billion drug budget.
NYT Reports on Ramifications of IRS Ruling on ACOs
On May 29, the New York Times published an article titled, “I.R.S. Ruling Is Obstacle to Health Care Networks Promoted by Obama.” The article assesses the implications of a recent IRS ruling denying a tax exemption sought by an accountable care organization (ACO) that coordinates care for people with commercial insurance, citing the fact that the ACO does not operate exclusively for charitable purposes and provides private benefits to some doctors in its network. The ruling poses a threat to ACOs, which collectively cover more than 28 million Americans and better incentivize providers to keep patients healthy and to control costs – especially ACOs that do not participate in Medicare. Unlike those ACOs that cover Medicaid beneficiaries and/or privately insured individuals, Medicare-associated ACOs are deemed to better “advance ‘the charitable purpose of lessening the burdens of government'” and frequently enjoy a tax-exempt status.
HHS OIG Report Analyzes Medicaid MCO Identification of 340B Drug Claims
Earlier this month, the Health and Human Services Office of the Inspector General (OIG) published a report titled “State Efforts to Exclude 340B Drugs from Medicaid Managed Care Rebates.” The report analyzes methods states and their Medicaid managed care plans use to identify and exclude drugs purchased under the 340B drug discount program from invoiced rebates under the Medicaid drug rebate program (MDRP), in compliance with statutory requirements prohibiting the so-called “duplicate discount” scenario.
OIG reviewed 37 states to inform its report, and found 35 of those states have methods to identify 340B claims in managed care, and 30 of those states utilize provider-level claims identification methods to identify 340B covered entities. 22 of these 30 states reported using provider-level claims identification exclusively, while the remaining 8 used other methods in addition to the provider-level claims. OIG stated that reliance only on provider-level claims identification may not be sufficient to accurately capture 340B utilization, meaning duplicate discounts or unclaimed rebates may exist.
OIG recommended that:
CMS require states to use claims-level methods to identify 340B claims; and
HRSA should clarify its guidance on preventing duplicate discounts for MCO drugs.
CMS disagreed with OIG’s recommendation. While CMS agrees that claims-level identification is important, the 340B and Medicaid statutes do not contemplate such a requirement for states and that states may develop their own procedures to identify 340B claims on the individual claim level. HRSA agreed with OIG’s recommendations and noted it will need to accept public comment on its proposed 340B omnibus guidance prior to implementation of the recommendation.
Recently, the Health and Human Services Office of the Inspector General (HHS OIG) released its mid-year update to its FY 2016 work plan. New initiatives are indicated below. Medicaid-related work includes:
Medicaid Prescription Drug Reviews
Physician -Administered Drugs for Duals (NEW)
Specialty Drug Pricing and Reimbursement
State Actions Based on Drug Utilization Reviews
State Collection of Rebates on Physician Administered Drugs
State Collection of Rebates for Drugs Dispensed to MCO Enrollees
Home Health Services and Other Community-Based Care
Oversight and Effectiveness of Medicaid Waivers (NEW)
Adult Day Health Services
Room and Board Costs Associated with HCBS Waiver Programs
Other Medicaid Services, Equipment, and Supplies
Mandatory Review of Express Lane Eligibility
Transportation Services – Compliance with Federal and State Requirements
State Claims for Federal Reimbursement
Dental Services for Children – Inappropriate Billing
Family Planning Services – Claims for Enhanced FFP
Community First Choice State Plan Option
Payments to States Under the Balancing Incentive Program
Medicaid Beneficiary Transfers from Group Homes and Nursing Facilities to Hospital Emergency Rooms
State Management of Medicaid
States’ Compliance with Requirements for Treatment of Health Care-Related Taxes on Medicaid Managed Care Organizations (NEW)
State Use of Provider Taxes to Generate Federal Funding
State Compliance with Federal Certified Public Expenditures Regulations
State Cost Allocations that Deviate from Acceptable Practices
Enhanced Federal Medical Assistance Percentage
Medicaid Eligibility Determinations
State Reporting of Medicaid Collections
State Use of Incorrect FMAP for Federal Share Adjustments
States’ Experiences with Enhanced Provider Screening
OIG Oversight of State Medicaid Fraud Control Units
State MFCU FY 2015 Annual Report (NEW)
Medicaid Information System Controls and Security
State Medicaid Agency Breach Protections and Responses (NEW)
Completeness of Data in Transformed Medicaid Statistical Information System: Early Implementation
Medicaid Managed Care
Medical Loss Ratio (REVISED)
Review of States’ Methodologies for Assigning Managed Care Organization Payments to Different Medicaid FMAPs
Medicaid Managed Care Entities’ Identification of Fraud and Abuse
Milliman Releases 2015 Medicaid Risk-Based Managed Care Financial Analysis Report
Recently, Milliman published its analysis of 2015 financial results for Medicaid managed care plans, based on plans reporting Medicaid experience in their annual National Association of Insurance Commissioners (NAIC) statements. The report covers 191 MCOs in 37 states and territories. In 2015, plans reported over $144 billion in Medicaid revenue, representing a growth of over 130% since 2011 (driven in part by a growth in enrollment of 70% over the 2011 – 2015 time period). Notably, the report found that over 75% of analyzed MCOs were at or above an 85% medical loss ratio (MLR).
Recently, GenWorth, a long-term services and supports (LTSS) insurer, released results from a survey of LTSS cost of care via an interactive tool. The tool provides information on costs and five-year growth trends for home health care, adult day health care, assisted living facilities, and nursing home care, with the ability to break down information across states and costs by year, month, and day.
KFF Publishes Issue Brief on Justice-Involved Community Transitions in AZ, CT, MA
Recently, the Kaiser Family Foundation published an issue brief analyzing initiatives in Arizona, Connecticut, and Massachusetts to connect eligible persons transitioning from corrections settings to the community with Medicaid services. The brief notes that each state connects these individuals to Medicaid coverage at multiple points within the justice system, such as suspending rather than terminating Medicaid eligibility upon incarceration and enrolling inmates prior to release. They also work with individuals to connect them to the providers and services they need upon transition.
New Research ExaminesCommunity Transitions for Disabled Persons
In their article, “Understanding Deinstitutionalization: What Families Value and Desire in the Transition to Community Living,” Jennifer L. Jones and Kami L. Gallus investigate the experience of mandated deinstitutionalization for parents and siblings whose relatives with intellectual and developmental disabilities (IDD) transitioned from institutionalization to community living within the past 1 to 3 years. Findings from the study align with previous research wherein, over time, most families shift from opposition to satisfaction regarding community living. Across the board, participants emphasized respect, collaboration, consistency and quality of care, and the importance of family as critical factors in ensuring a smooth transition to community living.
On May 25, the National Association of State and Territorial AIDS Directors (NASTAD) announced the launching of its “Ready to End the HIV and Viral Hepatitis Epidemics” campaign. The campaign challenges health departments across the nation to take action to eliminate these diseases via a three-step process:
Signing a pledge and policy statement reaffirming the opportunity and role played by state and territorial health departments.
NASTAD will survey health departments to identify the minimum program and policy steps necessary to address HIV and hepatitis care and prevention, and assess where health departments currently are in regards to these steps.
NASTAD will develop a report card for health departments on core department competencies, and provide technical assistance to departments where greatest impact can be made.
The campaign announcement notes that the federal government and professional societies are backing their own major strategies to address HIV and hepatitis, and the time is right for states to do the same.
Earlier this month, state staff from New Hampshire and Illinois spoke on a panel at an event organized by the Center for Medicare and Medicaid Innovation (CMMI). At this “Datapalooza” panel, both states discussed their Medicaid programs’ use of Medicare data to support ongoing work. New Hampshire discussed the utility of this data in their participation in CMS’s Innovation Accelerator Program, while Illinois discussed their participation in the Financial Alignment Initiative aimed at improving care for the dually eligible Medicare-Medicaid population.