This measure would urge a resolution of noncooperation between TRICARE and the federal Centers for Medicare and Medicaid Services to immediately restore mutual data sharing regarding active military members, veterans, and their families who are eligible for both TRICARE and Medicaid health coverage and to waive a restriction for the payment of claims that have been impacted by the inability of TRICARE and Medicaid to share data.

This measure would urge a resolution of noncooperation between TRICARE and the federal Centers for Medicare and Medicaid Services to immediately restore mutual data sharing regarding active military members, veterans, and their families who are eligible for both TRICARE and Medicaid health coverage and to waive a restriction for the payment of claims that have been impacted by the inability of TRICARE and Medicaid to share data.

This measure would urge a resolution of noncooperation between TRICARE and the federal Centers for Medicare and Medicaid Services to immediately restore mutual data sharing regarding active military members, veterans, and their families who are eligible for both TRICARE and Medicaid health coverage and to waive a restriction for the payment of claims that have been impacted by the inability of TRICARE and Medicaid to share data.

WHEREAS, The federal Centers for Medicare and Medicaid Services (CMS), a part of the United States Department of Health and Human Services (HHS), works with the states to fund and implement the Medicaid program, which provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities; and

WHEREAS, TRICARE, which is managed by the United States Department of Defense Military Health System, provides civilian health benefits for active duty and reserve military members of the United States Armed Forces, military retirees, and their dependents, and which relies on the Defense Enrollment Eligibility Reporting System (DEERS) computerized database that contains TRICARE eligibility data for these individuals; and

WHEREAS, Approximately 1.75 million military veterans, their families, and active duty family members (nearly 1 in 10) have TRICARE and Medicaid coverage, including family members of active duty members who qualify under Medicaid income limits, veterans and their families who qualify under Medicaid income limits, disabled veterans and their families, and active duty family members that qualify for Medicaid due to disability; and

WHEREAS, For individuals who have both TRICARE and Medicaid coverage, TRICARE must pay as primary coverage; and

WHEREAS, Historically, identifying individuals with both TRICARE and Medicaid coverage has been a challenging, yet necessary, process, as acknowledged and documented in an HHS Inspector General report, Medicaid Third Party Liability (TPL) Savings Have Increased, But Challenges Remain; and

WHEREAS, Prior to 2017, TRICARE had matched their DEERS eligibility files and provided information back to the states about the individuals who had both TRICARE and Medicaid coverage; and

WHEREAS, The agreement to cross-match between CMS and TRICARE has expired and the parties have been unable to reestablish terms to coordinate benefits between the two programs; and

WHEREAS, In early 2017, TRICARE ceased its support in the data-match process in which states provide Medicaid enrollee eligibility information to TRICARE in order to identify those members who have both TRICARE and Medicaid; and

WHEREAS, The expiration of the agreement has the effect of preventing the recovery of millions of payments annually where Medicaid erroneously paid, because TRICARE should have paid as primary coverage, resulting in a shift of additional costs from the federal government to the states; and

WHEREAS, TRICAREs timely filing limitation precludes Medicaid from billing a claim that should be TRICAREs responsibility if the service was rendered more than one year prior, resulting in additional annual costs shifting to California and other states; and

WHEREAS, TRICARE refuses to share data with, and process eligibility information from, Medicaid managed care organizations that provide care to more than 60 percent of all Medicaid members nationally. It is estimated that millions of dollars annually paid in claims should have been TRICAREs responsibility, not Medicaid managed care organizations, resulting in even more cost shifting to the states and leading to improper Medicaid capitation payments; and

WHEREAS, Approximately 8.6 percent of TRICARE beneficiaries, or approximately 804,724 uniformed service members and their families, are located in California, and thus it is estimated that California could be paying millions of dollars it is not responsible for if this issue of data sharing between TRICARE and CMS is not resolved; now, therefore, be it

Resolved by the Senate and the Assembly of the State of California, jointly, That the Legislature of the State of California urges the United States Department of Defense and the United States Department of Health and Human Services to implement and the United States Congress to require, if necessary, a resolution between the federal Centers for Medicare and Medicaid Services and TRICARE to immediately restore data sharing and to waive the one-year timely filing restriction for all claims caught in this stoppage; and be it further

Resolved, That the Secretary of the Senate transmit copies of this resolution to the President and Vice President of the United States, the Speaker of the House of Representatives, the Minority Leader of the House of Representatives, the Majority Leader of the United States Senate, the Minority Leader of the United States Senate, and to each Senator and Representative from California in the Congress of the United States.

WHEREAS, The federal Centers for Medicare and Medicaid Services (CMS), a part of the United States Department of Health and Human Services (HHS), works with the states to fund and implement the Medicaid program, which provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities; and

WHEREAS, TRICARE, which is managed by the United States Department of Defense Military Health System, provides civilian health benefits for active duty and reserve military members of the United States Armed Forces, military retirees, and their dependents, and which relies on the Defense Enrollment Eligibility Reporting System (DEERS) computerized database that contains TRICARE eligibility data for these individuals; and

WHEREAS, Approximately 1.75 million military veterans, their families, and active duty family members (nearly 1 in 10) have TRICARE and Medicaid coverage, including family members of active duty members who qualify under Medicaid income limits, veterans and their families who qualify under Medicaid income limits, disabled veterans and their families, and active duty family members that qualify for Medicaid due to disability; and

WHEREAS, For individuals who have both TRICARE and Medicaid coverage, TRICARE must pay as primary coverage; and

WHEREAS, Historically, identifying individuals with both TRICARE and Medicaid coverage has been a challenging, yet necessary, process, as acknowledged and documented in an HHS Inspector General report, Medicaid Third Party Liability (TPL) Savings Have Increased, But Challenges Remain; and

WHEREAS, Prior to 2017, TRICARE had matched their DEERS eligibility files and provided information back to the states about the individuals who had both TRICARE and Medicaid coverage; and

WHEREAS, The agreement to cross-match between CMS and TRICARE has expired and the parties have been unable to reestablish terms to coordinate benefits between the two programs; and

WHEREAS, In early 2017, TRICARE ceased its support in the data-match process in which states provide Medicaid enrollee eligibility information to TRICARE in order to identify those members who have both TRICARE and Medicaid; and

WHEREAS, The expiration of the agreement has the effect of preventing the recovery of millions of payments annually where Medicaid erroneously paid, because TRICARE should have paid as primary coverage, resulting in a shift of additional costs from the federal government to the states; and

WHEREAS, TRICAREs timely filing limitation precludes Medicaid from billing a claim that should be TRICAREs responsibility if the service was rendered more than one year prior, resulting in additional annual costs shifting to California and other states; and

WHEREAS, TRICARE refuses to share data with, and process eligibility information from, Medicaid managed care organizations that provide care to more than 60 percent of all Medicaid members nationally. It is estimated that millions of dollars annually paid in claims should have been TRICAREs responsibility, not Medicaid managed care organizations, resulting in even more cost shifting to the states and leading to improper Medicaid capitation payments; and

WHEREAS, Approximately 8.6 percent of TRICARE beneficiaries, or approximately 804,724 uniformed service members and their families, are located in California, and thus it is estimated that California could be paying millions of dollars it is not responsible for if this issue of data sharing between TRICARE and CMS is not resolved; now, therefore, be it

Resolved by the Senate and the Assembly of the State of California, jointly, That the Legislature of the State of California urges the United States Department of Defense and the United States Department of Health and Human Services to implement and the United States Congress to require, if necessary, a resolution between the federal Centers for Medicare and Medicaid Services and TRICARE to immediately restore data sharing and to waive the one-year timely filing restriction for all claims caught in this stoppage; and be it further

Resolved, That the Secretary of the Senate transmit copies of this resolution to the President and Vice President of the United States, the Speaker of the House of Representatives, the Minority Leader of the House of Representatives, the Majority Leader of the United States Senate, the Minority Leader of the United States Senate, and to each Senator and Representative from California in the Congress of the United States.

WHEREAS, The federal Centers for Medicare and Medicaid Services (CMS), a part of the United States Department of Health and Human Services (HHS), works with the states to fund and implement the Medicaid program, which provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities; and

WHEREAS, TRICARE, which is managed by the United States Department of Defense Military Health System, provides civilian health benefits for active duty and reserve military members of the United States Armed Forces, military retirees, and their dependents, and which relies on the Defense Enrollment Eligibility Reporting System (DEERS) computerized database that contains TRICARE eligibility data for these individuals; and

WHEREAS, Approximately 1.75 million military veterans, their families, and active duty family members (nearly 1 in 10) have TRICARE and Medicaid coverage, including family members of active duty members who qualify under Medicaid income limits, veterans and their families who qualify under Medicaid income limits, disabled veterans and their families, and active duty family members that qualify for Medicaid due to disability; and

WHEREAS, For individuals who have both TRICARE and Medicaid coverage, TRICARE must pay as primary coverage; and

WHEREAS, Historically, identifying individuals with both TRICARE and Medicaid coverage has been a challenging, yet necessary, process, as acknowledged and documented in an HHS Inspector General report, Medicaid Third Party Liability (TPL) Savings Have Increased, But Challenges Remain; and

WHEREAS, Prior to 2017, TRICARE had matched their DEERS eligibility files and provided information back to the states about the individuals who had both TRICARE and Medicaid coverage; and

WHEREAS, The agreement to cross-match between CMS and TRICARE has expired and the parties have been unable to reestablish terms to coordinate benefits between the two programs; and

WHEREAS, In early 2017, TRICARE ceased its support in the data-match process in which states provide Medicaid enrollee eligibility information to TRICARE in order to identify those members who have both TRICARE and Medicaid; and

WHEREAS, The expiration of the agreement has the effect of preventing the recovery of millions of payments annually where Medicaid erroneously paid, because TRICARE should have paid as primary coverage, resulting in a shift of additional costs from the federal government to the states; and

WHEREAS, TRICAREs timely filing limitation precludes Medicaid from billing a claim that should be TRICAREs responsibility if the service was rendered more than one year prior, resulting in additional annual costs shifting to California and other states; and

WHEREAS, TRICARE refuses to share data with, and process eligibility information from, Medicaid managed care organizations that provide care to more than 60 percent of all Medicaid members nationally. It is estimated that millions of dollars annually paid in claims should have been TRICAREs responsibility, not Medicaid managed care organizations, resulting in even more cost shifting to the states and leading to improper Medicaid capitation payments; and

WHEREAS, Approximately 8.6 percent of TRICARE beneficiaries, or approximately 804,724 uniformed service members and their families, are located in California, and thus it is estimated that California could be paying millions of dollars it is not responsible for if this issue of data sharing between TRICARE and CMS is not resolved; now, therefore, be it

Resolved by the Senate and the Assembly of the State of California, jointly, That the Legislature of the State of California urges the United States Department of Defense and the United States Department of Health and Human Services to implement and the United States Congress to require, if necessary, a resolution between the federal Centers for Medicare and Medicaid Services and TRICARE to immediately restore data sharing and to waive the one-year timely filing restriction for all claims caught in this stoppage; and be it further

Resolved, That the Secretary of the Senate transmit copies of this resolution to the President and Vice President of the United States, the Speaker of the House of Representatives, the Minority Leader of the House of Representatives, the Majority Leader of the United States Senate, the Minority Leader of the United States Senate, and to each Senator and Representative from California in the Congress of the United States.

Date of Hearing: June 12, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SJR 23

Author:(Newman) – As Introduced Ver:March 19, 2018

SENATE VOTE: 38-0

SUBJECT: Health care coverage for active military, veterans, and their families.

SUMMARY: Urges the United States Department of Defense (DoD) and the United States Department of Health and Human Services (DHHS) to implement, and the United States Congress to require, if necessary, a resolution between the federal Centers for Medicare and Medicaid Services (CMS) and TRICARE to immediately restore a data sharing agreement in which states provide Medicaid enrollee eligibility information to TRICARE, and to waive the one-year timely filing restriction for all claims caught in this stoppage. Specifically, this resolution:

1. States the following legislative findings:
   1. CMS, a part of DHHS, works with the states to fund and implement the Medicaid program, which provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities;
   2. TRICARE, which is managed by DoD Military Health System, provides civilian health benefits for active duty and reserve military members of the United States Armed Forces, military retirees, and their dependents, and which relies on the Defense Enrollment Eligibility Reporting System (DEERS) computerized database that contains TRICARE eligibility data for these individuals;
   3. Approximately 1.75 million military veterans, their families, and active duty family members (nearly one in 10) have TRICARE and Medicaid coverage, including family members of active duty members who qualify under Medicaid income limits, veterans and their families who qualify under Medicaid income limits, disabled veterans and their families, and active duty family members that qualify for Medicaid due to disability;
   4. For individuals who have both TRICARE and Medicaid coverage, TRICARE must pay as primary coverage;
   5. Historically, identifying individuals with both TRICARE and Medicaid coverage has been a challenging, yet necessary process;
   6. Prior to 2017, TRICARE had matched their DEERS eligibility files and provided information back to the states about the individuals who had both TRICARE and Medicaid coverage;
   7. The agreement to cross-match between CMS and TRICARE has expired and the parties have been unable to reestablish terms to coordinate benefits between the two programs;
   8. In early 2017, TRICARE ceased its support in the data-match process in which states provide Medicaid enrollee eligibility information to TRICARE in order to identify those members who have both TRICARE and Medicaid;
   9. The expiration of the agreement has the effect of preventing the recovery of millions of payments annually where Medicaid erroneously paid, because TRICARE should have paid as primary coverage, resulting in a shift of additional costs from the federal government to the states;
   10. TRICARE’s timely filing limitation precludes Medicaid from billing a claim that should be TRICARE’s responsibility if the service was rendered more than one year prior, resulting in additional annual costs shifting to California;
   11. It is estimated that millions of dollars annually paid in claims should have been TRICARE’s responsibility, not Medicaid managed care organizations, resulting in even more cost shifting to the states and leading to improper Medicaid capitation payments; and,
   12. Approximately 8.6% of TRICARE beneficiaries, or approximately 804,724 uniformed service members and their families are located in California, and thus it is estimated that California could be paying millions of dollars it is not responsible for if this issue of data sharing between TRICARE and CMS is not resolved.
2. Urges the DoD and the DHHS to implement, and the United States Congress to require, if necessary, a resolution between the CMS and TRICARE to immediately restore data sharing and to waive the one-year timely filing restriction for all claims caught in this stoppage.

FISCAL EFFECT: None

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, TRICARE is a health care program administered by the DoD Military Health System which provides comprehensive health coverage to approximately 9.4 million current and former uniformed service members and their families around the world. The beneficiaries of TRICARE include: active duty and retired members of the U.S. Army, U.S. Air Force, U.S. Navy, U.S. Marine Corps, U.S. Coast Guard, the Commissioned Corps of the U.S. Public Health Service and the Commissioned Corps of the National Oceanic and Atmospheric Association.

Under federal statute, when an individual is covered by both TRICARE and Medicaid, TRICARE is considered the primary payer and Medicaid the payer of last resort. The author notes that prior to early 2017, TRICARE had an agreement with CMS to cross-match data in order to coordinate benefits for beneficiaries covered by both providers. According to the author, failure to re-establish a data matching agreement places a substantial fiscal burden on the state of California by shifting approximately $18-21 million in costs annually from the federal government to the state for unrecovered claims that TRICARE should have paid. TRICARE precludes Medicaid from billing a claim that should be TRICARE's responsibility if the service was rendered more than one year prior. This timely filing limitation shifts at least another $70 million to the states on average.

The author concludes that the breakdown in coordination of benefits negatively impacts veterans, their families and our communities, as well as the state budget. It is likely that the state will continue to incur a burden of millions of dollars in additional costs if the issue of data sharing between TRICARE and CMS is not resolved soon.

1. BACKGROUND. By law, Medicaid is the payer of last resort. If another insurer or program has the responsibility to pay for medical costs incurred by a Medicaid-eligible individual, that entity is required to pay all or part of the cost of the claim prior to Medicaid making any payment – known as third party liability (TPL) or coordination of benefits (COB). Third parties that may be liable to pay for services include private health insurance, Medicare, TRICARE, employer-sponsored health insurance, settlements from a liability insurer, workers' compensation, long-term care insurance, and other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.

The DoD provides healthcare benefits to current and retired military and their families through the TRICARE program. Most of the general COB/TPL principles apply to TRICARE, but there are a few special considerations related to the TRICARE program.

The DoD maintains DEERS, a database containing information about, among other things, individuals eligible for TRICARE. To identify individuals eligible for both Medicaid and TRICARE, the DoD has established a process to match data with State Medicaid Agencies. The data match enables the DoD and State Medicaid Agencies to do the following:

• 1. Identify Medicaid beneficiaries who may be eligible for TRICARE;
  2. Prevent fraud and abuse; and,
  3. Ensure that the appropriate agency is paying for health care services.

The data match process complies with the Health Insurance Portability and Accountability Act of 1996 requirements.

1. SUPPORT. Health Management Systems (HMS) writes that approximately 1.75 million Veterans, nearly one in 10, have Medicaid coverage. According to HMS, all coordination of benefits activities between TRICARE and Medicaid have ceased, resulting in Medicaid paying more than $18 million in claims annually that should have been the responsibility of TRICARE. Veterans and their families are also losing the benefits they were promised. Further, HMS states that 8.6% of TRICARE beneficiaries are located in California and it is estimated that California could be responsible for roughly $6.02 million if this issue is not resolved.

REGISTERED SUPPORT / OPPOSITION:

Support

Health Managed Systems

Opposition

None on file.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097

 THIRD READING 

Bill No: SJR 23

Author: Newman (D), et al.

Introduced: 3/19/18

Vote: 21

SUBJECT: Health care coverage for active military, veterans, and their families

SOURCE: Health Management Systems

DIGEST:

This resolution urges the United States Department of Defense and the United States Department of Health and Human Services to implement and the United States Congress to require, if necessary, a resolution between the federal Centers for Medicare and Medicaid Services and TRICARE to immediately restore data sharing and to waive the one-year timely filing restriction for all claims caught in this stoppage.

ANALYSIS: This resolution makes the following legislative findings:

1. The federal Centers for Medicare and Medicaid Services (CMS), a part of the United States Department of Health and Human Services (HHS), works with the states to fund and implement the Medicaid program, which provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities.
2. TRICARE, which is managed by the United States Department of Defense Military Health System, provides civilian health benefits for active duty and reserve military members of the United States Armed Forces, military retirees, and their dependents, and which relies on the Defense Enrollment Eligibility Reporting System (DEERS) computerized database that contains TRICARE eligibility data for these individuals.
3. Approximately 1.75 million military veterans, their families, and active duty family members (nearly 1 in 10) have TRICARE and Medicaid coverage, including family members of active duty members who qualify under Medicaid income limits, veterans and their families who qualify under Medicaid income limits, disabled veterans and their families, and active duty family members that qualify for Medicaid due to disability.
4. For individuals who have both TRICARE and Medicaid coverage, TRICARE must pay as primary coverage.
5. Prior to 2017, TRICARE had matched their DEERS eligibility files and provided information back to the states about the individuals who had both TRICARE and Medicaid coverage.
6. The agreement to cross-match between CMS and TRICARE has expired and the parties have been unable to reestablish terms to coordinate benefits between the two programs.
7. In early 2017, TRICARE ceased its support in the data-match process in which states provide Medicaid enrollee eligibility information to TRICARE in order to identify those members who have both TRICARE and Medicaid.
8. The expiration of the agreement has the effect of preventing the recovery of millions of payments annually where Medicaid erroneously paid, because TRICARE should have paid as primary coverage, resulting in a shift of additional costs from the federal government to the states.
9. Approximately 8.6 percent of TRICARE beneficiaries, or approximately 804,724 uniformed service members and their families, are located in California, and thus it is estimated that California could be paying millions of dollars it is not responsible for if this issue of data sharing between TRICARE and CMS is not resolved.

This resolution urges the United States Department of Defense and the United States Department of Health and Human Services to implement and the United States Congress to require, if necessary, a resolution between the federal Centers for Medicare and Medicaid Services and TRICARE to immediately restore data sharing and to waive the one-year timely filing restriction for all claims caught in this stoppage.

Comments

According to the author,

TRICARE is a health care program administered by the United States Department of Defense Military Health System which provides comprehensive health coverage to approximately 9.4 million uniformed service members and their families around the world. The beneficiaries of TRICARE include: active duty and retired members of the U.S. Army, U.S. Air Force, U.S. Navy, U.S. Marine Corps, U.S. Coast Guard, the Commissioned Corps of the U.S. Public Health Service and the Commissioned Corps of the National Oceanic and Atmospheric Association.

Nearly 1 in 10 TRICARE beneficiaries also receive Medicaid coverage concurrently for a number of reasons, that is to say, approximately 1.75 million service members and their families are eligible to receive Medicaid due to low income levels, disability, retirement, and other qualifying reasons. Under federal statute, when an individual is covered by both TRICARE and Medicaid, TRICARE is considered the primary payer and Medicaid the payer of last resort.

Prior to early 2017, TRICARE had an agreement with the federal Centers for Medicare & Medicaid Services (CMS) to cross-match data in order to coordinate benefits for beneficiaries covered by both providers. This coordination of benefits was governed by a memorandum of understanding which has since expired, and the two agencies have so far been unable to re-establish terms for the continuation of the program.

Failure to re-establish a data matching agreement places a substantial fiscal burden on the state of California by shifting approximately $18-21 million in costs annually from the federal government to the state for unrecovered claims that TRICARE should have paid. Additionally, TRICARE precludes Medicaid from billing a claim that should be TRICARE's responsibility if the service was rendered more than one year prior. This timely filing limitation shifts at least another $70 million to the states on average.

The breakdown in coordination of benefits negatively impacts veterans, their families and our communities, as well as the state budget. Approximately 8.6 percent of TRICARE beneficiaries, or approximately 805,000 uniformed service members and their families, are located in California, and it is therefore likely that out state will continue to incur a burden of millions of dollars in additional costs if the issue of data sharing between TRICARE and CMS is not resolved soon.

FISCAL EFFECT: Appropriation: No Fiscal Com.: No Local: No

SUPPORT: (Verified 4/3/18)

Health Management Systems (source)

OPPOSITION: (Verified 4/3/18)

None received

Prepared by: Jonas Austin / SFA / (916) 651-1520

4/4/18 15:18:47

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