Dual-eligible beneficiaries are low-income seniors and individuals with disabilities enrolled in both Medicare and Medicaid. In 2010, there were about 9.9 million dual-eligible beneficiaries. Both programs have requirements to protect the rights of beneficiaries. The Government Accountability Office (GAO) released
a report which (1) compared selected consumer protection requirements within Medicare FFS and Medicare Advantage, and Medicaid FFS and managed care, and (2) described related compliance and enforcement actions taken by CMS and selected states against managed care plans.
Medicare and Medicaid consumer protection requirements vary across programs, payment systems and states. Within Medicare, enrollment in managed care through the Medicare Advantage (MA) program must always be voluntary, whereas state Medicaid programs can require enrollment in managed care in certain situations. In addition, Medicare and state Medicaid programs require managed care plans to meet certain provider network requirements. Subject to federal parameters, states also establish network requirements for their Medicaid programs. Finally, Medicare and Medicaid have different appeals processes that do not align with each other. The Medicare appeals process has up to five levels of review for decisions to deny, reduce, or terminate services, with certain differences between FFS and MA. In Medicaid, states can structure appeals processes within federal parameters. States must establish a Medicaid appeals process that provides access to a state fair hearing and Medicaid managed care plans must provide beneficiaries with the right to appeal to the plan, though states can determine the sequence of these appeals.