January 27, 2006 FAMILIES USA 2006 HEALTH ACTION CONFERENCE Daniel J. Schreiner Medicare Beneficiary Ombudsman CMS Office of the Medicare Ombudsman Meet the Medicare Beneficiary Ombudsman

The Medicare Ombudsman: A Voice for Beneficiaries Agenda Medicare Beneficiary Ombudsman Ombudsmans Responsibilities Ombudsmans Goals Performance-Based Approach Benchmarks for Success The Plan for 2006 Beneficiary Outreach Working with the Ombudsman Ombudsman Resources

The Medicare Ombudsman: A Voice for Beneficiaries Medicare Beneficiary Ombudsman Created by Section 923 of the Medicare Modernization Act (MMA) Voice for Medicare Beneficiaries Work closely with the Centers for Beneficiary Choices Direct access to CMS Administrator

The Medicare Ombudsman: A Voice for Beneficiaries Ombudsmans Responsibilities Receive and provide assistance to beneficiaries –Complaints –Grievances –Inquiries Assist in collecting information to file an appeal Help with Medicare Advantage Disenrollment

The Medicare Ombudsman: A Voice for Beneficiaries Ombudsmans Responsibilities Assist with information related to the new income-related premium adjustment Work with State Health Insurance Programs (SHIPs) Submit an annual report to Congress –Ombudsman activities –Recommendations on improvements to Medicare

The Medicare Ombudsman: A Voice for Beneficiaries Ombudsmans Goals Holding the System Accountable Create a process to capture and incorporate the voice of the beneficiary as a critical component to the development and improvement of all assistance programs Implement a performance measurement system to identify and help resolve systemic issues in the beneficiary service experience Make recommendations for overall program improvement based on analysis of trends and information from Medicare beneficiaries and advocates

The Medicare Ombudsman: A Voice for Beneficiaries Performance-Based Approach Achieve continuous improvement of –Medicares existing contractors –Federally staffed complaint, grievance, and inquiry operations Provide better coordination among existing entities Provide opportunity for sustained improved performance

The Medicare Ombudsman: A Voice for Beneficiaries Performance-Based Approach Desired results are articulated Performance standards defined Performance will be measured Patterns of problems identified Best Practices shared Data fed back into the system

The Medicare Ombudsman: A Voice for Beneficiaries Benchmarks for Success Proven institutionalized process for hearing beneficiary needs Business processes aligned with customer needs Reported service experience improvements

The Medicare Ombudsman: A Voice for Beneficiaries The Plan for 2006 Develop mechanisms for hearing the Voice of the Beneficiary (e.g., Open Door forums, regional/local partner meetings, beneficiary meetings) Develop a Web Site as a communication vehicle - center/ombudsman.asp Develop training materials and programs to meet identified needs Establish a system to track performance metrics Develop standard operating procedures Train people and organizations on using the new standard operating procedures Communicate with Beneficiaries and their Advocates Implement PerformanceManagement System Report to Congress Gather quantitative data from internal CMS systems Gather qualitative data from local/regional partners and beneficiaries Develop a set of data- driven recommendations to Congress

The Medicare Ombudsman: A Voice for Beneficiaries Beneficiary Outreach Regional/Local Advocate Meetings Open Door Forums Beneficiary Feedback Meetings Opportunity for beneficiaries, their caregivers and advocates to publicly interact with the Medicare Beneficiary Ombudsman to identify, discuss and address opportunities to improve the systems and processes within the Medicare program. National conference calls open to beneficiaries, their caregivers and advocates beginning February 15, 2006 Targeted discussions with regional and local advocates within the beneficiary communities that they support Roundtable discussions with small groups of beneficiaries within their community

The Medicare Ombudsman: A Voice for Beneficiaries Working with the Ombudsman The Medicare Beneficiary Ombudsman Will: –Work with CMS and partners to implement service improvements –Take action on issues under its purview –Refer questions/issues to CMS leadership for awareness as appropriate –Provide updates on major CMS initiatives The Medicare Beneficiary Ombudsman Will Not: –Make agency decisions –Duplicate existing processes for resolving issues –Lobby Congress or intervene in legal action

The Medicare Ombudsman: A Voice for Beneficiaries Working with the Ombudsman The OMO is seeking input on issues that: Affect large numbers of beneficiaries Involve unique or exceptional circumstances Fall under the Ombudsmans purview (systems/processes v. policy/statute) Are actionable Enhance awareness

The Medicare Ombudsman: A Voice for Beneficiaries Working with the Ombudsman Partners have actively communicated situations arising from Part D implementation These are the types of things that the OMO wants to hear CMS has established mechanisms for resolving specific circumstances. The OMO should not duplicate those, but should understand the underlying, systemic issues

The Medicare Ombudsman: A Voice for Beneficiaries Working with the Ombudsman CMS Role: –Resolve Specific Situations Existing Mechanisms: –Tools for Verifying Plan Enrollment/LIS Status –Procedures to Provide Immediate Access to Medications –Escalation of Emergency Situations to CMS Regional Offices

The Medicare Ombudsman: A Voice for Beneficiaries Working with the Ombudsman Example: A dual-eligible beneficiary does not know if he or she has been enrolled in a plan: –Pharmacist should send an E1 Query to determine plan enrollment –If no match, the pharmacist should verify Medicare and Medicaid eligibility –If dual-eligibility has been determined, but no plan has been identified, the pharmacist can use the Point-of-Sale facilitated enrollment option

The Medicare Ombudsman: A Voice for Beneficiaries Working with the Ombudsman If a beneficiary is still unable to obtain medications, and the backup systems are not working: –Call Medicare –Medicare has special caseworkers in each of the CMS Regional Offices who will provide individualized help in getting prescriptions filled –Medicare is here to help – 24 hours/day, 7 days/week

The Medicare Ombudsman: A Voice for Beneficiaries Working with the Ombudsman The Ombudsmans role: –Understand what beneficiaries are experiencing –Identify underlying systemic issues and make recommendations to Congress for long-term resolution –Communicate findings with CMS leadership –Connect partners and beneficiaries to appropriate resources

The Medicare Ombudsman: A Voice for Beneficiaries Working with the Ombudsman Todays session is an opportunity for you to share your experiences I dont have all the answers! I will listen to your feedback, and follow up with the appropriate resources

The Medicare Ombudsman: A Voice for Beneficiaries Ombudsman Resources The following Ombudsman resources are available. Please help us promote these resources within the beneficiary and advocacy communities: OMO Website Contact the Ombudsman - Refer to the link on the above website Listserv - To subscribe to the Medicare Beneficiary Ombudsman Listserv - BENEOMBUDODF-L, visit ience=4 and follow the instructions ience=4 Medicare Beneficiary Ombudsman Open Door Forum –Wednesday, February 15, 2006 from 2:00p.m.-3:30p.m. –Call in number: , Conference ID: