Copyright © Center for Medicare Advocacy, Inc. IN THE TRENCHES: MAKING MEDICARE CHANGES WORK FOR BENEFICIARIES Families USA January 23, 2009 Tatiana Fassieux California Health Advocates Vicki Gottlich Center for Medicare Advocacy.
Copyright © Center for Medicare Advocacy, Inc. 2 MEDICARE OVERVIEW Medicare is the universal health insurance coverage for people age 65 and over; people under age 65 who receive SSDI; People with ESRD Medicare is divided into four Parts Part A – hospital, SNF, hospice, home health Part B – doctors, labs, home health Part D – prescription drugs Part C – other delivery mechanisms for Parts A, B, & D
Copyright © Center for Medicare Advocacy, Inc. 3 MEDICARE CHANGES IN 2008 Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) Primary goal to address payments to doctors Included important protections for beneficiaries Not all are currently in effect Actions by the Medicare Agency (CMS) To implement MIPPA To address Part A issues To address Part D problems
Copyright © Center for Medicare Advocacy, Inc. 4 MEDICARE CHANGES IN 2008 Not all changes are in effect in 2009 Not all changes require advocacy by beneficiary advocates Plenty of opportunities for advocates Influence implementation by a new administration Influence activities by states and other entities
Copyright © Center for Medicare Advocacy, Inc. 5 CHANGES TO PART A Information for Advocates New Hospice regulations give patients the right to: Participate in developing their care plan Have effective pain management Choose their own doctor File grievances Choose their own treatment
Copyright © Center for Medicare Advocacy, Inc. 6 CHANGES TO PART A Information for Advocates Medicare no longer pays hospitals for hospital acquired conditions (HAC) or never events reasonably preventable conditions Examples include: Object left in patient during surgery Blood incompatibility Catheter-associated urinary tract infection Pressure ulcers Surgical site infections following certain procedures Hospital-acquired injury due to external causes
Copyright © Center for Medicare Advocacy, Inc. 7 CHANGES TO PART B Information for Advocates Extension of therapy cap exception process through 12/09 Starting 1/10, phase-down of beneficiary cost-sharing for mental health services 2009 – 50% – 45% 2012 – 40% % 2014 – 20% Starting 1/09, easier for Medicare to cover new preventive benefits
Copyright © Center for Medicare Advocacy, Inc. 8 CHANGES TO MEDIGAP POLICIES Medigap insurance policies pay some or most of Medicare cost-sharing Standardized plans developed by NAIC and approved by states Plans A – L, plus high deductible plans Starting in June 2010 new standard plans Will be able to keep current plan
Copyright © Center for Medicare Advocacy, Inc. 9 INCREASED ACCESS TO MEDICARE SAVINGS PROGRAMS 3 Medicare Savings Programs (MSP) QMB, SLMB, QI – asst. w/Part B premium QMB – asst. w/Part B cost-sharing Starting 1/10 MSP will use LIS asset limits $6000 individual/$9000 couple indexed 1/10 SSA to transfer information from LIS applications to states to determine MSP eligibility 1/10 no estate recovery for MSP
Copyright © Center for Medicare Advocacy, Inc. 10 CHANGES TO PART C Information for Advocates Starting 1/10, type of plan (HMO, PPO, PFFS, MSA) must be included in plan name Starting 1/11 changes to PFFS plans Must have provider networks if at least 2 coordinated care network plans in area served by PFFS plan Such plans can no longer deem providers
Copyright © Center for Medicare Advocacy, Inc. 11 CHANGES TO PART C: SPECIAL NEEDS PLANS Extended through 2010 by MIPPA Require restriction in MA enrollment to focus on specified populations: Dual Eligibles (D-SNPs) Institutionalized individuals (I-SNPs) People with chronic and disabling conditions (C-SNPs) In 2010 enrollment limited to specified population
Copyright © Center for Medicare Advocacy, Inc. 12 CHANGES TO PART C: SPECIAL NEEDS PLANS New Requirements for 2010 for all SNPs Evidence-based model of care with appropriate networks of providers and specialists Initial assessment and annual reassessment of individuals physical, psychosocial and functional needs and Development of care plan with individuals participation as feasible
Copyright © Center for Medicare Advocacy, Inc. 13 CHANGES TO PART C: SPECIAL NEEDS PLANS New Requirement for I-SNPs If enrolling individuals from the community but needing an institutional level of care, must use a state assessment tool and must have the assessment performed by an entity other than the plan sponsor
Copyright © Center for Medicare Advocacy, Inc. 14 CHANGES TO PART C: SPECIAL NEEDS PLANS New Requirements for D-SNPs Must provide each prospective enrollee with information about their state Medicaid benefits and cost-sharing protections and which, if any, of those is available under the plan Must have contract with State Medicaid agency to provide or arrange for provision of state Medicaid benefits; if plan does not have such a contract, it cannot expand service area
Copyright © Center for Medicare Advocacy, Inc. 15 CHANGES TO PART C: SPECIAL NEEDS PLANS New Requirements for D-SNPs (cont) Prohibits D-SNPs from imposing cost-sharing on Qualified Medicare Beneficiaries (QMB) that is more than would be required under their State Medicaid plan
Copyright © Center for Medicare Advocacy, Inc. 16 CHANGES TO PART C: SPECIAL NEEDS PLANS New Requirement for C-SNPs Enrollees must have "one or more [co-morbid] and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care."
Copyright © Center for Medicare Advocacy, Inc. 17 CHANGES TO PART D Information to Advocates Few changes affect all beneficiaries Formulary changes 2010 – required coverage of certain drugs 2013 – plans can cover barbiturates and benzodiazepines
Copyright © Center for Medicare Advocacy, Inc. 18 CHANGES TO PART D – LOW INCOME SUBSIDY Elimination of late enrollment penalty for LIS-eligible individuals Changes in how SSA determines LIS- eligibility Judicial review of denials of eligibility As of 1/10, do not count in-kind support and maintenance and value of life insurance
Copyright © Center for Medicare Advocacy, Inc. 19 CHANGES TO PART D – LOW INCOME SUBSIDY Changes in how CMS determines whether plans are LIS-plans Did not prevent loss of LIS-plans and need to reassign beneficiaries for 2009 Best Available Evidence (BAE) Process for proving LIS co-pay level Plan must help beneficiary gather BAE
Copyright © Center for Medicare Advocacy, Inc. 20 CHANGES TO MARKETING RULES FOR C & D PLANS No unsolicited marketing contacts No door-to-door cold contacts No outbound calls, not even to confirm receipt of mailed information Permissible un-requested outbound calls: To Extra Help members being reassigned, subject to prior approval by CMS of call scripts To conduct normal business of the plan By express permission of the beneficiary By the agent or broker who enrolled the beneficiary No marketing at educational events No post-event solicitations in lobbies, or parking lots
Copyright © Center for Medicare Advocacy, Inc. 21 CHANGES TO MARKETING RULES FOR C & D PLANS Nominal gift limitation - $15 No meals Scope of sales appointments Identify in advance line of business to be discussed Documented by the plan in writing or via recording phone calls To market additional lines of business the beneficiary must request in advance again, with at least a 48 hour cooling off period and a new appointment Line of business is PDP, Medicare Advantage or Medigap
Copyright © Center for Medicare Advocacy, Inc. 22 CHANGES TO MARKETING RULES FOR C & D PLANS Changes relating to agents/brokers Training and testing requirements Compensation limitations Must comply with state appointment rules Report termination to states
Copyright © Center for Medicare Advocacy, Inc. 23 USEFUL WEB SITES