California Health Advocates (c) 2008 1 Update on Medicare Law: Review of Current and Pending Legislation and Rules Presented June 2008 by David Lipschutz.

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Presentation transcript:

California Health Advocates (c) Update on Medicare Law: Review of Current and Pending Legislation and Rules Presented June 2008 by David Lipschutz & Elaine Wong Eakin This special regional educational effort is supported by funding provided by The California Endowment.

California Health Advocates (c) Our Focus California Health Advocates is dedicated to Medicare beneficiary advocacy and education for Californians. Policy – Public policy research and recommendations for improved rights and protections, partner with national Medicare organizations based in Washington D.C. Training – Professionals and informal helpers, vibrant web resources, newsletter and regional forums Advocacy – Bring the experience of Medicare beneficiaries to the public through media and educational campaigns with the legislative staff at federal and state levels.

California Health Advocates (c) Overview I. Congressional Action II. Final Rules III. Proposed Rules

California Health Advocates (c) I. Congressional Action Medicare, Medicaid, and SCHIP Extension Act of 2007 Sen. Baucus introduced the “Medicare Improvements for Patients and Providers Act” (S. 3101) on June 6, Sen. Grassley introduced a rival bill, the “Preserving Access to Medicare Act” (S. 3118), on June 11, 2008.

California Health Advocates (c) Medicare, Medicaid, and SCHIP Extension Act of 2007 Stopped 10% cut in reimbursement to doctors and provided half-percent update in payment through June 30, Extended exceptions process for therapy caps extended to June 30, Extension of qualifying individual (QI) program to June 30, Moratorium on Special Needs Plans (SNP).

California Health Advocates (c) Baucus bill (S. 3101)Grassley bill (S.3118) Increases physician payment by 1.1% effective Jul 1, 2008, through Dec 31, Increases physician payment by 0.5% effective Jul 1, 2008, through Dec 31, 2008, then by 1.1% effective Jan 1, 2009 through Dec 31, Extends exceptions process for therapy caps to Dec 31, Same. Extends QI program to Dec 31, Extends QI program to Sep 30, Increases asset level for MSP beginning Jan 1, No mention. Eliminates late enrollment penalty (LEP) paid by LIS- eligible beneficiaries through No mention.

California Health Advocates (c) Baucus vs. Grassley highlights (p. 2) Extends authority of SNPs to target enroll certain populations through Dec 31, Lifts moratorium on new SNPs; revisions similar to proposed rules. Authorizes Sec to cover new preventive services. No mention. Waives deductible for “Welcome to Medicare” physical exam and extends coverage period from 6 months to 1 year. No mention. Increase number of sites for EHR demo.

California Health Advocates (c) Baucus vs. Grassley highlights (p. 3) Decreases cost sharing for outpatient mental health services, from 50% to 20%. No mention. Requires Medicare to promptly pay pharmacies for medications dispensed to Medicare beneficiaries. No mention. Promotes electronic prescribing.Same. Removes $1.8 mil from Medicare Advantage stabilization fund from regional PPOs by Removes $1.3 mil from Medicare Advantage stabilization fund from regional PPOs by 2013.

California Health Advocates (c) II. Final Rules Regulations LIS Benchmark – “Modification to the Weighting Methodology Used to Calculate the Low-income Benchmark Amount” 2009 Call Letter

California Health Advocates (c) Change in calculation of benchmark premium Final rule published in Federal Register on April 3, 2008; effective May 31, What is the benchmark premium amount? Who is affected? Why is CMS changing the calculation? When is the final rule effective? How is the benchmark premium amount calculated? What are the projected outcomes?

California Health Advocates (c) What is the benchmark premium amount? Weighted average of premiums. Benchmark premium amount is based on premiums of PDPs and MA-PDPs submitted by plan sponsors each year. Benchmark premium amount determines what the low income subsidy would be each year. Plans with premiums below the amount are known as benchmark plans.

California Health Advocates (c) Who is affected? Beneficiaries who qualify for the full LIS and enroll in a benchmark plan pay $0 premium. Due to changes in the benchmark premium amount, a plan may be a benchmark plan one year but not the next. Thus, LIS eligible beneficiaries May be reassigned to a different plan; Voluntarily change plans to avoid paying a premium; or Pay a premium to stay in the plan.

California Health Advocates (c) How is the benchmark premium amount calculated? Old methodology: each plan’s premium was weighted by its share of total Part D enrollment. New methodology: each plan’s premium will be weighted by its share of total LIS enrollment. Weight is a percentage = Number of LIS eligibles enrolled in a plan Number of LIS eligibles enrolled in all PD and MA- PD plans

California Health Advocates (c) Call Letter Instructions to Medicare Advantage and Part D plans for the following calendar year. Changes include: Greater scrutiny of MA plan benefit packages and cost- sharing (to ensure no discrimination). Members of MA plans that are terminating contracts with Medicare may be subject to “beneficiary transition plan” that would move people to plans meeting certain criteria. Marketing: 48-hour “cooling off” period – Marketing representatives who initially meet with a beneficiary to discuss specific lines of plan business must inform the beneficiary of all products that will be discussed prior to the in-home appointment; additional lines of plan business that are not identified prior to the in-home appointment will require a separate appointment, at least 48 hours after the initial appointment.

California Health Advocates (c) Call Letter (continued) Special Needs Plans (SNPs) must develop and execute an appropriate model of care. PFFS plans – enhanced oversight, monitoring, compliance efforts, including requiring education and outreach to providers to encourage them to participate in PFFS plans. Part D sponsors are required to offer their enrollees access to negotiated prices used for payment for covered Part D drugs (e.g., if applicable, charge beneficiaries the lesser of a drug’s negotiated price or applicable copayment amount).

California Health Advocates (c) III. Proposed Rules Regulations Part D Appeals Process Revisions to MA and Part D Programs

California Health Advocates (c) Part D Appeals Process CMS proposes to extend the 90 day time frame for Part A/B ALJ decisions to decisions concerning Part D cases. Also, expedited hearing decisions to be issued within 10 days. Limitations on Part D plan enrollee’s ability to submit evidence (all written evidence to be considered at an ALJ hearing must be submitted within 10 days, 2 if expedited, of receiving notice of hearing). If enrollee wishes to have evidence about changes in his/her condition since coverage determination considered in an appeal, the submission of the new evidence will result in a remand of the case to the Part D sponsor.

California Health Advocates (c) Revisions to MA and Part D Programs Overview: Proposed regulations issued in May 2008 incorporate a number of requirements that CMS previously imposed through operational guidance (plus some additional proposals). Comment period open until mid-July 2008.

California Health Advocates (c) Revisions to MA and Part D Programs (continued) Special Needs Plans (SNPs) Require that 90% of new enrollees in SNPs be “special needs” individuals (re: disproportionate share SNPs). SNPs must obtain verifying info re: eligibility. SNPs must develop a model of care specific to the special needs population they are serving (more clearly establish and clarify delivery of care standards for SNPs). Dual eligible SNPs must have a documented relationship, such as a contract, MOU, data exchange agreement, or some other agreed upon arrangement with the state Medicaid agency.

California Health Advocates (c) Revisions to MA and Part D Programs (continued) All MA plans with dual eligible enrollees must specify in their contracts with providers that enrollees will not be held liable for Medicare Parts A and B cost-sharing when the State is liable for the cost-sharing; must also inform providers of the Medicare and Medicaid benefits and rules for enrollees eligible for Medicare and Medicaid. Require plans to use Best Available Evidence (BAE) process. Greater flexibility for CMS to impose penalties (e.g. up to $25,000 for each enrollee affected, or likely to be affected, by the violation).

California Health Advocates (c) Revisions to MA and Part D Programs (continued) Prohibition on door-to-door marketing Expanded to cover other unsolicited instances of direct contact, such as outbound calling without the beneficiary initiating contact. Prohibition on sales activities at educational events such as health information fairs and community meetings or areas such as waiting rooms. Prohibition on cold calling. Sales visits Any appointment with a beneficiary to market health care related products would have to be limited to the scope that the beneficiary agreed to in advance (48 hour cooling off period re: additional lines of business not identified prior to the in-home appointment).

California Health Advocates (c) Revisions to MA and Part D Programs (continued) Cross-selling of non-health care related products prohibited during MA or Part D sales. Plans using independent agents must use agents licensed in a given state and report to states that they are using such agents. Plans would be required to develop agent training modules and tests based on CMS guidelines. Agent/broker commissions Require MA plans to establish commission structures that are level across all years and across all MA plan product types (e.g. HMOs, PPOs, PFFS); PDP commission structures would have to be level too (but not between PDP and MA products).

California Health Advocates (c) Contact Information California Health Advocates Sacramento HQ – (916) Elvas Avenue, Suite 104 Sacramento, CA Oakland satellite office – (510) th Street, Oakland, CA Website: