1. Medicare Savings Program Advocacy: Garcia v. Sebelius Pam Walz Amy Hirsch Wey-Wey Kwok

2. The problems we kept seeing (over and over again)  Delays in enrollment Data matches between DPW and SSA just once per month Data matches between DPW and SSA just once per month At least 2-3 months if everything went perfectly At least 2-3 months if everything went perfectly Several months to more than a year if the data did not match Several months to more than a year if the data did not match No system to timely address these errors No system to timely address these errors No notice to applicants No notice to applicants Need to wait for Part A enrollment until after Part B enrollment completed Need to wait for Part A enrollment until after Part B enrollment completed

3. Problems, cont.  QMBs enrolled in Part B, but not Part A Individuals who became eligible for Medicare after age 65 Individuals who became eligible for Medicare after age 65 Individuals who initially rejected Medicare due to misinformation Individuals who initially rejected Medicare due to misinformation SSI recipients who were missed by auto- accretion SSI recipients who were missed by auto- accretion

4. Problems, cont.  Frequent failure to review for 3 months’ retroactive coverage Short form MSP application did not have a place to request and did not ask for verification of retroactive eligibility Short form MSP application did not have a place to request and did not ask for verification of retroactive eligibility

5. Problems, cont.  Misinformation provided to applicants Lack of knowledge by DPW caseworkers Lack of knowledge by DPW caseworkers Applicants bounced back and forth between the welfare and Social Security offices when trying to enroll in Part A and the MSP Applicants bounced back and forth between the welfare and Social Security offices when trying to enroll in Part A and the MSP Social Security staff telling MSP eligible individuals that they would have to pay for Medicare and not telling them about MSP Social Security staff telling MSP eligible individuals that they would have to pay for Medicare and not telling them about MSP

6. Garcia v. Sebelius  State told us problems all Feds’ fault— so we sued feds as well as state  SSA & DHHS (for CMS) officials as fed defendants  State & local welfare officials as state defs

7. Litigation Strategy  State approves individuals for MA, and Buy-In  Feds also must approve indiv (data match) & deduct premiums from Social Security & deduct premiums from Social Security  Need all three agencies (state, CMS, SSA) to resolve data exchange issues

8. Litigation Theories  Claims under Medicaid statute & regs  Claims under Medicare statute  Due Process Claims

9. Litigation Strategy  Complex facts, dense statutes -- need to make it very simple & clear for court: Low income elderly & disabled individuals being denied access to medical care because of out-dated bureaucratic computer problems

10. Litigation Strategy  Convince state of savings through getting folks onto Medicare as primary payor  Seek early negotiations, ask for tech & program staff involvement  Issues are extremely fact intensive, not well suited to judicial resolution

11. Negotiations  Surprise! Feds were already: Accepting data daily from other states (but would not disclose which states!) Accepting data daily from other states (but would not disclose which states!) Responding to data daily Responding to data daily Allowing advance submissions Allowing advance submissions Allowing simultaneous Part A & Part B submissions Allowing simultaneous Part A & Part B submissions

12. Negotiations  State had out-dated info on fed procedures  State needed lots of tech assistance from feds

13. Settlement  DPW agreed to begin submitting MSP enrollment requests on a daily basis.  DPW also agreed to begin accepting responses to its MSP enrollment requests on a daily basis.  Notice to applicants whose MSP enrollment is not effectuated by the first month after submission

14. Settlement, cont.  Computer runs every 2 months to identify (and enroll) individuals 65 or older who are not enrolled in MSP for both Parts A and B.  Simultaneous enrollment in MSP for Parts A and B.  Protocols and timeframes for case workers to resolve data errors in enrollment submissions

15. Settlement, cont.  Protocols to facilitate case worker communication with central DPW staff and with local SSA offices to resolve enrollment problems.  Training for County Assistance Office staff!  Instructions for case workers on retroactive eligibility, and notice to applicants not found eligible for retroactive coverage

16. Settlement, cont.  Revision of MSP application to solicit information to determine retro coverage.  Notice of availability of retroactive coverage on MSP eligibility notices.  Revision of Medical Assistance Eligibility Handbook sections on MSP.  Reports to plaintiffs’ counsel.