Www.medicareadvocacy.org Copyright © Center for Medicare Advocacy, Inc. IN THE TRENCHES: MAKING...
23
www.medicareadvocacy.org 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.
-
Upload
dominic-porter -
Category
Documents
-
view
215 -
download
2
Transcript of Www.medicareadvocacy.org Copyright © Center for Medicare Advocacy, Inc. IN THE TRENCHES: MAKING...
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
IN THE TRENCHES:MAKING MEDICARE CHANGES
WORK FOR BENEFICIARIES
Families USAJanuary 23, 2009
Tatiana FassieuxCalifornia Health Advocates
Vicki GottlichCenter for Medicare Advocacy.
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
5
CHANGES TO PART AInformation 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
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
6
CHANGES TO PART AInformation 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
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
7
CHANGES TO PART BInformation 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%• 2010-2011 – 45%• 2012 – 40%• 2013 - 35%• 2014 – 20%
Starting 1/09, easier for Medicare to cover new preventive benefits
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
10
CHANGES TO PART CInformation 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
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © 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 individual’s physical, psychosocial and functional needs and
• Development of care plan with individual’s participation as feasible
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
15
CHANGES TO PART C: SPECIAL NEEDS PLANS
New Requirements for D-SNPs (con’t)• Prohibits D-SNPs from imposing cost-sharing
on Qualified Medicare Beneficiaries (QMB) that is more than would be required under their State Medicaid plan
www.medicareadvocacy.orgCopyright © 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."
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
17
CHANGES TO PART DInformation to Advocates
Few changes affect all beneficiaries Formulary changes
• 2010 – required coverage of certain drugs
• 2013 – plans can cover barbiturates and benzodiazepines
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © 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
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
20
CHANGES TO MARKETINGRULES 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
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
21
CHANGES TO MARKETINGRULES 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
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
22
CHANGES TO MARKETINGRULES 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
www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
23
USEFUL WEB SITES
www.cms.hhs.gov www.medicare.gov www.cahealthadvocates.org www.hapnetwork.org www.medicareadvocacy.org
