HAP's monthly Conference Calls are an opportunity to partner with the SHIP network to improve the capacity of the SHIPs. Often call participants have questions that require a little research on our end in order to provide the best and most accurate information. Through the SHIP Shout Out feature, we answer the questions raised during a particular month's call and provide additional resources that we hope are useful in SHIPs' work with their beneficiaries.
June 2009
When must Private Fee-for-Service plans meet MIPPA's network requirements?
Beginning in 2011, Private Fee-for-Service (PFFS) plans (specifically, non-employer/union sponsored PFFS plans) are required to have networks of providers like other managed care plans. PFFS plans operating in regions of the country where there are fewer than two other network-based Medicare Advantage (MA) plans will not have to meet this requirement.
In addition, all employer/union sponsored PFFS plans must operate using a network of providers beginning in 2011. These MIPPA changes for MA and Part D have been codified into the Code of Federal Regulations and are available in the Federal Register.
Do SNPs have the authority to discontinue the continued enrollment of beneficiaries who do not qualify as the special need for their 2010 plans?
Due to MIPPA, SNPs are no longer allowed to operate as "disproportionate" SNPs, meaning they must limit new enrollments only to beneficiaries who are eligble for the special need of the SNP.
In the final 2010 Call Letter, CMS states "CMS will issue detailed guidance later this spring that will outline the specific rules for plan transitions for SNP enrollees from 2009 to 2010." The Call Letter also states that CMS may permit C-SNPs to passively enroll certain individuals into new plans in 2010. The final Medicare Advantage Enrollment and Disenrollment chapter of the Medicare Managed Care Manual (currently available as a draft version) should provide more details about this process.
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Is Medicaid required to pay the costs of MSP enrollees in Original Medicare?
Medicare Savings Programs (MSPs) are programs administered by State Medicaid agencies to assist Medicare beneficiaries with limited income and resources in paying for some of the costs of Medicare. The type and amount of assistance that MSP-eligible beneficiaries receive depend on the level of MSP for which each beneficiary qualifies. The levels of MSP are:
QMB (Qualified Medicare Beneficiary Program)
The QMB program covers the following costs:
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Medicare Part A monthly premium (when applicable)
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Medicare Part B monthly premium and annual deductible
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Co-insurance and deductible amounts for services covered under both Medicare Parts A and B
SLMB (Specified Low-Income Medicare Beneficiary Program)
The SLMB program covers the following costs:
QI (Qualified Individual Program)
There are specific eligibility criteria (income and assets) that distinguish each category of MSPs. Federal standards for these programs exist, though some states have set more flexible standards. More information about these programs and their eligilibity criteria is available from the Center for Medicare Advocacy.
Is the purpose of a state's contract with D-SNPs that the plan become a primary source of coverage for Qualified Medicare Beneficiaries (QMBs)?
Medicare is the primary payer for all beneficiaries with QMB. Medicaid pays second for QMBs. This applies to QMBs enrolled in Medicare Advantage plans (including SNPs). The Medicare coverage (i.e., the MA plan) is the primary payer. Medicaid pays second for QMBs receiving Medicare-covered services from MA plans, including SNPs. MA plans may cover some Medicaid services that are not Medicare services, so in those cases Medicaid provides coverage for those services.
D-SNPs with state Medicaid contracts will have an opportunity to receive from the state some sort of payment (e.g., capitation) to provide Medicaid services for those dual-eligible enrollees. Many consider this to be the "purpose" of the contractual relationship between a D-SNP and Medicaid.
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Are there specific requirements for information an agent must disclose to potential enrollees?
No. However, HAP would like to hear from those of you who would like to partner with us to create a checklist of information the beneficiaries should ask agents before enrolling in a plan. Contact us to share your ideas!
In the meantime, we offer Alabama's Medicare Protection Toolkit as an example of a checklist for beneficiaries and agents. Thanks to Alabama SHIP for offering this resource to assist other SHIPs.
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