HAP's monthly Conference Calls are an opportunity to partner with the SHIP network to improve the capacity of the SHIPs. Through the SHIP Shout Out feature, we answer the questions and comments raised during the SHIP Shout Out section of each month's call. We also provide additional resources that we hope are useful in your work with beneficiaries.
July 2009
Will the Troubleshooting Medicare project target major employers?
The Troubleshooting Medicare project will identify the persistent and systemic issues affecting Medicare beneficiaries based on feedback provided by the SHIP network on the problems encountered by their clients.
In order for the "Troubleshooting Medicare" project to help drive positive change for beneficiaries across the Medicare program, HAP has developed a framework with four broad categories to assess the issues identified by the SHIP network:
- Access to care (e.g., cost sharing)
- Informed decision making (e.g., ABNs)
- Healthcare inequities and disparities (e.g., language barriers)
- Plan design and benefits (e.g., Part D and MA plan features)
The issues identified by SHIPs will be used in two ways:
- To inform the trainings that HAP develops for the SHIP network to address the issues when counseling clients
- To develop recommendations for policymakers, including lawmakers and CMS staff, which bring attention to specific system-level issues in the Medicare program, and highlight solutions that are beneficiary-centered and SHIP-based
For more information about how to share issues with us, please read about our Issue Log.
[Back to Top | July Conference Call]
How are SHIPs doing Medicare outreach to individuals who are approaching age 65? What about the under-65 population who are new to Medicare?
With baby-boomers beginning to retire in 2011, many SHIPs are interested in innovative and replicable ways to identify and reach new Medicare beneficiaries. The Ohio SHIP (OSHIIP) has developed a "Welcome to Medicare" program which was featured in the SHIP Weekly Digest last fall. OSHIIP obtained a list of people turning 65 from the Department of Motor Vehicles and then sent postcard invitations to attend a "Welcome to Medicare" event. For more information about OSHIIP's program, please see this article.
If you have a strategy or an idea that you would like to share with other SHIPs, please contact us at SHIPhelp@hapnetwork.org.
It is important for SHIPs and their partners to keep in mind the under-65 Medicare population.
The Medicare beneficiary population is diverse, and includes groups with varying but equally important needs. These include, but are not limited to, seniors age 65 and older, individuals with permanent disabilities under the age of 65, vulnerable populations including 8 million "dual eligible" beneficiaries who also qualify for Medicaid, young Medicare-eligible veterans with permanent service-connected disabilities, and limited English proficient beneficiaries. SHIPs work to reach and assist all of these different populations.
HAP has developed a public education document — SHIPs Helping Medicare Consumers — to assist SHIPs in communicating the complex and vital role they play in helping various beneficiary populations.
[Back to Top | July Conference Call]
Is there a standardized process for disenrolling Medicare Advantage (MA) enrollees?
There is a standardized process for MA disenrollment. Medicare beneficiaries who are currently enrolled in MA plans may only disenroll from that plan during certain periods: the Annual Enrollment (or Election) Period (AEP) from November 15 through December 31; in certain situations during the Open Enrollment Period (OEP) from January 1 through March 31; and any applicable Special Enrollment Period (SEP).
There are a few ways for a Medicare beneficiary to disenroll from an MA plan:
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By enrolling in another plan
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By sending or faxing a signed written notice to the MA organization
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By requesting disenrollment online to the MA organization (if the MA organization offers this option)
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By calling 1-800-MEDICARE
CMS's disenrollment policy guidance states that "if a member verbally requests disenrollment from the MA plan, the MA organization must instruct the member to make the request in one of the ways described above. […]The disenrollment request must be dated when it is initially received at the MA organization's business offices." ( See Medicare Managed Care Manual (CMS Pub. No. 100-16, Chapter 2, Section 50.1)
Please be in touch with us at SHIPhelp@hapnetwork.org if you encounter difficulties with helping beneficiaries disenroll in any of the above-mentioned methods of disenrollment.
[Back to Top | July Conference Call]
Is CMS or SSA planning a national TV promotion to encourage folks to ask about assistance programs, like LIS?
HAP will inquire with CMS about any national activities to promote financial assistance programs. In the meantime, CMS recently released new data to help identify areas to best target LIS outreach efforts. The data also contain information on the number of Medicare beneficiaries eligible for Medicare Part D and can be sorted by state, county, and zip code. CMS has prepared a document to provide information about using the new LIS data. Additionally, this summer CMS is planning radio and print ads to promote LIS.
As in past years, the Social Security Administration plans to promote Low-Income Subsidy applications each spring near Mother's Day and Father's Day.
What rules protect Qualified Medicare Beneficiaries (QMBs) from bills for Medicare cost-sharing charges?
According to Title 42 of the United States Code, section 1396a (n), neither providers nor Medicare Advantage (MA) plans can bill Qualified Medicare Beneficiaries (QMBs) for Medicare cost-sharing. Therefore, providers cannot balance bill QMBs for any Original Medicare deductibles and coinsurance charges or for MA plan copayments for office visits, consultations with specialists, and Durable Medical Equipment (DME). QMBs are not liable under Medicare law to pay providers for these charges.
In addition, states do not need to have a special agreement, or contract, in place for the provider to bill Medicaid on a QMB-eligible patient's behalf. This includes providers both in Original Medicare and Medicare Advantage (MA). Some MA plans may have a contract to bill the state, and those that do usually process claims more smoothly. However, the provider does need a contract to bill the state for a QMB's copayments but the simple act of submitting the bill to the state by the provider creates an "agreement." This applies in all states.
NOTE: The law that established the QMB program does not require states to pay Medicare's deductibles, coinsurance, or copayment charges if the Medicare payment (including an MA plan payment) for a given service or procedure is greater than the Medicaid payment rate. Despite the fact that Medicaid may not cover the full amount of a coinsurance or copayment charge, Medicare law states that QMBs have no legal liability for payment to providers or to MA plans for these charges. In most cases, this means that physicians and other providers who serve QMBs must accept the Medicare payment as payment in full and write off the cost-sharing charge. In addition, states have the option of paying an MA plan's monthly premium on behalf of a QMB.
QMBs who are billed by their MA plan providers (even those who are not "set up" to bill Medicaid) can file grievances with their plans. Plans should have a billing procedure for QMBs, regardless of the plan's contract status with the state. Under ideal circumstances, MA plans should refund these copayments to the QMB (or have the provider reimburse the QMB), AND the plans should advise the provider to bill Medicaid for future copayments. QMBs in Original Medicare can follow up with the state Medicaid office or directly with their provider for reimbursement.
For more information and the authority language that speaks to the provider agreement as well as to the sanction against providers billing QMBs, see CMS's State Medicaid Manual, Chapter 3 - Eligibility, Section 3490.14.
HAP has flagged the recurring practice of Medicare providers billing Qualified Medicare Beneficiaries (QMBs) and full dual eligible beneficiaries for Medicare's cost-sharing as an example of an "access to care" issue the Troubleshooting Medicare project can help to identify.
HAP first alerted the SHIP network to the issue in the June issue of our eNewsletter. HAP followed up in the July eNewsletter with an example of a letter that SHIPs can modify and send to providers to secure reimbursements on behalf of their QMB clients.
[Back to Top | July Conference Call]
