Archive
I. Conference Call Information
Next Medicare Conference Call on July 19
II. In the News
GAO Releases Study on PDP Call Centers
CMS Regulations Exempt Medicare & SSI Beneficiaries from Medicaid Citizenship Documentation
III. Helpful Information
Target Data Released at the LIS Outreach Event
HAP Involved in Part D Workgroup
CMS Regulations Exempt Medicare & SSI Beneficiaries from Medicaid Citizenship Documentation
CMS Releases New Draft PDP Enrollment Guidance
CMS Revises Appeals Chapter of the Prescription Drug Benefit Manual
CMS Releases Two FAQs on Insulin Syringes in LTC settings and Eligibility and Notice Requirements
IV. HAP Resources
SHIP State Director Conference Sessions Highlight HAP’s Partnerships with Iowa and Ohio SHIPs
Follow-up on SHIP Directors Conference
I. Conference Call Information
Next Medicare Conference Call on July 19
HAP’s next Medicare Conference Call, “New Medicaid Citizenship Documentation Rules,” will take place on Wednesday, July 19, at 3:00 p.m., EDT. The Deficit Reduction Act (DRA) of 2005 requires state Medicaid programs to implement new rules to document the citizenship of those who apply or re-apply for Medicaid benefits, starting on July 1, 2006. But recent federal regulatory developments now exempt Medicare beneficiaries and Supplemental Security Income (SSI) recipients from the documentation requirements (see article below). As the state Medicaid agencies move forward to implement the citizenship documentation requirements and other features of the DRA, what will be the impact on SHIP counseling programs? Gene Coffey, an attorney with the National Senior Citizen Law Center, will join us as a guest speaker. During the first part of the call, we will discuss the DRA and its implications for SHIP programs. Next, Hilary Dalin will facilitate a discussion on the role of SHIPs in counseling and assisting Medicaid recipients. For more information about the call, contact Rana Suliman at rsuliman@healthassistancepartnership.org.
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II. In the News
GAO Releases Study on PDP Call Center Service
The United States General Accountability Office (GAO) on July 10 released the results of a study of customer service at Medicare Part D prescription drug plans’ call centers. Based on 900 calls to ten of the largest plan sponsors’ call centers, the GAO found that Customer Service Representatives (CSRs) gave accurate and complete responses 34 percent of the time in the 864 calls CSRs actually answered. CSR responses were inaccurate or incomplete for more than half of the calls. In 15 percent of the cases, they could not provide answers, related mainly to questions about plan costs. The GAO determined that the general accuracy and completeness rate for each call center ranged from 20 to 60 percent.
The GAO researchers asked CSRs to identify the plan sponsor’s least expensive PDP for beneficiaries with both low and high drug use, and a zero premium PDP for beneficiaries who qualify for the low-income subsidy. Two other questions addressed coverage for non-formulary drugs and utilization management tool restrictions.
The ten plan sponsors were all nationwide plans which, as a group, account for 62 percent of the PDPS. They apparently included Aetna, Cigna, Coventry, Medco, MemberHealth, PacifiCare, Silver Script, United Healthcare, Well Care and Wellpoint UniCare, the ten national sponsors identified in a Kaiser Family Foundation report released earlier this year. The GAO, evidently, did not include Humana among the plan sponsors it studied.
On a positive note, the GAO report commended the CSRs for providing prompt and courteous service. CSRs answered the phone in less than one minute in 46 percent of the GAO’s calls, and in less than five minutes for 96 percent of the calls. The agency made the calls in March 2006.
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CMS Regulations Exempt Medicare & SSI Beneficiaries from Medicaid Citizenship Documentation
CMS published interim final regulations in the Federal Register on July 12, providing additional guidance to state Medicaid agencies as they implement the Deficit Reduction Act’s (DRA) new requirement for applicants to document their citizenship. In a Fact Sheet that gives an overview of the regulation, CMS announced that it intends to exempt Medicare beneficiaries and Supplemental Security Income (SSI) recipients from the new documentation requirements when they apply or reapply for Medicaid benefits. CMS’s announcement came on July 6, the day before attorneys from the National Senior Citizens Law Center and other organizations were scheduled to request a Temporary Restraining Order in federal court in Chicago, seeking a delay in the implementation of the DRA’s documentation requirements. CMS’s action also addressed some of the concerns of members of Congress who had begun work on a technical corrections bill to address the DRA’s shortcomings.
Although most seniors and many people with disabilities will not have to produce passports or birth certificates to document their citizenship to maintain their dual eligibility, the DRA’s citizenship documentation requirements still apply to as many as 40 million U.S. citizens. In the next edition of HAP’s E-mail Update we will provide more information on the affected individuals and groups, and discuss the revised implications for SHIP programs.
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III. Helpful Information
Target Data Released at the LIS Outreach Event
On July 6, HAP staff attended the Low-Income Subsidy (LIS) Outreach Event at CMS during which the agency released a new Extra Help/LIS outreach kit. In addition to providing SHIPs and other community-based organizations with tools and tip sheets about the Extra Help program, the toolkit includes target data that provide county-level estimates of the number of people who may be eligible for the LIS. CMS estimates that about 3.25 million Part D-eligible beneficiaries (who have not enrolled in Part D) are eligible for the Extra Help. The estimate derives from national data on the estimated total number of beneficiaries eligible for the low-income subsidy, the number of LIS-eligible beneficiaries who are either in Part D and receiving the LIS or in an employer/union plan qualifying for the retiree drug subsidy, and the estimated number of LIS-eligible beneficiaries who have additional sources of coverage, such as Veterans Affairs coverage, Indian Health Service coverage, or State Pharmaceutical Assistance Program wraparound coverage. CMS clearly stated that the “data are not measures of enrollment activity success,” but rather are “general estimates designed to help CMS and its partners to better target their outreach activities.”
The LIS Outreach Toolkit and the county-level data are available in a WinZip file from CMS. HAP also has a copy of the data and would be happy to share it if you have trouble unzipping the file. Please contact Rana Suliman at rsuliman@healthassistancepartnership.org.
HAP Involved in Part D Workgroup
In past conference calls, HAP staff has mentioned our participation in a workgroup whose goal is to identify resolve problematic issues within Medicare’s Prescription Drug Coverage. The workgroup includes representatives of the American Medical Association (AMA) and America’s Health Insurance Plans (AHIP), the trade association for many of the drug plan sponsors. This workgroup meets periodically with CMS staff to discuss Part D implementation issues. One output of this workgroup is the standard form for physicians to use to request formulary exceptions and appeals on their patients’ behalf. HAP is committed to addressing the needs of the SHIPs through its involvement as a member of this workgroup. For more information about the workgroup, please contact Kelly Brantley at kbrantley@healthassistancepartnership.org.
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CMS Postings
CMS Releases New Draft PDP Enrollment Guidance
On June 30, CMS made public an updated draft version of prescription drug plan enrollment guidance. The changes in this version include deletion of all irrelevant 2005 language and policy, several clarifications, and new appendices and exhibits. In chapter 10, CMS added a clarification stating that beneficiaries who are not eligible to enroll in a Part D plan during their Initial Enrollment Period (IEP) for Part B, or who were not eligible for Part D between November 15, 2005 and May 15, 2006 Initial Enrollment Period, will get a seven month period to join Part D surrounding the month they become eligible for Part D. This applies to people who are incarcerated or living abroad at the time of their IEP. Section 20.1 contains an added clarification which says that individuals who have Medicare based on disability and then turn 65 will get an additional IEP for Part D, but only if they have a lapse in benefits before turning 65. In Section 20.3.8, an addition states that full-benefit dual-eligibles with retroactive uncovered months will receive a special enrollment period (SEP). For more details, please see the summary of changes.
CMS Revises Appeals Chapter of the Prescription Drug Benefit Manual
On July 5, Anthony Culotta, Director of the Medicare Enrollment & Appeals group, sent a memo to Part D plan sponsors summarizing significant changes that CMS has made to Chapter 18, the appeals portion of the Part D manual. The changes include reorganization of several sections, several clarifications on exceptions and appeals issues, and some new information. In Section 20.2, Distinguishing Between Grievances and Coverage Determinations, a new subsection 20.2.4, titled Excluded Drug Complaints, explains a CMS policy that transactions involving excluded drugs may fall into three categories, including inquiries, grievances, and coverage determinations. Clarifications have also been made to Section 30.1, Prior Authorization or Other Utilization Management Requirements. CMS wrote that it requires plans to accept any written request for coverage determination, and that it does not allow plans to require that an enrollee or physician use a specific form to submit a coverage determination or exceptions request. A new section, 130.1, Effectuating Coverage Determinations, states that if a plan sponsor approves a standard request for benefits or payment, it must authorize or provide the benefits or payment within seventy-two hours after it receives the request.
CMS Releases FAQs on Insulin Syringes in LTC settings and Eligibility and Notice Requirements
On July 5, Cynthia Tudor, Director of CMS’s Medicare Drug Benefit Group, sent a memo to Part D sponsors, detailing a new Q&A about insulin syringe use in Long term care (LTC) settings. The question asks if Part D plans are required to cover "safety syringes." CMS's response is that it requires the plans to contract with LTC pharmacies which provide safe needle devices and that plans should integrate this into their standard network contracts.
A second Q&A addresses a notice issue that State Medicaid Directors raised. The question asks if Medicaid programs that do not learn of a person’s Part D eligibility until after the effective date of coverage, or before eligibility starts but without enough time to provide a required ten day advance notice of the discontinuation of Medicaid benefits, must still continue drug coverage through the notice period and while a hearing is pending. CMS responded that once a state receives notice of Part D eligibility, it must terminate Medicaid coverage as of the first day of Part D eligibility, regardless of whether or not advance notice or hearing rights have been sent to the individual. States should send a notice of action to beneficiaries stating their Medicaid services have been reduced and effective date of termination, but only grant hearing rights to those who claim they are not eligible for Part D benefits.
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Announcement Regarding Late Enrollment Penalties for Plan Year 2006
On June 30, Cynthia E. Moreno, Director of CMS’s Plan Oversight and Accountability group, released a memo to Medicare Contractors about late enrollment penalties (LEPs)as addressed in April call letters to Medicare Advantage Prescription Drug Plans (MA-PDs) and stand-alone Prescription Drug Plans (PDPs). Following an individual’s initial enrollment period (IEP), a LEP will be assessed for each full month that falls in a continuous sixty-three day period in which the individual: 1) was eligible to enroll in a Part D plan, 2) was not enrolled in a Part D plan, and 3) was not covered under any other creditable prescription drug coverage. Those who have a special election period (SEP) and enroll in Part D plans between July 1, 2006 and November 30, 2006, are among the first group of beneficiaries to face a LEP in 2006. Beneficiaries who are eligible for extra help or reside in an area affected by Hurricane Katrina will be able to enroll in a PDP without penalty through December 31, 2006.
IV. HAP Resources
SHIP State Director Conference Sessions Highlight HAP Partnerships with Iowa and Ohio
The SHIP State Directors for Iowa and Ohio, along with HAP staff, gave overviews of two CMS Competitive Leadership Grant projects during the 12th Annual SHIP Director’s Conference, held in Denver, Colorado from June 25 to 28. HAP partnered with the Iowa Senior Health Insurance Information Program (SHIIP) and the Ohio Senior Health Insurance Information Program (OSHIIP) to successfully meet objectives set forth under these grants that CMS awarded in March 2005. Rachel Gussett-Williams, HAP’s Director of National Technology Initiatives, co-presented with Kris Gross, the Iowa SHIIP State Director, on the Online Recertification System (ORS). ORS is a web-based training tool that conveys information to SHIP volunteers and then assesses their knowledge of that information in support of SHIIP’s recertification process. Gretchen Margraf, OSHIIP State Director presented on a new Volunteer Team Model which allows volunteers to specialize in specific roles that best suit their skills and comfort level, and on a series of web-based tools that enhance communication among OSHIIP staff, volunteers and the public. For more information about the products developed under these Competitive Leadership Grants, please contact Rachel Gussett-Williams (202-737-6340 or rgwilliams@healthassistancepartnership.org), Kris Gross (515-281-5705 or kris.gross@iid.state.ia.us), or Gretchen Margraf (614-644-3399 or gretchen.margraf@ins.state.oh.us).
Follow-up on SHIP Directors Conference
At the SHIP Directors Conference, Mike Klug, HAP’s Director of Program Development and Hilary Dalin, Director of Education and Counseling Development, led a workshop on “Managing the Counseling Process”. The session began with a discussion of the session participants’ concerns with Part D counseling, education and assistance, especially Part D enrollment activities. The session included a review of the Volunteer Protection Act (VPA) provisions, with the group acknowledging that the VPA is important for SHIP managers in that it shelters volunteer counselors from certain forms of legal liability. The session participants then offered and discussed many steps that SHIP Program managers can take, or have taken, to minimize the potential for errors or omissions as SHIP staff and volunteers educate, counsel and assist Medicare beneficiaries. The session was an initial step in HAP’s effort to collaborate with SHIPs to identify and address risk management issues. HAP staff welcomes the opportunity to continue that collaboration. We are preparing a summary of the many ideas the session participants raised as a part of HAP’s follow-up activities from the session. For more information, or to share your ideas on managing the counseling process, please contact us by e-mailing shiphelp@healthassistancepartnership.org.
Finally, we want to thank those of you who attended the Monday night “HAPpy Hour” at the SHIP Directors Conference. It was a pleasure for us to see many of you again, and to meet some of you anew.
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