I. Conference Call Information

II. In the News
CHAMP Act of 2007
House appropriations bill includes increases to SHIP funding
Special Enrollment Period (SEP) for deceived beneficiaries
One Company Resumes Marketing PFFS Plans
CMS terminates MA plan
LOEP ends

III. Reports
Exculsion of off-label drugs from Medicare coverage
Higher costs in Medicare for those uninsured before enrollment
Lack of accountability for marketing abuses

IV. New from CMS
Tip sheets
Finding those eligible for the Part D Low-income Subsidy (LIS)
CMS released the model 2008 Annual Notice of Change (ANOC)
Anemia drug coverage
Reopening of clinical trail policy national coverage determination

V. Useful Information
Premium withholding issues
LIS fact sheet from Kaiser
Private fee-for-service "toolkit"
KFF offers Educational tutorial on MA

VI. News and Information from HAP
HAP welcomes Kristi Remkus
AHIP has provided an expanded list of plan contacts for SHIPs
HAP will be testifying at NAIC hearing in September 

I. Conference Call Information

HAP's next monthly conference call, An Update on SHIP Funding, will be held on August 15, 2007 at 3:00 PM ET. On August 1, the U.S. House of Representatives passed the Children's Health and Medicare Protection Act, HR. 3162. If enacted, the law would expand health insurance coverage to all children whose families cannot afford health insurance. The bill also contains a number of Medicare provisions, including mandating that in 2009 CMS fund SHIP in the amount of $55 million and that for all subsequent years SHIP funding be increased by at least $10 million. If enacted, this provision would supersede CMS' current discretionary funding of SHIP. On August 2, the Senate passed its version of the CHAMP bill, which unfortunately does not include any Medicare provisions, including those related to SHIP funding.

During this call we will discuss the process of federal funding of SHIPs, from a brief overview of the legislative process to the difference between mandatory and discretionary funds. Marc Steinberg and Jen Beeson, from Families USA, will address recent happenings on the Hill related to Medicare and SHIP funding. Further, we would like to talk about the ways that SHIP staff and volunteers can become more involved in these processes. We will certainly leave time for questions and discussion. More information is available.

II. In the News

CHAMP Act of 2007 contains Medicare protections and SHIP funding increase; Bush threatens veto
On Thursday, August 1, 2007, the House of Representatives passed H.R. 3162, the Children's Health and Medicare Protection (CHAMP) Act of 2007. 

The Act provides expansions to low-income subsidy (LIS) eligibility and greater ease of access, reduction in Medicare Advantage payments, increased oversight of plans, expansions to preventative care, increased access to mental health care, and support for better use of the benefits provided.

In addition, the CHAMP Act contains exciting provisions that would increase SHIP funding over the next five years. The Act would direct the fees raised from Medicare Advantage and PDPs (under Part D) to SHIPs. The effect of the provisions - if enacted – would remove SHIP funding from CMS' discretion and the annual appropriations process. The bill says that the fees collected ($55 million in 2009, $65 million in 2010, $75 million in 2011, $85 million in 2012) shall be used to support Medicare Part C (managed care within Medicare) and Part D counseling and assistance provided by SHIPs.

This is the beginning of a long process to enact legislation. The Senate bill does not have these provisions. The House and Senate bills will have to be reconciled, and President Bush has threatened a veto.

The Center for Medicare Advocacy has written a brief overview of the Act’s provisions and will publish comprehensive information on these expansions in their weekly alerts.

House appropriations bill includes increases to SHIP funding
On July 19th the House of Representatives passed an appropriations bill that funds the federal Department of Health and Human Services (DHHS). Committee report language recommending that CMS fund SHIPs in 2008 at $45 million accompanies the bill.

In support of the recommendation for a SHIP funding increase, the Committee report states that, “SHIP is an important vehicle to help the nearly 45 million Medicare beneficiaries grapple with changes in coverage and prescription drug plans. SHIP provides one-on-one counseling to those who have trouble accessing the internet or the toll-free hotlines.”

The Senate Committee is recommending that not less than $35 million be made available for SHIP.

The Senate will most likely pass the Labor-HHS appropriation with the $35 million recommendation. At that point, the differences in the House and Senate bills will be negotiated and resolved by a conference committee consisting of House and Senate members.

Special Enrollment Period (SEP) for deceived beneficiaries
On July 18th the Centers for Medicare & Medicaid Services (CMS) officially eased the ability of Medicare Advantage enrollees who want to leave their Medicare Advantage (MA) and Part D drug plans because they joined "based on misleading or incorrect information provided by plan employees, agents, or brokers."

In a memorandum to MA and Part D drug plan sponsors, Anthony J. Culotta, director of CMS’ Medicare Enrollment and Appeals Group, stated that under a special election period (SEP), CMS customer service representatives will evaluate enrollees' requests on a case-by-case basis to confirm that they qualify. Caseworkers in the regional offices will process the requests and “discuss the possible ramifications of retroactive changes with affected beneficiaries.” Thus far, CMS has not issued guidance to help the CSRs make these case-by-case determinations.

One Company Resumes Marketing PFFS Plans
On August 9th Universal American Financial Corporation announced that CMS had cleared the company to resume marketing its Medicare Advantage Private-Fee-for-Service (PFFS) plans. Universal American markets four PFFS plans in 35 states under the “Today’s Option” trademark.

In mid-June, CMS reported that Universal American and six other Medicare Advantage PFFS plan sponsors had voluntarily suspended marketing due to substantiated complaints of abusive sales tactics. In all, these seven companies represent 90 percent of the PFFS plans covering 8 million Medicare Advantage members.

According to its news release, Universal American received the approval to resume marketing “pending training of its broker and agent force.” Per CMS guidelines, Universal American’s agents and brokers will “be re-trained and certified to market [their] 2007 PFFS plans.” HAP was not able to find any additional information regarding training requirements for agents and brokers, or about the resumption of Universal American’s PFFS marketing, on the CMS or HHS websites.

If a client presents a situation reflecting Medicare Advantage PFFS abuses, please use this form to let us know about it.

CMS terminates MA plan
On July 20th CMS terminated the contract for America's Health Choice Medical Plans Inc. (AHC), of Vero Beach, Florida for quality of care issues. The organization offered a Medicare Advantage health maintenance organization (HMO) plan with prescription drug coverage.

The 12,000 HMO members in seven counties will be moved to United Healthcare’s SecureHorizons plan. According to CMS, this plan has the largest doctor network and the benefits most similar to the terminated plan. Those transferred can choose a new plan or return to original Medicare until September 30th.

LOEP ends
A change in Federal law canceled, as of July 31 2007, the Limited Continuous Open Enrollment Period (LOEP) for Medicare Advantage plans that provided beneficiaries with original Medicare an ongoing opportunity to enroll in a Medicare Advantage plan.

III. Reports

Exclusion of off-label drugs from Medicare coverage
An August report from the Medicare Rights Center, “Off-Base: The Exclusion of Off-Label Prescriptions from Medicare Part D Coverage”, describes how CMS rules allow prescription drug plans to deny coverage of medications prescribed for "off-label" uses despite widespread prescribing practices for medically necessary “off-label” purposes.

Higher costs in Medicare for those uninsured before enrollment
According to a recent Commonwealth Fund report published in the New England Journal of Medicine, uninsured adults ages 59 through 64 who suffer from hypertension, diabetes, heart disease or stroke had health costs that were 51 percent higher than their insured counterparts once they entered Medicare. Moreover, those higher costs continued through age 72 for the individuals who did not have health insurance before entering the federal health care program for the elderly and disabled.

The authors note that the costs of expanding health insurance for uninsured adults before age 65 may be partially offset by subsequent reductions in health care services after they reach age 65.

Lack of accountability for marketing abuses
The Bush Administration refuses to hold Medicare private health plans accountable for their sales representatives’ marketing practices according to a new report, "The Reluctant Regulator: CMS's Response to Marketing Misconduct by Medicare Advantage Plans,” by California Health Advocates and the Medicare Rights Center. The report also cites a lack of any meaningful steps to stop the ongoing abuses.

IV. New from CMS

Tip sheets
CMS has published new tip sheets on Medicare Parts A and B appeals, Medicare Advantage grievances and appeals, and Part D appeals.

“Information Partners can Use: Medicare Drug Coverage Under Medicare Part A, Part B and Part D”, provides an overview of drug coverage under the various parts of Medicare.

Finding those eligible for the Part D Low-Income Subsidy (LIS)
On July 25th, CMS released information on how to find low-income persons who have no prescription drug coverage and may be eligible for extra help paying for their Medicare Part D drug plans. CMS says this data can be used to identify where the highest concentrations of potentially eligible elderly and disabled individuals live, down to the zip code level. CMS released this as part of a Low-Income Subsidy (LIS) Toolkit.

CMS released the model 2008 Annual Notice of Change (ANOC)
In a July 25th memo to Medicare Advantage Plans, Prescription Drug Plans, and Medicare Cost Plans, CMS outlines procedures for 2008 issuances of ANOCs and Evidence of Coverage. Plans can either mail beneficiaries a document that combines the ANOC with the Evidence of Coverage (EOC), or mail the documents separately. Regardless of the type of mailing, ANOCs must be received by October 31. It is possible that the combined approach will become mandatory for future contract years.

Anemia drug coverage
CMS has posted Questions and Answers related to National Coverage Determination 000383: ESAs in Cancer and Neoplastic Conditions. CMS has relaxed some of its restrictions on anemia drugs use by cancer patients and now will cover the medications to treat anemia caused by chemotherapy but not anemia caused by cancer.

Reopening of clinical trial policy national coverage determination
The Medicare program reopened its clinical trial policy national coverage determination, and issued a proposed decision memorandum for public comments due August 19th.

V. Useful Information

Premium withholding issues
In July of 2007 the Social Security Administration (SSA) notified 92,000 beneficiaries that they were entitled to premium payment refunds from 2006. The 2007 refund processing is ongoing. HAP is following up with SSA to learn how the agency is processing these refunds and how beneficiaries can avoid issues in the upcoming year.

LIS fact sheet from Kaiser
Kaiser Family Foundation updated its fact sheet on low-income assistance for Medicare beneficiaries. The fact sheet explains eligibility for the low-income assistance for Part D, how the benefits work and estimates for the number of seniors eligible and the number enrolled.

Private fee-for-service “toolkit”
A compilation of articles, booklets, and other forms of information on Medicare Advantage private fee-for-service plans is available from the Alliance for Health Reform.

KFF offers Educational tutorial on MA
The Kaiser Family Foundation has posted a narrated slide tutorial on Medicare Advantage by Michelle Kitchman Strollo, DrPH. The tutorial discusses the different types of Medicare Advantage plans, trends in participation and enrollment, enrollee characteristics, and key policy issues.

VI. News and Information from HAP

Welcome to HAP
We would like to welcome Kristi Remkus to HAP. Kristi has joined the HAP team as its Health Education and Information Specialist. Kristi has a Master of Public Health degree and a background in communications. Kristi will be working on a variety of projects and will be contacting SHIPs to ensure that HAP's services are meeting your needs; she will welcome your suggestions and recommendations. Welcome Kristi!

AHIP has provided an expanded list of plan contacts for SHIPs
America’s Health Insurance Plans (AHIP) has provided HAP with an expanded list of Part D plan contacts for each state. Contact HAP at info@hapnetwork.org for updated information for your state if you are having difficulty contacting a plan.

HAP will be testifying at NAIC hearing in September
The National Association of Insurance Commissioners (NAIC) will hold a hearing on September 11 and 12 about ongoing MA and Part D problems. The NAIC has invited HAP to testify. Please share your experiences. We are particularly interested in: how beneficiaries make choices, how the annual changes in plan formularies and drug restrictions impact beneficiaries, Medigap issues, MA plan disenrollment backlogs and premium withhold problems. What else are you seeing? Email us at info@hapnetwork.org.