Archive
I. Conference Call Information
II. In the News
New KFF Issue Briefs Examine Medicare Plans
Increasing Reports of Medicare Advantage Marketing Abuses
Response from CMS to Advocate Concerns Regarding the L-OEP
III. Helpful Information
National Volunteer Week
Changes Made to Chapter 5 and 6 of the Prescription Drug Benefit Manual
Revisions Made to Chapter 18 of the Prescription Drug Benefit Manual
Clarification of "All or Nothing" Rule for Premium Withholding
Revised Auto-Enrollment Letters
Coverage Year Issues Associated with Coordination of Benefits (COB)
Clarification of Involuntary Disenrollment Policy for Beneficiaries Who Elect Social Security Premium Withholding
IV. HAP News and Resources
HAP News: SHIP Tools
HAP News: HAP Comments on Revised Important Message from Medicare
HAP Resources: MedicareAdvantage Disenrollment
I. Conference Call Information
HAP's next conference call for the SHIP Network is scheduled for Wednesday, April 18, at 3:00 p.m. Eastern Time. Please look for an email announcement with details about the call earlier that week.
II. In the News
New KFF Issue Briefs Examine Medicare Plans
As SHIPs continue to provide consumers objective information about Private-Fee-for-Service (PFFS) plans and other Medicare Advantage (MA) options, three new Issue Briefs that the Kaiser Family Foundation released in March give background that will be helpful in preparing for presentations and other outreach efforts. “An Examination of Medicare Private Fee-for-Service Plans” contains an excellent summary of the legislative history of PFFS plans. The brief describes the lobbying effort and Congressional thinking that led to PFFS plans operating, for the most part, without the federal oversight that applies to other MA plans. The 17-page issue brief also describes PFFS payment policy, key plan features and the dramatic growth in enrollment since Sterling Life Insurance offered the first PFFS plan in July 2000. National enrollment in PFFS plans has increased at the staggering rate of 535 percent from December 2005 to February 2007, rising from about 209,000 to more than 1,338,000 beneficiaries in that fifteen month span. The authors note that “industry analysts expect this enrollment trend to continue in 2007.” Finally, the brief contains a useful description of five important considerations that Medicare beneficiaries should weigh as they compare PFFS plans to other Medicare options. The brief cites the potential for high out-of-pocket spending in some plans, lack of access to physicians, marketing abuses, plan stability, and the statutory exemption from quality reporting as concerns for beneficiaries.
A second KFF Issue Brief, entitled “Medicare Consumer-Directed Health Plan: Medicare MSA and HSA-like Plans in 2007,” examines the development of consumer-directed health plans in Medicare, including Medicare Medical Savings Account (MSA) plans. This 22-page Issue Brief examines how these plans operate in Medicare, how they differ from other MA plans, and the potential implications for the beneficiaries who enroll in them. It also contains helpful charts, including one that shows the major differences between MSAs and other MA plans and another that contrasts the key features of Wellpoint Unicare’s and American Progressive’s plan offerings for 2007. The authors note that current nationwide enrollment in the three available Medicare MSA plans is fewer than 3,000.
KFF also issued a more general report on recent developments in CMS’s efforts to privatize Medicare. “Private Plans in Medicare: A 2007 Update” examines changes between 2006 and 2007 in the enrollment and availability of Medicare Advantage plans and Medicare prescription drug plans in both urban and rural areas. The report’s key findings include the news that 86 percent of Medicare beneficiaries now have three or more PFFS plan sponsor choices. In addition, for the first time more than 70 percent of Medicare beneficiaries can choose to enroll in the Medicare MSA plan option primarily because Wellpoint is offering its product in many parts of the country.
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Increasing Reports of Medicare Advantage Marketing Abuses
During HAP’s last two conference calls with SHIP staff from throughout the country, we heard alarming reports of troubling sales tactics of insurance company representatives and independent brokers who are aggressively marketing Medicare Advantage (MA) plans to seniors. They specifically target the dually eligible because of their ongoing ability to enroll in MA plans.
The abusive marketing tactics that SHIPs reported include fraudulently inducing seniors to sign applications by mischaracterizing the application as "a form asking for more information" or a document proving that the agent actually "talked to the beneficiary". SHIPs also reported that some sales agents are even suspected of forging beneficiary signatures on applications. Moreover, these unscrupulous agents are not providing beneficiaries with copies of the MA applications. Consequently, the beneficiaries were unaware that they were enrolled in the specific MA plans at issue.
Call participants also reported instances of sales agents flagrantly misrepresenting their identity by simply stating that they are from "Medicare Advantage." These agents often do not explain Medicare Advantage or distinguish the types of MA plans they are marketing. Nor do agents explain how their MA product differs from the beneficiary's current benefits structure. By far, one of the most misleading tactics reported during our call involved agents in several states flashing red, white and blue business cards that closely resemble the Medicare card. Equally disturbing were reports of unsolicited door-to-door sales and agents cold-calling seniors who are registered on state and/or federal "do not call" lists.
Several call participants stated that representatives of many MA Private Fee for Service Plans from around the U.S. are grossly misrepresenting how the plans actually work. Clearly, some of the reported practices blatantly violate federal and state laws, as well as CMS marketing regulations and guidelines.
HAP has brought these practices to the attention of CMS. CMS has provided HAP and other organizations a direct contact for reporting these marketing abuses to CMS. As CMS strives to identify trends, SHIPs can provide evidence that these trends already exist by reporting the facts and circumstances surrounding these events. HAP is collecting individual stories with the name and telephone number of the beneficiary and as much information regarding the abuse as possible. If a beneficiary is amenable, please forward this information directly to HAP for reporting to CMS.
If you have any questions about our request or your response, do not hesitate to contact us at SHIPhelp@hapnetwork.org.
Response from CMS to Advocate Concerns Regarding the L-OEP
As reported in the February 2007 HAP eNewsletter, several organizations signed on to a letter sent by the California Health Advocates to CMS on February 7th. In raising concerns about the agency’s apparent misinterpretation of Medicare law with respect to elections permitted under the new “Limited Open Enrollment Period (L-OEP),” the letter highlighted a particular concern regarding the cancellations of Part D coverage by Medicare for individuals who enroll in certain Medicare Advantage-only coordinated care plans.
CMS responded on March 8th. Anthony Cullota, Director, CMS Medicare Enrollment and Appeals Group asserts that CMS is interpreting the law correctly and that the inadvertent loss of prescription drug coverage by Medicare beneficiaries signing up for MA-Only plans will be mitigated by:
1) The requirement that MA-only plans call prospective enrollees before enrollment and advise them they will lose Part D coverage if they choose to proceed with enrollment.
2) A case by case SEP to make sure that those who, “despite the required confirmation process, they subsequently indicate that they were unaware that they would lose their prescription drug coverage as a result of their L-OEP election.”
It is unclear how the SEP will be used or what type of process the various MA plans will implement in their call confirmation effort.
Concerns remain regarding the manner in which confirmation calls will occur. In addition, it is unclear whether the SEP will offer a meaningful process to counter assertions that an MA Plan’s call to a beneficiary is sufficient confirmation that the beneficiary wants to enroll and lose their current drug coverage.
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III. Helpful Information
National Volunteer Week is April 15-21
The Points of Light Foundation is once again sponsoring National Volunteer Week between April 15 and 21 as a way to thank volunteers by calling the public’s attention to the many good things they do to improve our communities. The special week may be a good time to ask a local reporter to feature the work of SHIP volunteers. Points of Light Foundation has prepared an extensive National Volunteer Week tool kit that contains sample Op-Ed pieces, facts on volunteerism and two pages of famous quotes on volunteering, including this by Winston Churchill: “We make a living by what we do, but we make a life by what we give.”
CMS Postings
Changes Made to Chapter 5 and 6 of the Prescription Drug Benefit Manual
CMS released changes to the final version of Chapters 5 and 6 of the Prescription Drug Benefit Manual.
The Prescription Drug Benefit manual provides guidance to both PDP and MA-PD Part D plan sponsors. Chapter 5 provides guidance on benefits and beneficiary protections. Chapter 6 provides guidance on Part D drugs and formulary requirements. This guidance exists outside of the statutory and regulatory frameworks and does not have the weight of law.
In Chapter 5, CMS discusses information about Part D (benefits and service areas); access to Part D covered drugs, requirements that Part D plans give beneficiaries pricing information for Part D drugs (including rebates, discounts, and subsidies), and enrollee records.
In Chapter 6, CMS addresses formulary requirements for plans, enrollee transitions, Part D exclusions, as well as information on Part D versus Part B covered drugs.
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Revisions Made to Chapter 18 of the Prescription Drug Benefit Manual
On February 27, 2007 Anthony Culotta, Director of the Medicare Enrollment & Appeals Group, sent a memo to Part D plan sponsors outlining updates to Chapter 18 of the Drug Benefit Manual. Chapter 18 presents guidance regarding Part D grievances, coverage determinations, and appeals. The most notable changes concern: 1) Sending notice of a dismissal to an enrollee and a person who asserts representative status (§10.4.1); 2) Co-payment complaints must be processed as coverage determinations (§20.2.2); 3) Complaints regarding drugs not covered by Part D (§20.2.4); and 4) When an enrollee files an exception during the transition period and the plan does not make a timely decision, the plan must provide a temporary fill of the requested drug (§40.4). Please see the manual for more details and information about other changes made.
Clarification of "All or Nothing" Rule for Premium Withholding
On March 8, Abby Block, Director of the Center for Beneficiary Choices, sent a memo to plan sponsors regarding Social Security premium withholding and secondary coverage for plan premiums. CMS states that in accordance with guidance, plans must accept premium payments made by supplemental payers, such as SPAPs. Plans must work with these supplemental payers to coordinate premium payments. CMS is clarifying this rule because it does not have the authority to create a coordination of benefits system directly for Social Security Premium withholding. Furthermore, plans must supply a refund to members who elect premium withholding, but have a supplemental payer covering premium payments. A specific timeframe for processing refunds is not mentioned.
Revised Auto-Enrollment Letters
On March 15, CMS released a revised version of the auto-enrollment letter for dually eligible beneficiaries. The letter explains that drugs are now covered by Medicare and not Medicaid. Additionally, if a dual eligible beneficiary does not take active steps to choose a prescription drug plan, CMS will auto-enroll the individual in a plan. Revisions include language describing auto-enrolled beneficiaries’ rights to have prescription costs reimbursed retroactively by the plan. Abby Block, Director of the Center for Beneficiary choices, sent a memo to plan sponsors detailing this information.
Coverage Year Issues Associated with Coordination of Benefits (COB)
According to a March 21st memo sent to Part D plans by Cynthia Tudor, Director of CMS’s Drug Benefit Group, the March 31st deadline for receipt and payment for claims related to third party payers is no longer applicable. These include processes such as State-to-Plan Demonstration Project, and direct COB with State Medicaid Programs, and State Pharmaceutical Assistance Programs. CMS attributes this to “extraordinary circumstances in the start-up year that created a large number of COB issues.”
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Clarification of Involuntary Disenrollment Policy for Beneficiaries Who Elect Social Security Premium Withholding
Abby L. Block, Director of the Center for Beneficiary Choices, sent a memo to Part D plans on March 23rd clarifying the involuntary disenrollment policy for beneficiaries who elect Social Security premium withholding. Current guidance states that plans can not disenroll or threaten to disenroll beneficiaries for failure to pay premiums when the beneficiary requests to have premiums withheld from their Social Security benefit check until CMS denies the request and notifies the plan. Furthermore, any beneficiary with withhold status may not be involuntarily disenrolled from their plan.
IV. HAP News and Resources
HAP News: SHIP Tools
In early 2007, through continued work with Ohio and Iowa, HAP created SHIPTools, a ‘one-stop shop’ that connects together all of the functionality of the three web-based tools that HAP has developed as well a host of exciting new features. This includes HAP's electronic National Performance Reporting (eNPR) as well as the functionality of the Online Recertification System (ORS) and the Collaborative Tools. This connection through SHIPTools makes it possible to turn on and off features in any of the tools on a case by case basis depending on the wants and needs of any particular state SHIP program. It also makes it possible to add on to the tools, just as you would add a room onto a house that already has a solid foundation laid.
For more information on SHIPTools or HAP's technology initiatives, please contact Rachel Gussett-Williams or Steve DeRosa at tools@hapnetwork.org.
HAP News: HAP Comments on Revised Important Message from Medicare
HAP sent comments on March 6 to CMS about the agency’s revised Important Message (IM) from Medicare, the notice that hospitals provide to patients to explain discharge and appeal rights. HAP raised concerns about the IM’s lack of clarity and suggested alternative language to improve the quality of the notice.
HAP Resources: Medicare Advantage Disenrollment
In response to the growing number of MA issues voiced by SHIPs, HAP created a new set of tools to help SHIPs with MA disenrollment and MA retroactive disenrollment. Case examples illustrate how retroactive disenrollment may be used. A sample letter for confirming disenrollment and creating a paper trail is also included.
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