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In March's Issue:
HAP HAPpenings
- New Tools and Resources to Help SHIP Volunteer Programs
- Coverage Notices and Troubleshooting Medicare
- MSP and Medicare Advantage Counseling Tools Updated
What's Next for HAP
- Upcoming Changes to HAP's Web site
- March Marks Final Issue for Monthly eNewsletter
CMS News
- CMS Terminates Part D Contract with Fox Insurance Company
- New Making MIPPA Work Issue Brief Available
Interesting Items
- Health Reform Update
- Updates from the Social Security Administration
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HAP HAPpenings
New Tools and Resources to Help SHIP Volunteer Programs
HAP has collaborated with the Colorado and Virginia SHIP programs over the past 12 months to develop and design resources that help coordinators recruit, screen, and train new volunteers. As the Collaborative State Projects (CSPs) come to a close, HAP is excited to share the resources developed under this program with the entire SHIP network. We encourage you to customize these tools to meet the unique needs of your SHIP and volunteer program.
Customized Recruitment Toolkits to Engage New Volunteers
The Colorado and Virginia SHIP programs recognized that before they could begin engaging new volunteers, they first needed materials to help recruit them. HAP, in collaboration with both SHIP programs, developed a customized recruitment toolkit which offers resources to help SHIPs enlist new volunteers and provide a stronger foundation for the volunteer program. Each toolkit includes a recruitment brochure, volunteer job descriptions, an application, and a volunteer agreement.
Colorado's Medicare Navigators
Virginia's COMPASS Team
Resources to Screen and Train Potential SHIP Volunteers
It can sometimes be challenging to find the "right" SHIP volunteers. To make the process a little easier, HAP collaborated with the Colorado and Virginia SHIP programs to develop a variety of screening tools to help identify potential volunteers. Your program can save valuable time and resources using these tools to identify promising applicants.
Coverage Notices and Troubleshooting Medicare
HAP is now turning to another important beneficiary protection issue — Medicare coverage notices and due process — in the Troubleshooting Medicare project. Issues with coverage notices affect beneficiaries' access to care as well as the ability of beneficiaries to understand coverage decisions and make informed choices.
Medicare, its payment contractors, and many providers give written notices to Medicare beneficiaries about coverage, payment, and claims. The most common types of notices include Original Medicare Summary Notices (MSNs), Medicare Advantage and Part D drug plan Explanation of Benefit (EOB) statements, and Original Medicare and Medicare Advantage Advance Beneficiary Notices (ABNs) that include Coverage Termination Notices. In some cases, these notices do not adequately explain a decision to deny payment or to reduce or discontinue services. In other cases, plans and providers use them inappropriately. With help from the SHIP network, HAP would like to identify and document some of the problems that these inadequate or inappropriate notices create for Medicare beneficiaries.
Here are a few examples of how coverage notice issues can ultimately affect access to care:
Medicare Summary Notices: In Oregon, Medicare Summary Notices (MSNs) may not explain that a National Coverage Determination (NCD) is the basis for a coverage denial. NCDs are decisions issued by CMS as to whether and when certain medical services or treatments are covered by Medicare; they are binding and Medicare contractors are required to follow them. In one beneficiaries' case, the Medicare carrier denied payment for a diagnostic procedure that is the subject of an NCD, but the MSN only explained that "Medicare does not pay for this service or item." The MSN said nothing about an NCD being behind the denial. The lack of information led the beneficiary through a long and involved standard appeals process that was ultimately rendered futile because of the original denial was based on an NCD.
Advance Beneficiary Notices: Last year SHIP coordinators across the country confirmed that providers still issue Advance Beneficiary Notices (ABNs) on a routine basis. ABNs are designed to put a beneficiary on notice that Medicare may not pay for a certain service, procedure, or item when it is not medically necessary in a specific case. In one example, a clinic issued an ABN to a patient whose doctor ordered a test to check the Warfarin (blood thinner) levels in her blood. The ABN advised that Medicare might not cover the test because it was not medically necessary, even though the patient's heart valve condition clearly established a need for the test. Upon inquiry, the SHIP learned that the clinic issues ABNs routinely for lab work, regardless of the medical necessity in an individual case.
Coverage Termination Notices: The Centers for Medicare & Medicaid Services (CMS) expects home health agencies and skilled nursing facilities (SNF) to give coverage termination notices (a special type of ABN) to beneficiaries when the patient no longer meets Medicare's coverage rules (e.g., homebound, need for skilled nursing or rehabilitation care, etc.) and payment denial is expected. Providers sometimes issue these notices prematurely when they sense that Medicare payment is no longer a sure thing. Rather than assess an individual's unique condition in light of Medicare's numerous coverage rules, they issue coverage termination notices. In Florida, a home health agency issued a coverage termination notice to a patient recovering from a stroke. According to the agency, the patient didn't meet Medicare's criteria for physical therapy coverage because her condition had "plateaued" and she was no longer making progress. The beneficiary's daughter protested, saying that her mother needed skilled physical therapy to prevent deterioration and contractures. Medicare advocates report that beneficiaries with Multiple Sclerosis (MS), Alzheimer's disease, Lou Gehrig's disease (ALS), diabetes, and spinal cord injuries regularly face this problem as well.
HAP is interested in hearing from you about any issues your clients are experiencing around MSNs, ABNs, or Coverage Termination notices. In particular, we want to know if beneficiaries are receiving incomplete or inappropriate coverage decision notices from Medicare's payment contractors, health care providers, or MA plans. The information you provide will help HAP determine the scope of the problem and its impact on SHIP clients and counselors alike. Share your feedback now and stay tuned for further updates.
MSP and Medicare Advantage Counseling Tools Updated
HAP is pleased to announce that our Medicare Savings Programs (MSP) guide is now updated and revised to reflect changes that took effect on January 1 due to the Medicare Improvements for Patients and Providers Act (MIPPA). The three-page guide uses a question and answer format to explain MSP benefits, eligibility rules, and 2010 income and asset standards.
HAP's Making Informed Decisions: Navigating Medicare Advantage booklet has also been revised. It's designed to be a guide for SHIP counselors as they help clients navigate the Medicare Advantage program and weigh the pros and cons of different Medicare Advantage (MA) plans. Also included are key features of Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), Special Needs Plans (SNPs), and Private-Fee-for-Service (PFFS) plans. Making Informed Decisions raises and discusses questions that clients should ask when considering their access to care, a plan's affordability, and the differences between an MA plan and Original Medicare.
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What's Next for HAP
Upcoming Changes to HAP's Web site
April 1 marks a new phase for HAP as we mark our transition to fewer staff and a more focused set of activities.
Given our reduced funding effective April 1, we will not have the capacity to initiate new projects or products in the area of SHIP program development. However, we'd like to remind you of the various tools and resources that are already available — and will remain available — on our Web site:
- Best Practices: This center highlights the outstanding projects of SHIPs — in the areas of Medicare education, outreach, and training and management — who have shared their tools and resources over the years.
- HAPSavers: A HAPSaver is a quick "how-to" tip sheet on a specific topic that addresses an area of SHIP program operations. Because HAPSavers are based on research and experiences from the field, they offer practical advice to help SHIPs carry out and expand their daily activities in the areas of technology and certification.
- SHIP Certification: HAP has compiled resources to help strengthen your certification program. Learn about the methods employed by other SHIP programs, including training, testing, mentoring, and exercises, or explore certification strategies used by other volunteer programs.
- Volunteer and SHIP Program Development: Volunteer recruitment and training remain a top priority for SHIPs. Check out HAP's volunteer program development tools including tips and strategies to recruit new volunteers.
We encourage you to use and customize these tools as you continue to strengthen your programs over the coming months to meet the increased demand for SHIP services. For more information on the demand for services experienced by other state SHIP programs, check out HAP's 2010 State of the SHIPs report.
March Marks Final Issue for Monthly eNewsletter
As the HAP staff prepares for the upcoming transition, it is with sadness that we announce that this is the last regular edition of the monthly eNewsletter. Over the last several years, you have come to rely on HAP's monthly newsletter for the latest in Medicare updates, advocacy updates, CMS news, and other important news that affects you and the beneficiaries you serve.
Thanks to your continuous feedback, we have worked to grow these resources into better and more robust tools and updates. We thank you for your help and support in making these resources useful to your program.
We will continue to share information and updates affecting SHIPs and Medicare beneficiaries through periodic eAlerts. If you have any questions or would like to contact us, please e-mail us, as always, at SHIPhelp@hapnetwork.org.
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Update on LIS to MSP Data Transfer
On February 18, the Centers for Medicare and Medicaid Services (CMS) released a letter to state Medicaid directors offering guidance on the implementation of MIPPA provisions. The letter also includes an enclosure providing explicit instructions for states to follow as they make changes to be compliant with new requirements for their programs.
What actions has your state taken to implement these changes? Let us know at SHIPhelp@hapnetwork.org.
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CMS News
CMS Terminates Part D Contract with Fox Insurance Company
In a remarkable administrative oversight action involving a Medicare drug plan, the Centers for Medicare & Medicaid Services (CMS) announced on March 9 that it was terminating its contract with Fox Insurance Company effective immediately. CMS cited Fox's inability to meet Medicare requirements for providing enrolled beneficiaries with access to prescription drugs according to recognized standards of care as posing a serious threat to the health and safety of Fox's enrollees. This is the first such action of its kind involving a Part D prescription drug plan, and it underscores the seriousness of the barriers to care in this situation. This follows up on CMS's decision, announced February 26, to suspend Fox's marketing and enrollment of its Part D drug plans. There are more than 123,000 Fox enrollees in 21 states nationwide, with nearly three-fourths of them in Florida, North Carolina, and New York.
In onsite reviews of Fox's operations conducted less than one week after announcing its previous marketing and enrollment suspension, CMS found that Fox was imposing unapproved prior authorization and step therapy criteria, not meeting appeals deadlines, not complying with transition fill regulations, and not notifying enrollees about the plan's prior authorization and step therapy determinations. CMS also found that Fox improperly denied coverage of HIV, cancer, and seizure medications.
Fox enrollees will have until May 1 to choose a new Medicare prescription drug plan. CMS will enroll those who do not choose a plan into a new drug plan after that. In the interim, all current Fox enrollees can fill their prescriptions through LI NET. Jonathan Blum, the acting director for CMS's Center for Drug and Health Plan choices, said that CMS will send letters to the affected beneficiaries to explain the steps CMS is taking to ensure continued access to needed drugs. Blum stressed, "We take our oversight role of Medicare prescription drug plans seriously. We review and take action on all complaints received about Medicare health and drug plans and will take appropriate and immediate actions wherever necessary." CMS encourages Medicare prescription drug plan enrollees having concerns with access to drug coverage to contact 1-800-MEDICARE or their local SHIP.
Fox's compliance problems came to CMS's attention through complaints raised by plan members and their physicians. In a case brought to HAP's attention by the Colorado SHIP, Fox denied coverage of the brand-name heart medication Coreg for an 84-year-old beneficiary. The company denied coverage again after a redetermination request. At that point, the beneficiary's daughter called 1-800-MEDICARE to file a formal complaint that may have factored in to CMS's compliance action.
If you work in one of the 21 states with Fox enrollees, please let us hear from you about how LI NET is working in the interim for your clients, and about your efforts to help current Fox enrollees switch to new drug plans. More information about LI NET is available in a CMS fact sheet. Contact us at SHIPhelp@hapnetwork.org.
New Making MIPPA Work Issue Brief Available
Families USA, HAP's parent organization, recently released an issue brief, Making the Medicare Improvements for Patients and Providers Act (MIPPA) Work: How States Can Help People with Medicare. The six-page brief reviews the improvements MIPPA has made to the Medicare program, including aligning asset limits for the Medicare Savings Programs (MSP) with the full Part D low-income subsidy (LIS) program, and offers SHIP counselors and others in the aging network practical tips to ensure that MIPPA's improvements continue to gain traction at the state and local level.
In addition to the Families USA brief, HAP offers additional MIPPA resources to help complement your up-to-date counselor trainings. Check out our three-page fact sheet, Medicare Improvements for Patients and Providers Act: Key Changes for Low-Income Beneficiaries, which provides an overview of MIPPA changes, including their impact on the MSP and LIS programs.
Looking for a quick refresher on MIPPA? Test your knowledge and visit HAP's recent Check Your Skills edition devoted entirely to MIPPA changes.
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Interesting Items
Health Reform Update
As part of the health care reform effort, and HAP's Troubleshooting Medicare project, we've been working since last summer to inform Congress about the need to move and extend the annual enrollment period (AEP). This important legislative change would allow Medicare beneficiaries the time they need to make informed choices about their Medicare Advantage (MA) and Part D prescription drug plans. Thanks to this effort, both the Senate-passed and House-passed health care reform bills contain specific provisions that would change the timeframe of the current AEP.
In the coming weeks, Congress will cast an “up or down” vote on health care reform. Details on the final bill should be available soon, in the meantime check out the updated set of strategies, messages, and tools for passing meaningful reform on Families USA's Web site. The site also includes information on the President's proposal, which blends key features from the Senate-passed and House-passed bills.
For more information on this important beneficiary improvement, contact us.
Updates from the Social Security Administration
On March 2, HAP and other advocates met with the Social Security Administration (SSA) as part of our quarterly meetings at SSA headquarters to share and discuss the latest on the Medicare beneficiary experience, particularly for those beneficiaries on the low-income subsidy (LIS).
What's the latest?
- SSA would like the SHIP network to know that letters were sent in February to all previously denied LIS applicants, going back to 2006 when the LIS program first began. SHIP counselors may receive phone calls from these letter recipients requesting assistance. The letter advises beneficiaries that recent changes in the law may now make them eligible for Extra Help and possibly a Medicare Saving Program (MSP), so they should consider reapplying for LIS.
- SSA also asked that SHIPs and others working with beneficiaries discard any old LIS applications dated prior to January 1, 2010. Recent changes in law requires the SSA to find out whether LIS applicants would like their LIS application sent on to the state to see if they may be eligible for an MSP (see Question 15 on the LIS application). If SSA receives an old application, they must contact the beneficiary and ask them to complete a new application. This in turn delays the LIS application process, which as of now, SSA estimates is taking approximately 30 days. If SHIPs need new applications, they should call SSA at 1-800-772-1213 and request multiple copies.
In other exciting SSA news, the Social Security Administration recently announced that it has added 38 more conditions to its list of Compassionate Allowances. The list, which now includes early-onset Alzheimer's disease, allows SSA to expedite disability determinations for beneficiaries with any of these conditions. Individuals suffering from these conditions can now access Social Security and Supplemental Security Income disability benefits faster than they would through the customary two-year disability waiting period. SHIPs may begin to see more of these clients as they become eligible for Medicare.
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