Dual Eligibles and Medicare: Ongoing Issues California Medicare Coalition Webcast – April 9, 2008...

Dual Eligibles and Medicare:

Ongoing Issues

California Medicare CoalitionWebcast – April 9, 2008Presented by David LipschutzCalifornia Health Advocates

This webcast is supported by The California Endowment

California Health Advocates (c) 20082

Our Focus

California Health Advocates is dedicated to Medicare beneficiary advocacy and education for Californians.

Policy – Public policy research and recommendations for improved rights and protections, partner with national Medicare organizations based in Washington D.C.

Training – Professionals and informal helpers, vibrant web resources, newsletter and regional forums

Advocacy – Bring the experience of Medicare beneficiaries to the public through media and educational campaigns with the legislative staff at federal and state levels.

www.cahealthadvocates.org


Acknowledgments

National Senior Citizens Law Center www.nsclc.org

Center for Health Care Rights www.healthcarerights.org

Health Assistance Partnership www.hapnetwork.org

Also see: Center for Medicare Advocacy –

www.medicareadvocacy.org Medicare Rights Center – www.medicarerights.org


Outline

Overview – Dual Eligibles and Medicare Part D

Enrollment Issues

Auto-Assignment and Benchmark Plans

Reassignment

Point of Sale (POS) Process

Medicare Advantage & Dual Eligibles

Marketing Misconduct

Low Income Subsidy (LIS) Eligibility

Best Available Evidence (BAE)

Other Issues


Overview

Part D benefit only available through private, commercial plans Stand-alone prescription drug plans (PDPs) Medicare Advantage-Prescription Drug Plans

(MA-PDs) Individuals dually eligible for Medicare and Medi-

Cal (Medicaid) must be enrolled in a Medicare Part D drug plan in order to obtain drug coverage Medi-Cal still covers many drugs excluded under

Part D


Overview (cont’d)

Medicare Modernization Act (MMA) created a Part D Low-Income Subsidy (“LIS” or “Extra Help”) available for qualifying individuals Helps pay for some Part D costs Some people automatically eligible for LIS

• Full Dual Eligibles, Medicare Savings Program

Others must actively apply (through SSA)


Auto-Assignment

LIS enrollees auto-assigned to a Part D plan unless they are already enrolled in one

Auto-enrollment is random assignment into a standard plan with fully subsidized premium (“benchmark plan”)

Problems with delays …


Benchmark Plans

PDP qualifies as a benchmark plan only if it offers basic coverage w/ premiums at or below the regional benchmark levelFull subsidy LIS enrollees can enroll in

benchmark plans without paying any premium

2008 benchmark in CA = $19.80 (down from $21.03)

9 benchmark plans in CA – same # as 2007, but some different actors


Plan Reassignment

½ of the benchmark and other plans for which LIS enrollees paid no premium in 2007 (“de minimis” plans) are not benchmark or de minimis plans in 2008 De minimis plans – charge above benchmark but

are still premium-free for LIS enrollees Many benchmark plans raised premiums so they

are no longer benchmark plans in 2008 In CA, including UnitedHealth (AARP), Humana

Std., - 2 biggest plans Approximately 500,000 duals in CA were

reassigned


Plan Reassignment (cont’d)

Some LIS enrollees reassigned, others not CMS reassigned people who remained in PDP

into which CMS auto-assigned them • If plan sponsor offers another benchmark plan for 2008,

individual was reassigned to that plan • Everyone else – random assignment

Group that was NOT reassigned – “choosers”• LIS enrollees who chose their own Part D plan instead of

being auto-assigned• Approx 97,000 in CA at end of 2007

• Should have received a letter explaining that they have to pay portion of premiums unless they switched to a benchmark plan


Data Issues

Several data systems must share Medicare and Medi-Cal information in order for a dual eligible to be effectively enrolled into a Part D plan and show LIS eligibility See NSCLC webcast “Behind the Scenes of

Medicare Part D: Data Transfers and the Point of Sale Mechanism”

System delays often result in gaps between eligibility for LIS and enrollment in Part D plans leading individuals to pay out of pocket (if they are able)


Point of Sale (POS)

CMS Point of Sale (POS) Facilitated Enrollment Process (a.k.a. Wellpoint) for dual eligible beneficiaries who should have been automatically enrolled, but do not appear in a plan’s recordsProvides drug fill and assigns to a planPharmacist can choose whether or not to

use POS process


Dual Eligibles & Medicare Advantage Plans

Dual Eligibles can enroll in Medicare Advantage (MA) plans if they wish

How much value does a Dual Eligible get by enrolling in a particular MA plan?Specific care coordination?Access to more (or fewer) providers?Easier – or more difficult – access to Medi-Cal

benefits?Any benefits not already entitled to?

• If so, how much more, and is it worth it?More out-of-pocket expenses?


Duals and SNPs Special Needs Plans (SNPs) are Medicare Advantage

plans designed to serve 1 of 3 types of “special needs individuals”: Dual Eligibles Institutionalized Individuals with severe or disabling chronic conditions

SNPs can disproportionately enroll or limit enrollment to the designated population or even a subpopulation

Many Dual Eligibles were “passively enrolled” Moratorium on SNPs – legislation passed at end of

2007 extends existing SNPs through December 2009, but freeze on any new SNPs in areas where not offered as of 1/1/08


Marketing Misconduct

Ongoing egregious conduct by agents, driven partly by plan compensation CMS implemented some new marketing rules, but

abuse is ongoing Duals and other LIS enrollees attractive targets

because they can enroll year-round In addition to Dual Eligible SNPs, some other MA

plans specifically target Dual Eligibles E.g., certain Private-Fee-for-Service (PFFS plans)


Marketing Misconduct (cont’d)

Undoing the damage of marketing misconductProspective Disenrollment

• Duals have an ongoing Special Enrollment Period (SEP) right to change plans monthly

Retroactive Disenrollment• See, e.g., Health Assistance Partnership

materials at www.hapnetwork.org


LIS Eligibility

Individuals who are eligible for LIS must go through an annual process to determine continuing eligibility

Redeeming by CMS LIS enrollees who appear in info sent by state to

CMS between July and December will be re-deemed for following year (including SOC)

• In CA, 47,000+ not re-deemed for 2008 Redetermination by SSA

Most LIS folks passively redetermined as eligible in 2008 without receiving any notice from SSA

Active redetermination – certain people selected for review (e.g. subsidy changing events)


LIS – Best Available Evidence (BAE)

CMS “Best Available Evidence” policy – process through which Dual Eligibles and other LIS enrollees can show evidence of their LIS subsidy status E.g. copy of Medi-Cal card, copy of state document

(including print out of electronic system) that confirms active Medicaid status (see 6/27/07 CMS Memo)

Ongoing problems using this system E.g. plan customer service reps unaware of and/or

unwilling to use process


Recent Rules …

Ongoing Special Enrollment Period (SEP)CMS created an ongoing SEP right for all

LIS enrollees (only used to apply to Dual Eligibles and Medicare Savings Program)

Waiver of Late Enrollment PenaltyIndividuals who qualify for LIS and enroll in

a Part D plan by end of 2008 will be exempt from Part D late enrollment penalty

• CMS has extended policy from 2006 and 2007


Other Issues…

State budget crisis and Medi-Cal cutsE.g. provider reimbursement cuts – 10%Proposal to have state stop paying Part B

premiums for Duals with a SOC Ongoing 1-800-MEDICARE problems Language Access

At 1-800-MC, say “I speak ____”See materials by NSCLC, NHeLP, others


Questions…?

California Health Advocates ■ Sacramento Office – (916) 231-5110

5380 Elvas Avenue, Suite 104, Sacramento, CA 95819

■ Los Angeles Office – (213) 381-3670 3435 Wilshire Blvd., Suite 2860, Los Angeles, CA 90010www.cahealthadvocates.org

Health Insurance Counseling & Advocacy Program (HICAP) 1 (800) 434 - 0222

Dual Eligibles and Medicare: Ongoing Issues California Medicare Coalition Webcast – April 9, 2008...

Documents

Transcript of Dual Eligibles and Medicare: Ongoing Issues California Medicare Coalition Webcast – April 9, 2008...