Advocacy Bring the experience of Medicare beneficiaries t

1
Dual Eligibles and MedicareOngoing Issues

• California Medicare Coalition
• Webcast April 9, 2008
• Presented by David Lipschutz
• California Health Advocates

This webcast is supported by The California
Endowment
2
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

3
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.medicareadvocac
  y.org
• Medicare Rights Center www.medicarerights.org

4
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

5
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

6
Overview (contd)

• 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)

7
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

8
Benchmark Plans

• PDP qualifies as a benchmark plan only if it
  offers basic coverage w/ premiums at or below the
  regional benchmark level
• Full 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

9
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

10
Plan Reassignment (contd)

• 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

11
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)

12
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 plans records
• Provides drug fill and assigns to a plan
• Pharmacist can choose whether or not to use POS
  process

13
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?

14
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

15
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)

16
Marketing Misconduct (contd)

• Undoing the damage of marketing misconduct
• Prospective 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

17
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)

18
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

19
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 Penalty
• Individuals 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

20
Other Issues

• State budget crisis and Medi-Cal cuts
• E.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

21
Questions?

• California Health Advocates
• Sacramento Office [phone]
• 5380 Elvas Avenue, Suite 104, Sacramento, CA
  95819
• Los Angeles Office [phone]
• 3435 Wilshire Blvd., Suite 2860, Los Angeles, CA
  90010
• www.cahealthadvocates.org
• Health Insurance Counseling Advocacy Program
  (HICAP)
• 1 (800) 434 - 0222