Meet the Medicare Beneficiary Ombudsman

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Meet the Medicare Beneficiary Ombudsman
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Agenda

• Medicare Beneficiary Ombudsman
• Ombudsmans Responsibilities
• Ombudsmans Goals
• Performance-Based Approach
• Benchmarks for Success
• The Plan for 2006
• Beneficiary Outreach
• Working with the Ombudsman
• Ombudsman Resources

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Medicare Beneficiary Ombudsman

• Created by Section 923 of the Medicare
  Modernization Act (MMA)
• Voice for Medicare Beneficiaries
• Work closely with the Centers for Beneficiary
  Choices
• Direct access to CMS Administrator

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Ombudsmans Responsibilities

• Receive and provide assistance to beneficiaries
• Complaints
• Grievances
• Inquiries
• Assist in collecting information to file an
  appeal
• Help with Medicare Advantage Disenrollment

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Ombudsmans Responsibilities

• Assist with information related to the new
  income-related premium adjustment
• Work with State Health Insurance Programs (SHIPs)
• Submit an annual report to Congress
• Ombudsman activities
• Recommendations on improvements to Medicare

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Ombudsmans Goals

• Holding the System Accountable
• Create a process to capture and incorporate the
  voice of the beneficiary as a critical
  component to the development and improvement of
  all assistance programs
• Implement a performance measurement system to
  identify and help resolve systemic issues in the
  beneficiary service experience
• Make recommendations for overall program
  improvement based on analysis of trends and
  information from Medicare beneficiaries and
  advocates

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Performance-Based Approach

• Achieve continuous improvement of
• Medicares existing contractors
• Federally staffed complaint, grievance, and
  inquiry operations
• Provide better coordination among existing
  entities
• Provide opportunity for sustained improved
  performance

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Performance-Based Approach

• Desired results are articulated
• Performance standards defined
• Performance will be measured
• Patterns of problems identified
• Best Practices shared
• Data fed back into the system

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Benchmarks for Success

• Proven institutionalized process for hearing
  beneficiary needs
• Business processes aligned with customer needs
• Reported service experience improvements

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The Plan for 2006
Communicate with Beneficiaries and their Advocates
Implement Performance Management System
Report to Congress

• Gather quantitative data from internal CMS
  systems
• Gather qualitative data from local/regional
  partners and beneficiaries
• Develop a set of data-driven recommendations to
  Congress

• Develop mechanisms for hearing the Voice of the
  Beneficiary (e.g., Open Door forums,
  regional/local partner meetings, beneficiary
  meetings)
• Develop a Web Site as a communication vehicle -
  http//new.cms.hhs.gov/center/ombudsman.asp
• Develop training materials and programs to meet
  identified needs

• Establish a system to track performance metrics
• Develop standard operating procedures
• Train people and organizations on using the new
  standard operating procedures

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Beneficiary Outreach
Opportunity for beneficiaries, their caregivers
and advocates to publicly interact with the
Medicare Beneficiary Ombudsman to identify,
discuss and address opportunities to improve the
systems and processes within the Medicare
program.
Open Door Forums

• National conference calls open to beneficiaries,
  their caregivers and advocates beginning February
  15, 2006
• Targeted discussions with regional and local
  advocates within the beneficiary communities that
  they support
• Roundtable discussions with small groups of
  beneficiaries within their community

Regional/Local Advocate Meetings
Beneficiary Feedback Meetings
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Working with the Ombudsman

• The Medicare Beneficiary Ombudsman Will
• Work with CMS and partners to implement service
  improvements
• Take action on issues under its purview
• Refer questions/issues to CMS leadership for
  awareness as appropriate
• Provide updates on major CMS initiatives

• The Medicare Beneficiary Ombudsman Will Not
• Make agency decisions
• Duplicate existing processes for resolving issues
• Lobby Congress or intervene in legal action

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Working with the Ombudsman

• The OMO is seeking input on issues that
• Affect large numbers of beneficiaries
• Involve unique or exceptional circumstances
• Fall under the Ombudsmans purview
  (systems/processes v. policy/statute)
• Are actionable
• Enhance awareness

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Working with the Ombudsman

• Partners have actively communicated situations
  arising from Part D implementation
• These are the types of things that the OMO wants
  to hear
• CMS has established mechanisms for resolving
  specific circumstances. The OMO should not
  duplicate those, but should understand the
  underlying, systemic issues

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Working with the Ombudsman

• CMS Role
• Resolve Specific Situations
• Existing Mechanisms
• Tools for Verifying Plan Enrollment/LIS Status
• Procedures to Provide Immediate Access to
  Medications
• Escalation of Emergency Situations to CMS
  Regional Offices

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Working with the Ombudsman

• Example A dual-eligible beneficiary does not
  know if he or she has been enrolled in a plan
• Pharmacist should send an E1 Query to determine
  plan enrollment
• If no match, the pharmacist should verify
  Medicare and Medicaid eligibility
• If dual-eligibility has been determined, but no
  plan has been identified, the pharmacist can use
  the Point-of-Sale facilitated enrollment option

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Working with the Ombudsman

• If a beneficiary is still unable to obtain
  medications, and the backup systems are not
  working
• Call 1-800-Medicare
• Medicare has special caseworkers in each of the
  CMS Regional Offices who will provide
  individualized help in getting prescriptions
  filled
• Medicare is here to help 24 hours/day, 7
  days/week

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Working with the Ombudsman

• The Ombudsmans role
• Understand what beneficiaries are experiencing
• Identify underlying systemic issues and make
  recommendations to Congress for long-term
  resolution
• Communicate findings with CMS leadership
• Connect partners and beneficiaries to appropriate
  resources

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Working with the Ombudsman

• Todays session is an opportunity for you to
  share your experiences
• I dont have all the answers!
• I will listen to your feedback, and follow up
  with the appropriate resources

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Ombudsman Resources

• The following Ombudsman resources are available.
  Please help us promote these resources within the
  beneficiary and advocacy communities
• OMO Website - http//www.cms.hhs.gov/center/ombuds
  man.asp
• Contact the Ombudsman - Refer to the link on the
  above website
• Listserv - To subscribe to the Medicare
  Beneficiary Ombudsman Listserv - BENEOMBUDODF-L,
  visit http//www.cms.hhs.gov/apps/mailinglists/de
  fault.asp?audience4 and follow the instructions
  
• Medicare Beneficiary Ombudsman Open Door Forum
• Wednesday, February 15, 2006 from
  200p.m.-330p.m.
• Call in number 1-800-837-1935, Conference ID
  3102342