CHA Blog

• 01Sep

  7,000 Beneficiaries to be Disenrolled from Kaiser’s Special Needs Plan

  Low-income help, Medicare Advantage No Comments

  Kaiser will be disenrolling about 7,000 beneficiaries from their Medicare Advantage Special Needs Plan (SNP) by December 31, 2010. Most of these beneficiaries have Medi-Cal with a Share of Cost (SOC); they are not full benefit dual eligibles. Below is: 1) some background as to why this change is taking place and 2) tips on how to help these beneficiaries and an outline of what their options are.

  Why are these beneficiaries being disenrolled?

  This is to be in compliance with MIPPA (Medicare Improvements for Patients and Providers Act of 2008). Before MIPPA, SNPs were allowed to be disproportionate, meaning they could enroll beneficiaries who did not meet the special needs criteria. Yet per MIPPA, the Centers for Medicare and Medicaid Services (CMS) changed this rule. As of January 1, 2010, only beneficiaries who meet the special needs criteria of the SNP can enroll in an SNP. Furthermore, SNP sponsors who have any beneficiaries in their plans who do not meet their special needs criteria and who enrolled into the SNP prior to Jan. 1 2010 are required to disenroll them by the end of 2010.

  Because Kaiser did use the ‘disproportionate allowance’ and did enroll non-full benefit dual eligibles (mostly beneficiaries with Medi-Cal with a SOC who had not met their SOC as of 12/31/09) into their SNP for dually eligible beneficiaries (D-SNP, called Kaiser Senior Advantage Medicare Medi-Cal Plan), they now must disenroll these members by 12/31/10 to be in compliance with MIPPA.  Kaiser has sent the first of 4 notices to these members letting them know that they will be disenrolled and encouraging them to join Kaiser’s regular Senior Advantage MA plan.

  Beneficiaries have the right to join any MA plan, not just Kaisers, though in either case they will be facing higher copayment liability and, in some cases, significant premiums.

  Options for beneficiaries being disenrolled

  1. Sign up for the Low Income Subsidy – If a beneficiary does not already have the LIS (also known as Extra Help), s/he should apply for it at their local Social Security office. Even if they don’t meet their SOC, they may be eligible for the LIS and receive full or partial to help with prescription drug costs. More info: Extra help.
  2. Apply for a Medicare Savings Program (MSP) – Apply for QMB, SLMB or QI. Medi-Cal may have screened these beneficiaries for MSPs before putting them in the Medi-Cal SoC program, but their situation may have changed and they may now qualify for one of the MSPs. More info: MSPs.
  3. Apply for California’s 250% Working Disabled Program (WDP) – If they qualify, they will get the LIS and full Medi-Cal benefits if they pay the program’s premium (based on a sliding scale.) More info: California’s 250% WDP.
  4. Join either another Medicare Advantage plan (Kaisers or another MA plan available in their area) – These beneficiaries can enroll in another Medicare Advantage (MA) plan that is not an SNP. They have a Special Enrollment Period (SEP) through December 31, 2010 to enroll in any other MA plan that is accepting new members. In Kaiser’s later notices to these beneficiaries, Kaiser will inform them how they can enroll in Kaiser Senior Advantage, an MA-HMO that is not an SNP. The advantage here is continuity of care; these beneficiaries can continue seeing their Kaiser health care providers. Yet, they would have to pay the premium, which ranges from $0 (in Kern, LA, Orange, Riverside, San Bernardino, San Diego, Stanislaus and Ventura counties) to $99 (in Marin and San Mateo counties).If these beneficiaries do not choose an MA plan during their SEP, they will be enrolled in Original Medicare effective January 1, 2011.
  5. Return to Original Medicare and join a stand-alone prescription drug plan (PDP) –These beneficiaries who lost their special needs status have a Special Enrollment Period (SEP) through December 31, 2010 to enroll in a Part D plan. If a beneficiary does not enroll in a stand-alone Part D or MA plan during the SEP, he/she will be enrolled in Original Medicare effective January 1, 2011 and will not have prescription drug coverage.

  Please note that these beneficiaries may or may not have a guaranteed issue to buy a Medigap. Here are different scenarios:

  a)      If a beneficiary did not meet the special needs criteria, such as not meeting their SOC, as of December 31, 2009, losing special needs status does not give them a guaranteed issue right to buy a Medigap. Their Medi-Cal status did not change; it was the rule according to MIPPA – no more disproportionate SNPs – that changed.

  b)       If they had full Medi-Cal benefits and either do or do not have Medi-Cal with a SOC, they have a guaranteed issue period to buy a Medigap within 6 months of losing full Medi-Cal benefits.

  The Kaiser contact for questions about the disenrollments is:

  Janet Flores
  Project Manager
  California Medicare Marketing Sales & Operations
  1800 Harrison Street, 11th Floor, Oakland CA 94612
  510-625-2162 / 8-428-2162

  Please let us know if you and/or your clients encounter any issues with this disenrollment.

  Tags: California, disenroll, Kaiser, MA, Medi-Cal, Medicare, Medicare Advantage plans, SNP, Special Needs Plans

• 24Aug

  Some MA Plans Are Back-Billing Enrollees for Past Premiums

  Medicare Advantage, Medicare billing and claims No Comments

  Several Health Insurance Counseling and Advocacy Programs (HICAP) have reported on a few Medicare Advantage plans that are back-billing their enrollees for past monthly premiums. Many of these plans did not bill beneficiaries for months or even years at a time and are now sending them a bill for a large lump sum. Beneficiaries receiving such bills are rightly distressed and have contacted their local HICAP offices for help.

  If you are experiencing this problem or have clients who are: 1) file a grievance with the MA plan; and 2) file a complaint with CMS Region 9 Office and ask that you or your client be relieved of all payment responsibility and ask for a Special Election Period (SEP) to change to another MA plan.

  CMS Region 9 Contact: Ayanna Busby-Jackson

  Her email and phone number are: ayanna.busby-jackson@cms.hhs.gov; 415-744-3615.

  We, along with other advocacy organizations, are collecting information on such cases to report to the Centers for Medicare and Medicaid Services (CMS). With enough cases we can strongly recommend CMS file sanctions against these plans and/or impact litigation.

  Please email us with a summary of such cases.

  Tags: beneficiaries, billing, health insurance, Medicare Advantage plans, premiums

• 20Jul

  Insurance Agent Prohibited from Selling Medicare Advantage Plans

  Medicare Advantage, Medicare fraud No Comments

  The California Department of Managed Health Care (DMHC) has issued an order barring a Folsom health insurance agent from selling Medicare Advantage plans, due to unscrupulous and deceptive practices against nearly a dozen local senior citizens. The agent, Nadia King, cancelled the Medicare coverage of elderly consumers without their consent or knowledge, and then enrolled them in private Medicare Advantage plans she represented, causing some to unknowingly incur unexpected medical bills.

  Deceptive marketing of Medicare Advantage products to senior citizens is a growing problem in California and across the nation. California Health Advocates started receiving complaints from beneficiaries about deceptive marketing of Medicare Advantage products over 3 years ago, and has been working with both DMHC and California Department of Insurance (CDI) in finding resolution and ways for the 2 departments to work together in stopping such practices. California Department of Insurance has the power to revoke an agent’s license (as agents are licensed by CDI), and DMHC, according to state law, has the power to bar an agent from selling certain products if it is determined that a solicitor makes misrepresentations to consumers or acts in a manner that may expose them to substantial risk.

  In this case of Naida King, the DMHC has indefinitely barred her from operating as a solicitor of Medicare Advantage plans to individuals eligible for Medicare. The order alleges that King solicited unsuspecting Medicare enrollees, using deceptive sales tactics to enroll them into the particular Medicare Advantage plans that she was selling.

  Eleven local victims are identified in the order. In most cases, unsolicited contacts with elderly Medicare recipients either in their homes, by telephone, or some other means, resulted in Ms. King enrolling the victims in various Medicare Advantage plans, often without their knowledge or consent. Some of these victims experienced delays in medical treatment as a result of the unwanted change to their health coverage, or unexpected out-of-pocket charges, of up to $6,000 in one case.

  DMHC, CDI, CHA and our Senior Medicare Patrol (SMP) program are collaborating in ongoing efforts to protect consumers from health care fraud and fraud insurance products. Both CDI and DMHC are actively investigating Medicare Advantage marketing abuse cases, CDI revoking some insurance licenses and DMHC issuing sanctions against insurance agents engaged in fraudulent activities. In addition, the DMHC has also been ordering unlicensed and fraudulent discount health plans to cease operation or seek licensure to ensure that the plans are selling a legitimate product, and has shut down a phony labor union health coverage scheme that put hundreds of consumers at risk of losing coverage.

  Consumers and advocates with questions about health care fraud can contact our SMP program at 714-560-0309. People can also contact the DMHC Help Center for assistance in identifying legitimate health products at 888-466-2219, and CDI’s consumer hotline at 800-927-4357 for reporting insurance agent misconduct.

  Also, below are a few reminders on how to avoid deceptive health care marketing schemes:

  • Do not give personal information, such as Social Security numbers, bank account numbers, or credit card information.
  • Be wary of unsolicited calls or visits at home, or an approach by someone at your doctor’s office, pharmacy or hospital.
  • Do not take calls from someone claiming to be from Social Security or Medicare. Legitimate representatives from these programs will not call or come to your home unless you have contacted them to request it.
  • Read and understand the health plan information.
  • Consult family and friends before purchasing any health plan.

  For general information on Medicare fraud and abuse, see our section Medicare Fraud.

• 01Jul

  Obama Holds Tele-Town Hall Meeting to Discuss Health Reform with Seniors

  Health Care Reform, Low-income help, Medicare Advantage, Medicare and other health insurance, Medicare basics, Prescription drugs No Comments

  Early last month, President Obama hosted a ‘tele’-town hall meeting for Medicare beneficiaries about the Affordable Care Act and Medicare fraud prevention efforts in light of the first $250 donut hole rebate checks that were sent out mid June. This meeting can be viewed online at whitehouse.gov.

  In this video, President Obama discusses the following topics:

  (Note: By clicking on a linked question, it will take you directly to that section of the video.)

  • Why does it take 10 years to close the doughnut hole completely?
  • Will Medicare Advantage changes hurt benefits?
  • Is there more support for primary care?
  • How does reform affect living independently vs in a nursing home?
  • Are Medicare & Social Security going to run out of money for future generations?
  • What’s going to happen to COBRA subsidies?

  For more information on health care reform and Medicare, see our article, What Does Health Reform Mean for Medicare Beneficiaries? Summary of Key Provisions.

• 06May

  CMS Terminates Western Health Advantage’s Medicare Contract

  Medicare Advantage, Medicare fraud, Prescription drugs No Comments

  During our California Medicare Coalition statewide call yesterday, a representative from the Centers for Medicare and Medicaid Region IX office announced that CMS is terminating its contract with the Western Health Advantage plan as of May 31, 2010. This will affect about 600 Medicare beneficiaries in Sacramento, Yolo and Placer counties. These beneficiaries will be automatically enrolled into Humana’s Part D prescription drug plan as of June 1st. They will also be given a 30-day Special Election Period (SEP) to enroll into a different plan by July 31, 2010.

  CMS sent out a letter to affected enrollees this week with this information, and advised them to call 1-800 Medicare or their local Health Insurance Counseling and Advocacy Program (HICAP) with any questions.

  Julie Cohen at CMS Region IX is overseeing this transition. Advocates with client questions can contact her at julie.cohen(at)cms.hhs.gov.

• 10Apr

  Medicare Issues Sanction Notice to Aetna Insurance Company

  Medicare Advantage, Prescription drugs 2 Comments

  Last week Medicare issued an intermediate sanction notice to Aetna Insurance Company prohibiting any marketing or enrollment of new beneficiaries into their national Part D prescription drug stand-alone plan and their 25 Medicare Advantage Prescription Drug plans (MA-PDs) as of April 21, 2010.

  This sanction is in response to growing provider and beneficiary complaints of not being able to access their medications and having unnecessary obstacles and illegitimate denials for drugs for which they are entitled.

  The Centers for Medicare and Medicaid Services says the sanctions will stay in place until Aetna adequately demonstrates they have corrected these problems and that they will not re-occur. Aetna currently has 400,000 beneficiaries enrolled in their MA-PD plans, and 600,000 enrolled in their stand-alone PDP plan.

  Some of the obligations Aetna plans have failed to fulfill for their Medicare beneficiary enrollees as listed in CMS’ press release include:

  • Failing to meet Medicare’s transition requirements by ensuring that existing beneficiaries were able to continue to receive drugs they had been receiving in 2009 that were not on the plans’ formularies in 2010;
  • Improperly processing coverage determinations and expedited appeal requests in cases where delays would jeopardize the life or health of the enrollee;
  • Applying prior authorization (PA) and step therapy (ST) drug requirements that had not been approved by Medicare; and
  • Failing to take timely and proper steps to ensure that enrollees are eligible for the Part D low-income subsidy (LIS).

  If the situation fails to improve for Aetna’s enrollees, CMS has warned that Aetna Insurance Company could incur penalties and even termination of their Medicare contracts.

  In addition to Aetna, CHA has reports of potential problems with WellCare Part D plans – such as encountering prior authorization (PA) requests for certain drugs where in the past there had been none. If you or your clients encounter any such problems with WellCare or Aetna plans, please contact us and let us know.

• 26Jan

  GAO Report Examines Effect of Inappropriate Marketing by MA Plans on Beneficiaries

  Medicare Advantage No Comments

  A newly released report from the U.S. Government Accountability Office (GAO) examines: 1) some of the effects that inappropriate marketing of MA plans have had on beneficiaries; 2) ways the Centers for Medicare and Medicaid Services (CMS) is assisting these affected beneficiaries; and 3) some of the limitations of this help due to insufficient data collection.

  Below is an excerpt of the report’s highlights. For the full report, see: Medicare Advantage: CMS Assists Beneficiaries Affected by Inappropriate Marketing but Has Limited Data on Scope of Issue (GAO-10-36).

  Highlights on what the GAO found:

  CMS took compliance and enforcement actions for inappropriate marketing against at least 73 organizations that sponsored MA plans from January 2006 through February 2009. While the number of MA organizations varied during that time period, 192 MA organizations offered MA plans as of March 2009. Actions taken ranged from initial notices of noncompliance and warning letters to more punitive measures, such as civil money penalties and suspensions of marketing and enrollment. Nineteen of the 73 MA organizations had multiple types of actions taken against them.

  CMS helped beneficiaries who experienced inappropriate marketing by providing special election periods (SEP) through which beneficiaries could disenroll from their MA plan and enroll in new coverage without waiting for the twice yearly regular enrollment periods. However, some beneficiaries experienced financial or access-to-care problems as a result of inappropriate marketing that could not be addressed by a SEP.

  Financial hardships occurred, for example, when beneficiaries disenrolled from their MA plans and the withholding of premiums from Social Security for their former MA plan was not stopped promptly. In other cases, beneficiaries did not realize they had been enrolled in an MA plan until they tried to access services. Some of these beneficiaries experienced disruption of their access to providers and medications because their providers did not participate in the MA plan.

  CMS has limited information about the number of beneficiaries who experienced inappropriate marketing. Some beneficiaries who experienced inappropriate marketing may have exercised their option to disenroll from their MA plans during regular enrollment periods and might not have notified CMS of the marketing problems they encountered. For example, about 21 percent of beneficiaries disenrolled during the regular enrollment periods in 2007 from one type of MA plan that CMS officials acknowledged had a high incidence of inappropriate marketing. However, CMS discontinued a survey after 2005 that collected information on reasons for disenrollment and could have provided important information about the extent to which the disenrollments were the result of inappropriate marketing. CMS officials said that they plan to reinstitute a survey on disenrollment reasons in late summer 2010.

  CMS also has limited information about the number of beneficiaries who experienced inappropriate marketing because it did not directly track the number of SEP disenrollments. CMS did estimate the number of SEPs it provided for inappropriate marketing, but its estimates were based on data that were unreliable.

• 13Oct

  2010 Medicare Advantage Plan Summary Data for California Plans Available

  Medicare Advantage No Comments

  Our 2010 California Medicare Advantage Plans summary (PDF) is now available.  The document reviews the cost and types of MA plans offered throughout the state and also includes a county-by-county chart with the numbers of each MA plan type.  Information is summarized from the Center for Medicare and Medicaid  Services (CMS) data.

  The 2010 stand-alone prescription drug plan (PDP) chart will be posted soon as well.

• 23Sep

  HHS Investigates Misinformation Campaigns to Medicare Beneficiaries

  Medicare Advantage No Comments
  David Lipschutz, CHA’s Staff Attorney, was quoted in an article in the Huffington Post on Health and Human Services’ (HHS) recent investigation of Medicare Advantage plans’ massive misinformation campaigns to Medicare beneficiaires con…cerning health care reform. The article specifically highlights Humana and the recent letters they’ve sent to enrollees claiming that Congress and the President are considering proposals to cut “important benefits and services” of Medicare, thereby jeapardizing their coverage.

  Medicare Advantage plans are specifically barred from conducting any type of lobbying for legislation with beneficiaries and from discussing possible benefit cuts. They can only discuss benefits enrollees currently have.

  See the link below for the full article.

  This week the U.S. Health and Human Services Department (HHS) cracked down on Medicare Advantage (MA) organizations for their “massive misinformation campaigns” to beneficiaries. A recent article in the Huffington Post specifically highlights Humana and the letter (PDF) they sent last week to their plan enrollees claiming that Congress and the President are considering proposals to cut “important benefits and services” of Medicare, thereby jeapardizing their coverage.

  HHS has mandated Humana to cease all such mailings and to remove any such information from their website immediately.

  Medicare Advantage (MA) plans are specifically barred from using plan-related communications to lobby for policies or legislation. They are also supposed to only talk about an enrollee’s current benefits, or determined benefit changes that are soon to occur, not about changes that may occur.

  The Centers for Medicare and Medicaid Services (CMS) sent an official memorandum to all MA organizations and Medicare Advantage Prescription Drug (MA-PD) organizations stating:

  CMS has recently learned that some Medicare Advantage (MA) organizations have contacted enrollees alleging that current health care reform legislation affecting Medicare could hurt seniors and disabled individuals who could lose important benefits and services as a result of the legislation. The communications make several other claims about the legislation and how it will be detrimental to enrollees, ultimately urging enrollees to contact their congressional representatives to protest the proposals referenced in the letter.

  Our priority is ensuring that accurate and clear information about the MA program is available to our beneficiaries. Thus, we are concerned about the recent mailings as they claim to convey legitimate Medicare program information about an individual’s specific benefits or other plan information but instead offer misleading and/or confusing opinion and conjecture by the plan about the effect of health care reform legislation on the MA program and other information unrelated to a beneficiary’s specific benefits.

  David Lipschutz, our staff attorney, who has often voiced concern on the way Medicare providers communicate with Medicare plan members about political matters, said that: “While recent examples are more blatant than in the past, over the last few years the insurance industry has tried to convince Medicare private plan enrollees to join ‘grassroots’ organizations that are designed to protest any cuts to Medicare Advantage plan payments, sometimes using misleading and/or inaccurate rhetoric. We hope that this broader practice is also prohibited.”

  If you hear of any other plans sending similar letters and messages to beneficiaries as Humana, please let us know. You can contact David Lipschutz directly at .

  Read the full article for more information.

• 27Apr

  More Beneficiaries in MA plans Will Qualify for Free Pharmacy Consultation Services in 2010

  Medicare Advantage, Prescription drugs 1 Comment

  Currently, Medicare Advantage (MA) beneficiaries with at least $4,000 worth of annual drug costs are eligible for pharmacy consultations at no cost. These consultations are provided to ensure: 1) people understand how to use their medication, and 2) the medication prescribed will not produce adverse side-effects with other medications the person may be taking.

  In 2010, new guidelines from the Center for Medicare and Medicaid Services (CMS) will broaden the pharmacy consultation benefit to more MA beneficiaries. Health plans will be prohibited from restricting access to the benefit to members with a high number of chronic health conditions and medications, and the annual drug cost limit will be reduced from $4,000 to $3,000. Also, under the revised guidelines, MA plans will be required to review their member rolls on a quarterly basis to identify eligible members for the program. 

  Pharmacists will be paid $50 by the health plans to review a beneficiary’s medications and make recommendations to their physician. Pharmacists will receive additional payments if they recommend a less-costly, therapeutic equivalent to the patient. This may be an important step, both in reducing health care costs and in improving people’s overall health as less medications reduce side effects and harmful interactions between medications.

  For information on Medicare’s Part D drug coverage, see:

  • Prescription Drugs – Medicare Part D

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