CHA Blog

People with end stage renal disease (ESRD) are prohibited from enrolling in Medicare Advantage plans. If, however, they are already enrolled in one and then later develop ESRD, they can stay in their plan; the MA plan cannot drop their coverage.

While these are the general rules, there are a couple of exceptions to this prohibition of joining MA plans, as outlined in CMS’ Medicare Managed Care Manual. One such exception, revised and effective as of November 19, 2010 (Chapter 2, Section 20.2.2), is that a Medicare beneficiary with ESRD who is already enrolled in an MA plan may join any of the other MA plans within the same parent MA organization during certain enrollment periods.  One such period is the Annual Election Period (AEP) which is from November 15 – December 31 in 2010 and from October 15 – December 7 starting in 2011.

In the past, CMS limited this exception to apply only to MA plans under the same organization, not the same parent organization. For example, a beneficiary with ESRD who was enrolled in a Secure Horizons MA plan could only switch to another Secure Horizons MA plan if one was available. Now, however, a beneficiary meeting 3 conditions can switch to any MA plan under the parent organization, United. This includes switching from an HMO to a PPO or PFFS plan and vice versa. In many cases, this revision gives ESRD beneficiaries more MA plans to choose from if they’d like to switch plans.

The 3 conditions determining whether a beneficiary can switch MA plans within the same parent company include:

• The new MA plan must operate in the same state as the beneficiary’s previous MA plan,
• The beneficiary meets all the other requirements for enrollment in that MA plan (i.e. has both Medicare Parts A and B), and
• The effective date of enrollment is prospective from the date of CMS’ memorandum (11.19.10).

For questions about this exception, please contact Jim Canavan at (410) 786-5223 or James.Canavan@cms.hhs.gov.

For more information on ESRD and Medicare, see our fact sheet: Medicare and People with End Stage Renal Disease (ESRD).

A federal district court judge issued an order on 9/10/09 blocking California’s budget reductions to Adult Day Health Care (ADHC) services, marking a substantial victory for disability and senior rights advocates and thousands of California beneficiaries using ADHC. Earlier this summer, the Governor had signed budget revisions reducing the amount of days covered for ADHC services from 5 to 3 days per week, a 40% reduction. This cut would have forced many people who are able to live in the community due to ADHC services into institutionalized settings. Federal District Court Judge Saundra Brown Armstrong said that the cuts would likely be in violation of the federal Americans with Disabilities Act and Section 504 of the federal Rehabilitation Act, and therefore issued a preliminary injunction – or temporary order – to stop the cuts until appropriate replacement services are in place.

The case was filed on behalf of persons who use Adult Day Health Services, by Disability Rights of California (formerly Protection and Advocacy, Inc), the National Seniors Law Center and AARP Foundation Litigation.

The federal Judge’s Order (copy of the entire 24 page order) is available on the California Disability Community Action Network (CDCAN) website.

According to a recent report from California Disability Community Action Network (CDCAN), Governor Schwarzenegger is proposing major cuts that would end several optional Medi-Cal benefits and cut or reduce benefits to certain Supplemental Security Income (SSI), State Supplementary Payment (SSP) and In-Home-Supportive Services (IHSS) programs. These cuts would impact children and adults with disabilities, people with mental health needs, seniors, the blind, low-income children and families, and providers across California. Governor Schwarzenegger plans to call the Legislature back in for a special session before November 30th to address the state’s budget crisis – a budget shortfall projected to be as high as $11 billion. Governor Schwarzenegger hopes to have these proposed cuts approved by the current Legislature. This way the cuts would apply for this budget year which began July 1, 2008, and also extend through the next budget year (July 1, 2009 – June 30, 2010).  In some cases, such as with the proposed elimination of the Cash Assistance Program for Immigrants, which provides SSP level state funded grants to eligible legal immigrants who have disabilities, are blind or are over 65 years of age, would be permanent, as would the cuts proposed for IHSS and Medi-Cal.

Below are some highlights from CDCAN’s report that would affect California’s adults with disabilities and seniors:

Medi-Cal

• Proposal to reduce California Medi-Cal benefits to the level of benefits most other states’ Medicaid programs provide by permanently eliminating the following optional benefits: adult dental (excluding children), chiropractic, incontinence creams and washes, acupuncture, audiology, podiatry, and psychology Medi-Cal funded services.
• Proposal to reduce Medi-Cal benefits for newly qualified immigrants and immigrants who permanently live in California to the same level currently provided to undocumented immigrants. Medi-Cal benefits that would remain include emergency services, pregnancy related services, long-term care in nursing home facilities, and breast and cervical cancer treatments. 
• Proposal to reinstate share of cost for Medi-Cal services for persons with disabilities, people who are blind or seniors with incomes over the SSI/SSP limits.  Eligibility for Medi-Cal without a share of cost for those persons was expanded in January 2001 from 69% to up to 127% of the federal poverty level through the Aged and Disabled Federal Poverty Level program.  
• Proposal to cut emergency services for undocumented immigrants by implementing a monthly eligibility determination for emergency services for undocumented immigrants. Undocumented immigrants currently receive up to 6 months of health services after an initial eligibility determination.  The Governor’s proposal would limit those services to 1 month unless and until there is a subsequent health emergency.

In-Home Supportive Services (IHSS) 

• Proposal to cut the state’s participation (matching funds) for IHSS worker wages and benefits to the level of California’s minimum wage ($8/hour).
• Proposal to eliminate IHSS domestic and related services for some people receiving IHSS with a higher functionality.  (Note IHSS has an index to measure a person’s ‘functionality’). Would maintain those services for persons with less functionality.  Proposed effective date if approved would be March 1, 2009. 

SSI/SSP (Supplemental Security Income/State Supplemental Payment)

• Proposal to permanently eliminate the Cash Assistance Program for Immigrants (CAPI), effective (if approved) March 1, 2009. 

For more information, see CDCAN’s website for more information. 

World Institute on Disabilities’ (WID) website, Disability Benefits 101, has detailed information on Medi-Cal, IHSS and SSI/SSP.

See our website sections on Medi-Cal and other programs for people with low-incomes.