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

• 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.

• 24May

  Are You Eligible for the Part D $250 Rebate? CMS Posts Q&As

  Health Care Reform, Low-income help, Medicare basics 1 Comment

  The Affordable Care Act passed by Congress and signed by President Obama this year contains some important benefits for Medicare recipients. One benefit is the $250 rebate to help with beneficiaries’ Medicare Part D drug costs. Beneficiaries who do not receive the low-income subsidy (LIS), will automatically receive this one-time $250 rebate check from Medicare after they reach the coverage gap (also called the “donut hole”) in 2010. This rebate is the first step toward closing the Medicare prescription drug coverage gap as mandated in the new health care reform law.

  Below are a few common questions and answers on this $250 rebate that the Centers for Medicare and Medicaid Services (CMS) sent out last week. Please share it with your colleagues and beneficiary clients.

  What is the coverage gap and how will I know if I’ve reached it?

  Most Medicare drug plans have a coverage gap. This means that after you and your plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your drugs (up to a limit).

  The Explanation of Benefits notice, which your drug plan mails to you each month when you fill a prescription, will tell you how much you’ve spent on covered drugs and whether you’ve entered the coverage gap.

  Will I need to do anything to get this rebate check?

  No. There are no forms to fill out. Medicare will automatically send a check that’s made out to you. You don’t need to provide any personal information like your Medicare, Social Security, or bank account numbers to get the rebate check. Don’t give your personal information to anyone who calls you about the $250 rebate check. Call 1-800-MEDICARE (1-800-633-4227) to report anyone who does this. TTY users should call 1-877-486-2048.

  When will I get the rebate check?

  If you reach the coverage gap this year and enter the Part D “donut hole”, you will receive a one-time $250 rebate check if you are not already receiving Medicare Extra Help.  These checks will begin to get mailed to beneficiaries starting in mid-June.

  Checks will be mailed monthly throughout the year as beneficiaries enter the coverage gap. However, this is a one-time benefit and beneficiaries who qualify will only receive one check after they reach the coverage gap.

  What if I don’t get the rebate check when I should?

  Beneficiaries who hit the donut hole after the program has begun should expect to receive their check within 45 days. Your rebate may be delayed if Medicare doesn’t have information from your Medicare drug plan showing that you reached the coverage gap in time to include you in the next mailing. You should call your Medicare drug plan to make sure all of your information has been sent to Medicare.

  If you don’t get your rebate check, contact Medicare. Individuals receiving Medicare Extra Help will not receive a rebate check.

  You can also check to make sure Social Security has your correct home address. Call 1-800-772-1213 or your local Social Security office. TTY users should call 1-800-325-0778.

  What’s Next ….Coming in 2011

  If you reach the coverage gap in 2011, you may get a 50% discount on your brand name prescription drugs at the time you buy them. Stay tuned for more information from Medicare.

  Help  stop scams against beneficiaries
  

  Remember- there are no forms to fill out to receive this benefit once someone qualifies for it. Medicare will automatically send a check that’s made out to the qualified beneficiary.

  Beneficiaries also don’t need to provide any personal information like their Medicare, Social Security, or bank account numbers to get the rebate check. Please remind them to NOT give their personal information to anyone who calls them about the $250 rebate check. They should call 1-800-MEDICARE (1-800-633-4227) to report anyone who does this. TTY users should call 1-877-486-2048.

  Go to stopmedicarefraud.gov to learn more about how Medicare is working with law enforcement to stop scams against seniors.

  More questions about the $250 rebate check or the Affordable Care Act and Medicare?

  Beneficiaries with more questions can refer to the brochure Medicare and the New Health Care Law–What it Means for You (PDF) that Medicare sent them. (Also available in Spanish (PDF)). They can also visit www.medicare.gov, call 1-800-MEDICARE, or visit www.healthreform.gov.

• 12May

  How Do Denti-Cal Cuts Affect Our 8 Million Low-Income, Elderly & Disabled People?

  Low-income help No Comments

  Denti-Cal, Medi-Cal’s fee-for-service (FFS) dental program, was the primary source and payer of dental care for more than 8 million low-income, elderly, and disabled people in California in 2007. In 2009, most of the Medi-Cal adult dental benefits were eliminated due to the state’s budget deficit. Children’s services, as required by federal law, continue to be delivered.

  The California HealthCare Foundation (CHCF) recently published an almanac on Denti-Cal which covers the organization of Medi-Cal’s fee-for-service dental program in 2007, how it was funded, and the demographics of the population it served. It identifies the challenges the program faces in continuing to make dental care available to children, and the potential consequences of leaving a large segment of the adult Medi-Cal population with no care at all.

  See: Denti-Cal Facts and Figures (pdf)

• 23Feb

  Many Beneficiaries in Pain Due to California’s Dental Coverage Cuts

  Low-income help No Comments

  For 7 months, over 3 million Californians, many of which are also Medicare beneficiaries, have had no dental coverage. California’s state Medicaid program, Medi-Cal used to cover basicadult dental benefits such as annual exams, cleanings, and if necessary, root canals before the drastic budget cuts that went into effect July 1, 2009. Now, with no Medi-Cal adult dental services to cover their care, clients who are in pain but have no money or coverage to pay for care are being turned away from dentist offices and community clinics around the state.

  Even with dentists and clinics offering discounts and payment plans to Medi-Cal clients, it’s not enough. Often beneficiaries are left choosing between using money for rent and food or for needed dental work. Many clients are wait until the pain is unbearable to get their dental care, and often they resort to having their teeth pulled versus getting a root canal because of expense.

  In addition, dental schools and free dental clinics are overrun with clients and many community clinics that have relied on state funding have reduced their services and in some cases, have closed their doors.

  Under federal law, dental coverage is an optional benefit for state Medicaid programs. Yet all but 7 states have included it in their Medicaid programs because good dental hygiene and care is such an important piece of maintaining good health. Because of the recession, however, many states have scaled back their coverage and in some cases only cover emergency dental care.

  In California, the state will still pay to have a tooth pulled in an emergency, but it no longer covers the cost of expensive dentures. This presents a problem for dual-eligible Medicare beneficiaries (beneficiaries on Medicare and Medi-Cal).  As Medicare doesn’t cover dental care,  these low-income beneficiaries have long relied on the state’s dental benefits when needing dentures.

  For more information on the cuts to the adult dental benefits, including frequently asked questions on eliminated services, see Medi-Cal’s website.

  You can also listen to National Public Radio’s recent story highlighting this imminent problem.

• 12Nov

  New Safety Net System for Low-Income Beneficiaries Without a Part D Plan

  Low-income help No Comments

  CMS announced a new system to help beneficiaries who receive the Part D low-income subsidy (LIS) have better access to their prescription drugs when they’re not enrolled in a Part D plan. As of January 1, 2010, this system will replace the current Point of Sale (POS) system operated by WellPoint. The new system is called Limited Income Newly Eligible Transition (LI NET) program, and Humana has been awarded the CMS contract to operate it.

  The POS system is designed to provide temporary prescription drug coverage when someone who is enrolled in the LIS is not enrolled in a Part D plan. This can happen for a variety of reasons, including if there’s a glitch in the system and people who are supposed to be auto-enrolled in a Part D plan aren’t, or if a beneficiary experiences a time gap from when they are found LIS eligible and when their Part D plan enrollment becomes effective.  The POS system gives people coverage and therefore access to their prescription drugs AND at the same time randomly enrolls the people using the POS system into a Part D benchmark prescription drug plan.

  Starting in 2010, the new system, LI NET, in addition to offering temporary drug coverage and prospective random enrollment into a Part D plan for uncovered LIS-eligible beneficiaries, it will also offer some retroactive coverage to uncovered LIS eligible beneficiaries and full-benefit dual eligible and SSI-only beneficiaries.  Uncovered full-benefit dual-eligible and SSI-only beneficiaries will have retroactive coverage up to at least 36 months, while all other beneficiaries with LIS will have retroactive coverage for 30 days.

  For more information, see CMS’ webpage. It contains a helpful fact sheet (PDF) and ppt presentation on the new LI NET program.

• 21Oct

  Federal Judge Halts 11/1 Cuts to IHSS

  Long-term care insurance, Low-income help No Comments

  Yesterday, a federal judge in Oakland, California issued a preliminary injunction order stopping November 1, 2009, cuts to In-Home Supportive Services (IHSS) for more than 130,000 people statewide.  The court decided that plaintiffs were likely to succeed in a lawsuit challenging the state’s use of “functional index” score and ranks, and that the state is prohibited from implementing cuts while the case proceeds.

  This is good news for these 130,000 Californians and their families. To help get the news out and relieve the confusion and fear many IHSS consumers have had about the possibility of IHSS cuts, the court has ordered the state to send a “don’t worry” letter explaining that the cuts will not take place November 1 as previously thought.

  To find out more about IHSS functional index appeals and the status of IHSS cuts, you can join in on the National Senior Citizens Law Center webcast next Monday, Oct. 26th at 12 noon. Contact NSCLC for registration info.

  For more information on Medi-Cal benefits and coverage in general, see our Medi-Cal section.

• 30Sep

  Social Security to Repay Over $500 Million in Unlawfully Withheld Benefits

  Low-income help No Comments

  The Social Security Administration will repay more than $500 million in benefits that were illegally withheld from 80,000 people whose benefits have been suspended or denied since January 1, 2007.  SSA’s agreement to pay these funds is part of a class action settlement that was granted final approval last week by a U.S. District Court Judge.  In addition, people whose benefits were suspended or denied between 2000 and 2006 will be notified of the new policy and given a chance to re-establish eligibility. In total, over 200,000 people may see their benefits reinstated and/or receive back payments due to the settlement. All beneficiaries must continue to be eligible for benefits in order to receive payments.

  The settlement resolves a lawsuit, Martinez v. Astrue, challenging SSA’s method of implementing a narrowly drawn provision of the Social Security Act.  The law aims to prevent people from using government benefits to escape arrest.  Yet rather than figuring out which Social Security recipients were actually fleeing prosecution, SSA used a computer matching system that matched names in warrant databases to those at SSA.  Many of the matches and automatic benefit suspensions involved false or unproven allegations, minor infractions or long-dormant arrest warrants. Although regulations provide for an appeal process, individuals losing benefits were routinely, inaccurately informed by SSA staff that they could not appeal.

  Under the agreement, SSA has stopped, as of April 1, 2009, suspending or denying benefits due to the mere existence of a warrant – unless the warrant is issued in a criminal proceeding on a charge such as flight or escape.  This change in policy will benefit thousands of additional people every month from now on.

  Note: this case/settlement does not apply to beneficiaries whose benefits were suspended or denied due to suspected parole or probation violation.

  This agreement will take full effect as of November 30, 2009. Delivery of relief to class members will occur in 2010 and beyond. Class members should confirm their correct address is on file with the SSA, thus ensuring they receive the mailings when sent out next year.

  National Senior Citizens Law Center (NSCLC), pro bono counsel from the law firm of Munger, Tolles & Olson, the Mental Health Project of the Urban Justice Center, Disability Rights California, and the Legal Aid Society of San Mateo County all represented the plantiffs in this case.

  See NSCLC’s website section on the Martinez Settlement for more information.

  This article was edited in part from NSCLC’s press release and current update.

• 16Sep

  Learn About the Health Effects of the State’s Budget Cuts

  Low-income help No Comments

  As Congress is planning a major overhaul of our country’s health care system, this week KQED’s Health Dialogues program is taking a closer look at home. This program, airing on Thursday 9/17, will examine the health effects of the state’s budget cuts. Those of you living in San Francisco and Sacramento areas, the airing and rebroadcasting times are:

  • Thursday, 9/17 at 8 p.m.
  • Friday, 9/18 at 2 a.m.
  • Saturday, 9/19 at 2 p.m.

  For those of you living in other areas of the state, check your local listing to find out when Health Dialogues broadcasts in your city.

  check your local listing to find out when Health Dialogues broadcasts in your city.

• 11Sep

  Federal Judge Blocks State Budget Cuts to Adult Day Health Care Services

  Low-income help, Medicare and disabilities No Comments
  A federal district court judge issued an order on 9/10/09 blocking California’s budget reductions to Adult Day Health Care services, marking a substantial victory for disability and senior rights advocates and thousandsof California beneficiaries using ADHC services. 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 at www.cdcan.us.

  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.

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