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.

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.

Small business tax credits

503,000 small businesses in California could be helped by a new small business tax credit that makes it easier for businesses to provide coverage to their workers and makes premiums more affordable. Small businesses pay, on average, 18% more than large businesses for the same coverage, and health insurance premiums have gone up three 3 faster than wages in the past 10 years. This tax credit is just the first step towards bringing those costs down and making coverage affordable for small businesses.

Closing the Medicare Part D donut hole

Last year, roughly 382,000 Medicare beneficiaries in California hit the donut hole, or gap in Medicare Part D drug coverage, and received no extra help to defray the cost of their prescription drugs. Medicare beneficiaries in California who hit the gap this year will automatically be mailed a one-time $250 rebate check. These checks began being sent to beneficiaries in mid-June and will be mailed monthly throughout the year as new beneficiaries hit the donut hole. The new law continues to provide additional discounts for seniors on Medicare in the years ahead and completely closes the donut hole by 2020. (See our past blog article, Are You Eligible for the Part D Rebate: Q & A for more info.)

Support for health coverage for early retirees

An estimated 430,000 people from California retired before they were eligible for Medicare and have health coverage through their former employers. Unfortunately, the number of firms that provide health coverage to their retirees has decreased over time. On June 1, 2010, a $5 billion temporary early retiree reinsurance program started to help stabilize early retiree coverage and help ensure that firms continue to provide health coverage to their early retirees. Companies, unions, and state and local governments are eligible for these benefits.

New consumer protections in the insurance market beginning on or after September 23, 2010

• Insurance companies will no longer be able to place lifetime limits on the coverage they provide, ensuring that the 19 million California residents with private insurance coverage never have to worry about their coverage running out and facing catastrophic out-of-pocket costs.

• Insurance companies will be banned from dropping people from coverage when they get sick, protecting the 2.7 million individuals who purchase insurance in the individual market from dishonest insurance practices.

• Insurance companies will not be able to exclude children from coverage because of a preexisting condition, giving parents across California peace of mind.

• Insurance plans’ use of annual limits will be tightly regulated to ensure access to needed care. This will protect the 16.2 million residents of California with health insurance from their employer, along with anyone who signs up with a new insurance plan in California.

Health insurers offering new plans will have to develop an appeals process to make it easy for enrollees to dispute the denial of a medical claim. Patients’ choice of doctors will be protected by allowing plan members in new plans to pick any participating primary care provider, prohibiting insurers from requiring prior authorization before a woman sees an ob-gyn, and ensuring access to emergency care.

Extended coverage to young adults

Beginning on or after September 23, 2010, plans and issuers that offer coverage to children on their parents’ policy must allow children to remain on their parents’ policy until they turn 26, unless the adult child has another offer of job-based coverage in some cases. This provision will bring relief to roughly 196,000 individuals in California who could now have quality affordable coverage through their parents. Some employers and the vast majority of insurers have agreed to cover adult children immediately.

Affordable insurance for uninsured with preexisting conditions

$761 million federal dollars are available to California starting July 1 to provide coverage for uninsured residents with pre-existing medical conditions through a new transitional high-risk pool program, funded entirely by the Federal government. The program is a bridge to 2014, when Americans will have access to affordable coverage options in the new health insurance exchanges and insurance companies will be prohibited from denying coverage to Americans with pre-existing conditions. If states choose not to run the program, the Federal government will administer the program for those residents.

Strengthening community health centers

Beginning on October 1, 2010, increased funding for Community Health Centers will help nearly double the number of patients seen over the next 5 years. The funding could not only help the 1,049 Community Health Centers in California but also support the construction of the new centers.

More doctors where people need them

Beginning October 1, 2010, the Act will provide funding for the National Health Service Corps ($1.5 billion over 5 years) for scholarships to help the 1,049 Community Health Centers in California but also support the construction of new centers and loan repayments for doctors, nurses and other health care providers who work in areas with a shortage of health professionals. This will help the 9% of California’s population who live in an underserved area.

New Medicaid options for states

For the first time, California has the option of Federal Medicaid funding for coverage for all low-income populations, irrespective of age, disability, or family status. For more information on health care reform issues visit: www.healthcare.gov.

Also see our article, What Does Health Care Reform Mean for Beneficiaries? Summary of Key Provisions.

Some of the FAQs include:

• Who is eligible for the CLASS Act LTC insurance program?
• If I need long-term care insurance now, should I buy it or just wait for the CLASS Act program to begin?
• What benefit amount will the CLASS Act program pay if I require long-term care?
• How much will the premiums be and how will they be collected?
• Do I have to enroll in the CLASS Act program? What if I don’t want to?

See our FAQs on the CLASS Act.

See our CLASS Act Summary for more detailed information, and our long-term care section for general information on LTC.

See CMS’ press release for more information.

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

For more information on Part D, see our section Prescription Drugs.

The Senate Appropriations Committee approved the measure, which was inserted into a spending bill that funds the Federal Trade Commission’s budget. The measure would ban a “pay-to-delay” practice — opposed by the FTC in a series of lawsuits brought since 2001 — in which brand-name drug companies and generic drug makers both profit. Brand-name drug makers get higher prices while the generic companies are paid to stay out of the market.

The provision was authored by Sen. Herb Kohl, D-Wis., with support from Dick Durbin, D-Ill., the No. 2 Democrat in the Senate and the chief author of the underlying spending bill.

The vote was tight, first deadlocking 15-15 on an amendment by Sen. Arlen Specter, D-Pa., to strip the provision. Four Democrats voted with the drug lobby, and the drug company lobbyists thought they had the vote won, provided they could win over every panel Republican.

Yet, Sen. Richard Shelby, R-Ala., voted against the drug companies, helping give Kohl and Durbin a surprise win. With health care costs spiraling up, Senator Kohl said “we cannot turn a blind eye to these anti-competitive backroom deals that deny consumers access to affordable generic drugs.”

The FTC estimates that pay-to-delay deals cost consumers $3.5 billion a year. The agency suspects branded and generic drug companies made 21 such deals since last October. It would also save the government $2.6 billion over the next decade by reducing drug costs.

FTC Chairman Jon Leibowitz attended the panel session and cheered the vote.

The spending bill containing this provision has yet to advance to either the House or Senate floors and the drug lobby will be continuing their battle. To encourage the passage of this provision that can save consumers billions on prescription drugs, contact your Congress people.

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.

It also helps people compare hospitals using 44 quality of care measures. This section links to HospitalCompare.hhs.gov, a web tool created by the Centers for Medicare & Medicaid Services (CMS), HHS, and members of the Hospital Quality Alliance. In the past, this site only had data about the quality of care provided to hospital inpatients. As of July 7, 2010, however, it now has “data on the rates of outpatient MRIs for low back pain, outpatient re-tests after a screening mammogram, as well as two ratios that explain how frequently outpatient departments gave patients ‘double’ computed tomography (CT) scans when a single scan may be all that is needed….[It] also includes new measures that show whether outpatients who are treated for suspected heart attacks receive proven therapies that reduce mortality such as an aspirin at arrival, and how well outpatient surgical patients are protected from infection,” (see CMS press release). In the future, comparison information for nursing homes and dialysis centers will also be added, based on language in the Patient Protection and Affordable Care Act (PPACA) that requires broader quality of care information to be publicly available.

The section on health reform is extensive and provides a summary of the legislation, links to the law’s text and major provisions, and detailed information on 7 major topic areas. These areas include: the pre-existing condition plan, how health reform strengthens Medicare, young adult coverage, early retiree coverage, small employer tax credits, the Patients’ Bill of Rights, and the $250 Part D donut hole rebate. This section also provides a timeline for what’s changing and when according to the health care reform law.

As this is a new website, HHS invites comments and feedback to help make it even better. Some additional website improvements on the way include a full Spanish translation, which will be available at the end of July, and price information for private insurance plans, which will be available in October 2010.

The website is a first of its kind, providing over 500 pages of information in a user friendly, easily search-able way. In fact, according to White House New Media Director, Macon Phillips, this site’s design was inspired and guided by the question, “How would [a travel website like] kayak.com approach health insurance?” The result is a design with simple, focused searching that allows users to answer a few short questions and quickly find the info they require.

Questions and suggestions regarding healthcare.gov can be sent to public@who.eop.gov.

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

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.

Inside Edition video report

A report produced by Inside Edition, an American news magazine, has caught the attention of the U.S. Senate Committee on Aging, which has just launched an investigation into the company’s practices.

Among the many questionable sales pitches used is one where the agent calls on the elderly to sell Medicare supplemental insurance.  But once they are in an elder’s home, consumers say agents push them to invest their life savings into the company’s annuities, which can sometimes tie up their money well beyond their life expectancy.

As seen on Inside Edition’s undercover video, agents were told to think of themselves as “buzzards” and the elderly as their “prey.” They also told trainers to play on the fears of seniors, particularly their fear of confinement to a nursing home. “You need to actually put them in the nursing home,” said one trainer. “You need to almost bring them to tears,” said another. A trainer even encouraged the company’s agents to drive elderly clients to the bank to close the deal.

This national, well-known company is based in Chicago.  The training sessions caught on tape by Inside Edition were held in Charlotte, North Carolina.

The company has said it does not condone the depicted practices and is “conducting a thorough investigation of the issues raised by this report.”  So far, it says the investigation has found that the tactics shown in the report were limited to one branch office and “are not reflective of or consistent with our sales and training practices.”

View the full video online.

See our Medicare Fraud section for more information on fraud and abuse and who to contact for assistance.

This post was edited in part from Inside Edition’s report.