This termination will not impact drug access for the more than 123,000 Medicare beneficiaries enrolled in Fox plans. As of Tuesday March 9th, they can obtain their drugs through LI-NET, a program run by Medicare and administered by Humana, to ensure they receive their Medicare prescription drugs in a timely manner. Fox enrollees can choose a new Medicare Part D plan between now and May 1, 2010. Those who do not choose a new plan by then will be enrolled in one by Medicare.

CMS will send letters to all previous Fox enrollees explaining their continued access to prescriptions, and advising them to call 1-800-MEDICARE or their local state health insurance assistance programs if they have questions (which is HICAP – the Health Insurance Counseling and  Advocacy Program –  here in California).

During CMS’s onsite audit of Fox’s drug plans, they found Fox continuing to subject its enrollees to obstacles in getting needed and, in many cases, life–sustaining medicines, even after the enrollment and marketing sanctions CMS issued on the plan in late February. Fox enrollees were often required to have unnecessary and invasive medical procedures before being able to obtain their needed drugs.

Some of the violations CMS found in its audit as stated in their press release this week include:

• Failing to provide access to Medicare prescription drugs benefits by imposing unapproved prior authorization and step therapy criteria that made it more difficult for beneficiaries to get drugs that are protected by law.
• Not meeting the plan’s appeals deadlines.
• Not complying with Medicare regulations requiring enrollees to be transitioned to new drugs at the beginning of the new plan year.
• Failing to notify enrollees about prior authorization and step therapy determinations as required by Medicare.  

California beneficiaries who were enrolled in a Fox plan and who have any concerns with drug coverage access can call 1-800-MEDICARE (1-800-633-4227) or HICAP (1-800-434-0222) to help get them resolved.

NOTE: States in which the Fox plan was available were: Arkansas, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Louisiana, Maryland, Missouri, North Carolina, New Jersey, New York, Nevada, Ohio, Pennsylvania, South Carolina, Texas and West Virginia.

One example is with a drug, Finasteride. A beneficiary found that it cost her 2.5 times more to get it in her Part D plan than at Costco. Therefore, she bought her prescription at Costco instead of using her Part D plan. Subsequently, what she spent at Costco was not counted toward her  TrOOP (true out-of-pocket expenses). In this case, it happened to be a plus for her since it delayed her entrance into the coverage gap, or donut hole.

In another case, a beneficiary’s Part D plan drug copayment was higher than the retail price for the same drug outside the plan.

We have notified the Centers for Medicare and Medicaid Services about this issue.  Yet, it’s unclear what CMS can do since the Medicare Modernization Act (MMA) of 2005 prohibits the federal government or the Secretary of Health and Human Services (HHS) from negotiating Part D drug prices.

If you hear of additional cases like this, let us know. You can also contact your Congressional Representative or Senator to voice your concern on this issue.

The federal Medicare Improvements for Patients and Providers Act of 2008 required states to adopt certain changes to Medigap policies, and these changes were adopted in California law on July 2, 2009 with the signing of Assembly Bill 1543 (Chapter 10, Statutes of 2009).

Anyone enrolled in Medicare can purchase a Medigap policy, also referred to as Medicare supplement insurance. These plans are designed to cover some of the out-of-pocket expenses people have when they use their Medicare benefits.

Under the new state law, all of the Medigap plans (plans lettered A-L) have been revised; some of the lettered plans were changed, some were dropped and some new ones were added. As mentioned, these new Medigap plans will not take effect until June 1, 2010—but agents may advertise and market the new plans prior to that date.

For more information about the changes, see:

• FAQs on the New Standardized Medigap Policies Available June 2010
• Summary of Medigap Changes: A.B. 1543 (Jones)
• Snapshot of Changes to Medigap Policies

You can also see a copy of the CDI’s notice (PDF) to insurers, agents, brokers and other interested parties.

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.

In a recent AARP article, Selling Your Life Insurance? Proceed With Caution, Bonnie Burns, our Training and Policy Specialist, comments that most people don’t realize: 1) there may be tax consequences to selling a policy, and 2) money from a life settlement could affect their ability to qualify for public assistance like Medicaid.

Some of the report’s key findings include:

• California’s elderly population (those age 65 and older) is expected to more than double between 2000 and 2030.
• California has the largest number of Medicare beneficiaries of any state — 4.5 million enrollees. This number will continue to increase as California’s population ages and the percentage of those by Medicare rises.
• Medicare’s reimbursement for care delivered to California beneficiaries is higher than the national average — as of 2006, it’s about $600 more per beneficiary.
• In 2004 and 2005, total annual medical payments per Medicare beneficiary in California averaged $11,326, of which $1,330 (11%) came out of the beneficiaries’ own pockets.
• A large percentage of Medicare beneficiaries suffer from multiple chronic illnesses. In 2005, 79% reported having two or more chronic conditions and 37% reported four or more.

Download the full report for more information:

• California Health Care Almanac: Medicare Facts and Figures 2010 (PDF)

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.

Bonnie Burns posted this summary of the CLASS Act — it gives a broad overview of the major provisions of the Act, with notations where the Senate and House versions differed as of its writing on January 15, 2010.

• The older population (65+) numbered 38.9 million in 2008, an increase of 4.5 million or 13.0% since 1998.
• The number of Americans aged 45-64 – who will reach 65 over the next 2 decades – increased by 31% during this decade.
• Over 1 in every 8, or 12.8%, of the population is an older American.
• Persons reaching age 65 have an average life expectancy of an additional 18.6 years (19.8 years for females and 17.1 years for males).
• Older women outnumber older men at 22.4 million older women to 16.5 million older men.
• In 2008, 19.6% of persons 65+ were minorities–8.3% were African-Americans.** Persons of Hispanic origin (who may be of any race) represented 6.8% of the older population. About 3.4% were Asian or Pacific Islander,** and less than 1% were American Indian or Native Alaskan.** In addition, 0.6% of persons 65+ identified themselves as being of two or more races.
• Older men were much more likely to be married than older women–72% of men vs. 42% of women (Figure 2). 42% older women in 2002 were widows.
• About 31% (11.2 million) of noninstitutionalized older persons live alone (8.3 million women, 2.9 million men).
• Half of older women (50%) age 75+ live alone.
• About 471,000 grandparents aged 65 or more had the primary responsibility for their grandchildren who lived with them.
• The population 65 and over will increase from 35 million in 2000 to 40 million in 2010 (a 15% increase) and then to 55 million in 2020 (a 36% increase for that decade).
• The 85+ population is projected to increase from 4.2 million in 2000 to 5.7 million in 2010 (a 36% increase) and then to 6.6 million in 2020 (a 15% increase for that decade).
• Minority populations are projected to increase from 5.7 million in 2000 (16.3% of the elderly population) to 8.0 million in 2010 (20.1% of the elderly) and then to 12.9 million in 2020 (23.6% of the elderly).
• The median income of older persons in 2008 was $25,503 for males and $14,559 for females. Median money income (after adjusting for inflation) of all households headed by older people did not change in a statistically different amount from 2007 to 2008. Households containing families headed by persons 65+ reported a median income in 2008 of $44,188.
• Major sources of income for older people in 2007 were: Social Security (reported by 87% of older persons), income from assets (reported by 52%), private pensions (reported by 28%), government employee pensions (reported by 13%), and earnings (reported by 25%).
• Social Security constituted 90% or more of the income received by 35% of all Social Security beneficiaries (21% of married couples and 44% of non-married beneficiaries).
• About 3.7 million elderly persons (9.7%) were below the poverty level in 2008 which is not statistically different from the poverty rate in 2007 (9.7%).
• About 11% (3.7 million) of older Medicare enrollees received personal care from a paid or unpaid source in 1999.

The full report will be posted on the AoA’s website soon.

While a 2006 state law requires officials to publicly report hospital errors, California’s DPH has not yet reported the information to the state Legislature.

California hospitals reported 1,538 serious and preventable events for fiscal year 2008-2009, up from last year’s reported 1,224 errors. About 90% of the reported errors are currently under investigation, according to a recent article from the Sacramento Business Journal, 1/8.

Health insurers and hospitals are working to reduce the incidence of preventable medical errors through new policies and procedures. Medicare has also chosen not to pay for preventable medical errors, and many major health insurance companies are following suit.

In addition, hospitals are enacting new safety protocols in an effort to prevent such events. One system gaining more attention from lawmakers stems from a unique and successful strategy used in Pittsburgh to improve the quality, safety, efficiency and cost of hospitals in the area. The system took its ideas from one of the most efficient companies, Toyota. While this approach, modeling after an industry, may seem a bit strange and impersonal, hospital after hospital in the Pittsburgh area saw and sustained dramatic improvements. This approach is now being considered for other hospitals throughout the country. To learn more, see the book, The Pittsburgh Way to Efficient Health Care.

Here’s a chart that outlines the types and numbers of medical errors in California last year.