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www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.
CENTER FOR MEDICARE ADVOCACY, INC.
MEDICARE ADVANTAGE:2010 AND BEYOND
_____________Vicki Gottlich, Esq.
Families USAJanuary 28, 2010
www.medicareadvocacy.org
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THE ROLE OF ADVOCATES
Individual client representation Systemic advocacy
• Eyes and ears for CMS• Where plans are not in compliance with program
rules
• Fraud and abuse
• Working with states
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MARKETING ABUSES
A Continuing Saga New requirements - 42 CFR 422.2260-
422.2276• But old problems continue
New and devious methods using third parties The issue of political mailings
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PRIVATE FEE FOR SERVICE PLANS
Will they continue? New network requirements 42 CFR
422.114• 2010 - stricter network requirements
• Some plan sponsors terminated PFFS plans
• 2011 - most PFFS plans must have a provider network
• Will plans become PPOs? Changes to retiree PFFS plans
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SPECIAL NEEDS PLANS
New eligibility criteria 42 CFR 422.52• Enrollees must be a special needs person
• Including CMS approved categories of chronic conditions
• ID & notify enrollees who don’t meet eligibility• You will be hearing from these people!
• If lose eligibility can remain in plan for up to 6 months if expected to regain eligibility within 6 months
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SPECIAL NEEDS PLANS
What makes special needs plans special?• Models of care
• Distinguishing special features of SNPs• Plan finder and web site issues
• Special formularies if a C-SNP
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SPECIAL NEEDS PLANS
“…[M]any [Medicare Advantage Organizations] designed the same benefit package for both SNPs and other MA products offered in the same service area. The majority of MAOs offering both SNPs and other MA products in the same service area had only reduced cost sharing as the SNP-specific benefit. In fact, in several cases, the traditional MA [benefit package] was more robust than the MAO’s SNP benefit package”
CMS Memo to Plans Jan. 2010
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SPECIAL NEEDS PLANS FOR DUAL ELIGIBLES
Requirement for contract with State Medicaid agency 42 CFR 422.107• 2010 – New D-SNPs
• 2011 – All D-SNPs must have contract
Opportunity for advocacy with state
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PLAN TERMINATIONS
Plan termination rights:• Notice from terminating plan
• 90 days before the end of the calendar year
• Automatically return to traditional Medicare unless enroll in another MA plan
• Special enrollment periods• October of current year – January of next year• AEP
• Guaranteed issue of Medigap policies• 123 day period to purchase: 60 calendar days before the date
coverage ends to 63 days after coverage ends
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PLAN TERMINATIONS
Plan termination issues• Clarity and adequacy of notice
• Timing of SEP
• Prescription drug coverage
• Protections for duals/LIS –eligible individuals
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HEALTH CARE REFORM
Who knows??? Reduction in overpayments to MA plans
• May be some grandfathering-in of benefits Changes to annual/open enrollment periods Additional requirements for benefit
packages CMS authority not to contract with every
applicant
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RESOURCES
Center for Medicare Advocacy, Inc.• www.medicareadvocacy.org
• CT/(860)456-7790 • DC/ (202)293-5760
• Chiplin, Stein, et al, Medicare Handbook; Aspen Pub. Co. (2010)
Centers for Medicare & Medicaid Services (CMS)
• www.medicare.gov & http://www.cms.hhs.gov/
• CMS Policy Manual can be found on http://www.cms.hhs.gov/Manuals/
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CONCLUSION
CENTER FOR MEDICARE ADVOCACY, INC.
CT: (860) 456-7790
DC: (202) 293-5760
_______________
www.medicareadvocacy.org
