Medicare Advantage Plans & Other Medicare Plans Module 11 Session Topics Lesson 1 - Medicare Health Plan Choices Lesson 2 - Marketing Guidelines Lesson 1 - Medicare Health Plan Choices * What are Medicare Advantage (MA) Plans * Who can join and when * How MA Plans work * Types of MA Plans * Other Medicare Plans * Rights and protections - Including appeals What Are Medicare Advantage (MA) Plans? * Health plan options approved by Medicare * Run by private companies * Part of the Medicare program - Sometimes called "Part C" * Available in many areas of the country * Provide Medicare-covered benefits - May cover extra benefits, e.g.; vision or dental Who Can Join? * Eligibility requirements - Live in plan's service area - Entitled to Medicare Part A - Enrolled in Medicare Part B - Not have End-Stage Renal Disease (ESRD) at enrollment * Some exceptions * To join an MA plan, a person must also - Agree to provide the necessary information to the plan - Agree to follow the plan's rules - Belong to only one Medicare Advantage plan at a time Medicare Advantage Trial Right Special Election Period * People who join an MA plan for the first time - When first eligible for Medicare at age 65 or - Leave Original Medicare and drop Medigap policy * Can disenroll from MA plan during first 12 months - Join Original Medicare - Have guaranteed issue for Medigap policy How MA Plans Work * You get Medicare-covered services through the plan - All Part A and Part B covered services - Some plans may provide additional benefits * Most plans include prescription drug coverage - Part D * You may have to go to network doctors or hospitals * MA may be different than Original Medicare - Benefits and cost-sharing How Do Medicare Advantage Plans Work? (continued) * You are still in Medicare program * You still have Medicare rights and protections * If the plan leaves Medicare - You can join another MA plan - You can return to Original Medicare MA Costs * Must still pay Part B premium - Some plans may pay all or part for you - Some people may be eligible for state assistance * May pay an additional monthly premium to plan * You pay deductibles, coinsurance and copayments - Different from Original Medicare - Varies from plan to plan - Costs may be higher if you go out of network MA - New for 2011 * If you are accepted as a participant in an approved clinical research study - Your costs may be lower - Some costs may be covered by your plan (Section 2101) * MA Plans can't charge more than Original Medicare - For certain services, e.g., chemotherapy, dialysis, and skilled nursing facility care (Section 3202) * MA Plans must limit your out-of-pocket costs - For Part A and part B covered services (Section 3202) Types of Medicare Advantage Plans * Medicare Health Maintenance Organization (HMO) * Medicare Preferred Provider Organization (PPO) * Medicare Private Fee-for-Service (PFFS) * Medicare Special Needs Plan (SNP) * Point of Service Plan (POS) * Medicare Medical Savings Account (MSA) Changes in Access Requirements for PFFS Plans - By 2011 * Employer/non-employer PFFS plans may conform - With contracted provider network meeting CMS' rules - By paying the Original Medicare payment rate or more - Having providers deemed to be contracted as providers * With a sufficient number and range of providers * Non-employer PFFS must conform - If two or more network-based MA plan options exist Other Medicare Advantage Plans * Less common plans include - Point of Service (POS) Plan * May allow some services out-of-network for a higher cost - Medical Savings Account (MSA) Plans * Combines a high deductible health plan with a bank account * Medicare deposits money into the account * You use the money to pay for your health care services Other Medicare Plans * Not Medicare Advantage, but still part of Medicare * Some provide Part A and/or Part B coverage * Some provide Part D coverage * They include - Medicare Cost Plans - Demonstrations/Pilot Programs - Programs of All-inclusive Care for the Elderly (PACE) Cost Plans * Available in limited areas * Can join even if only have Part B * If you go to a non-network provider - Services are covered under Original Medicare * Join Cost Plan any time accepting new members * Can leave Cost Plan any time - Return to Original Medicare * Can get Medicare prescription drug coverage - From the plan (if offered) - Buy a Medicare prescription drug plan Demonstrations/Pilot Programs * Special projects that test improvements in - Medicare coverage - Payment - Quality of care * Eligibility usually limited - Specific group of people - Specific area of country * Examples - MA Plan for ESRD patients - New Medicare preventive services Medicare PACE Plans * Programs of All-inclusive Care for the Elderly * Combine services for frail elderly people - Medical, social, long-term care services - Include prescription drug coverage * Might be better choice than nursing home * Only in states that offer it under Medicaid * Qualifications vary from state to state - Contact state Medical Assistance office for information Rights in All Medicare Plans * All people with Medicare have guaranteed rights - To get the health care services they need - To receive easy-to-understand information - To have their personal medical information kept private Rights in Medicare Health Plans * Choice of health care providers * Access to health care providers (treatment plan) * Know how your doctors are paid * Fair, efficient, and timely appeals process - Fast appeals in certain health care settings * Grievance process * Coverage/payment information before service * Privacy of personal health information Appeals in Medicare Advantage * Plan must say in writing how to appeal if it - Will not pay for a service - Does not allow a service - Stops or reduces a course of treatment * Can ask for fast (expedited) decision - Plan must decide within 72 hours * See plan's membership materials - Include instructions on how to file an appeal or grievance Medicare Part C Appeals Process Medicare Health Plan Fast Appeals Process * Notice of Medicare Non-Coverage - Provider must deliver at least 2 days before Medicare-covered SNF, CORF, or HHA care will end * If you think services are ending too soon - Contact your Quality Improvement Organization (QIO) * No later than noon the day before Medicare-covered services end to request a fast appeal * See your Notice for how to contact your QIO and for other important information * QIO must notify you of its decision - By close of business of the day after it receives all necessary information Inpatient Hospital Appeals * When services are ending too soon * Provider/plan must give Notice of Discharge and Medicare Appeal Rights - At least the day before services end if * The enrollee disagrees with the discharge decision, or * The provider/plan lowers the enrollee's care level in the same facility * Decision from QIO usually within 2 days Rights if You File an Appeal with Your Medicare Health Plan * Right to plan's files about you (your case file) - Call or write your plan - May charge you a reasonable fee for copying and mailing Required Notices * Plan sponsors must provide notices after every - Adverse determination - Adverse appeal * Include - Detailed explanation of why services denied - Information on next appeal level - Specific instructions Lesson 2 - Marketing Guidelines Marketing Provisions * Medicare Marketing Guidelines - Revised August 7, 2009 * New Regulation-4085-F Codifies some areas of existing marketing guidance - Effective for contract year 2011 * CMS marketing requirements - Apply to Medicare Advantage Plans, Prescription Drug Plans and Cost Plans * Unless indicated otherwise in regulation or guidance New Marketing Provisions-4085-F * Certain beneficiary communication materials - Do not require review - Plan sponsors are required to use standardized model marketing materials under Parts C & D * When CMS provides standardized models materials Key Policy Updates Since August 2009 * Standardization of plan names on marketing materials * Plan ratings disclosure requirements * Outbound enrollment verification calls * Plan mailing statements on envelopes/mailings Disclosure of Plan Information for New and Renewing Members * MA and PDPs must disclose plan information - At time of enrollment and at least annually * Required Annual Notice of Change/Evidence of Coverage * Comprehensive or Abridged Formulary * Pharmacy Directory * Provider Directory * Member ID card o only at the time of enrollment and as needed Promotional Activity Reminders Nominal Gifts * Organizations can offer gifts to potential enrollees - Must be of nominal value * Defined in marketing guidelines * Currently set at $15, based on retail price * Must be given whether beneficiary enrolls or not Promotional Activity Reminders (continued) Unsolicited Contacts * Extends existing prohibition on door-to-door solicitation to other instances, e.g.; - Outbound marketing calls - In common areas like parking lots, hallways, lobbies - Calls/visits after attendance at sales event - Unless express permission given - Unsolicited emails Promotional Activity Reminders (continued) Cross Selling * Prohibited during any MA or Part D sales activity or presentation * Cannot market non-health care related products - e.g.; annuities, life insurance * Allowed on inbound calls when requested by beneficiary Promotional Activity Reminders (continued) Scope of Appointments * Must specify types of products to be discussed - Prior to marketing and/or in-home appointment * e.g.; Medigap, MA, or PDP * Additional products can only be discussed - On beneficiary request at a separate appointment Promotional Activity Reminders (continued) Health Care Settings * Marketing allowed in common areas - Hospital or nursing home cafeterias - Community or recreational rooms - Conference rooms * No plan marketing activities in health care setting - Waiting rooms - Exam rooms and hospital patient rooms - Dialysis centers and pharmacy counter areas Promotional Activity Reminders (continued) Educational Events * No plan marketing activities at educational events - Health information fairs - Conference expositions - State- or community-sponsored events * Plans may distribute - Medicare and/or health educational materials - Agent/broker business cards, upon beneficiary request * Containing no marketing information Promotional Activity Reminders (continued) Prohibition of Meals * Prospective enrollees may not - Be provided meals at sales events - Have meals subsidized * Applies at any event or meeting where - Plan benefits are being discussed, or - Plan materials are being distributed State Licensure of Agents * MA and PDP organizations agents/brokers - Must be state-licensed, certified, or registered * Applies to both contracted and employed agents/brokers State Appointment of Agents * MA and PDP organizations must comply with state appointment laws - Require plans to give state information about which agents are marketing their plans * Any required appointment fees must be paid - Became effective January 1, 2009 Reporting of Terminated Agents * MA and PDP organizations must report termination of any agents/brokers - In accordance with state appointment law - To state in which agent/broker is appointed - Must include reasons for termination Agent/Broker Compensation * Compensation rules for MA and PDPs that market through agents/brokers - Both contracted and employed - Designed to eliminate inappropriate plan moves Agent/Broker Training and Testing * All agents/brokers must be trained and tested annually - Medicare rules and regulations - Plan details specific to plan products being sold - Both contracted and employed agents - Completed prior to the start of the new marketing season * To market after that date Agent/Broker Training and Testing (continued) * Testing requires passing score of 85% - May be written or computerized - Training and testing programs must maintain integrity - Must have process for handling agents * Who don't pass the test on the first try CMS 2010 Marketing Surveillance * To detect, prevent and respond to marketing violations - Secret shopping of over 1300 public sales event - Pilot secret shopping of one-on-one appointments - Special focus on non-renewals (NR) * Secret shopping in 55 markets with highest NR rates * Secret shopping of plan call centers CMS 2010 Marketing Surveillance (continued) * To detect, prevent and respond to marketing violations - Review plan advertisements - Review of plans website Medicare information