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California Medicare Coalition Medicare and Part D: Who Regulates What? Federal and State Responsibilities The California Medicare Coalition is supported.

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Presentation on theme: "California Medicare Coalition Medicare and Part D: Who Regulates What? Federal and State Responsibilities The California Medicare Coalition is supported."— Presentation transcript:

1 California Medicare Coalition Medicare and Part D: Who Regulates What? Federal and State Responsibilities The California Medicare Coalition is supported by funding provided by the California HealthCare Foundation, based in Oakland, CA

2 California Health Advocates (c) Our Focus California Health Advocates is dedicated to Medicare beneficiary advocacy and education for Californians. Policy – Public policy research and recommendations for improved rights and protections, partner with national Medicare organizations based in Washington D.C. Training – Professionals and informal helpers, vibrant web resources, newsletter and regional forums Advocacy – Bring the experience of Medicare beneficiaries to the public through media and educational campaigns with the legislative staff at federal and state levels.

3 California Health Advocates (c) Types of Medicare Plans Part D – stand alone prescription drug plans (PDPs) Provide prescription drug benefit only Medicare Advantage (MA) plans Offer all services covered under Medicare Parts A and B Some may include Part D coverage (called MA-PDs)

4 California Health Advocates (c) Medicare Advantage Plans 3 Types of MA plans: Coordinated Care Plans Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) Special Needs Plans (SNPs) Private Fee-for-Service (PFFS) Plans Medicare Medical Savings Accounts (MSAs)

5 California Health Advocates (c) Medicare Advantage and Other Part D Coverage Individuals enrolled in an MA coordinated care plan (HMO, PPO, SNP) cannot also be enrolled in a PDP Even if MA plan does not provide Part D coverage If PFFS plan does not offer Part D coverage, enrollees can enroll in a PDP MSAs cannot offer Part D coverage So enrollees can also enroll in a PDP Some retiree plans include Part D benefits and retirees cannot have other Part D coverage

6 California Health Advocates (c) Marketing of Medicare Plans Enormous increase in numbers and types of plans being offered Many Part D sponsors offer multiple products (HMO, PPO, PDP, PFFS, SPNP, Medigap) Many agents sell multiple products for the same or different sponsors Informed decision making has become more difficult for Medicare beneficiaries Lock-in rules mean limited opportunities to change plans if mistakes are made

7 California Health Advocates (c) Marketing … Multiple plan designs and variations are not always understood by agents and beneficiaries Some MA rules, benefit designs not adequately explained PPO deductibles Not all providers will accept PFFS plans Plans can pay higher commissions to agents for certain products Agent are paid more for PFFS plans than a PDP Some plan sponsors convinced current PDP enrollees to switch to their MA products

8 California Health Advocates (c) Federal Law Preempts States All Medicare Advantage plans and free standing Part D plans are regulated by federal law State law preempted, except State license required by federal law Unless waived by CMS Plan solvency as part of state license Or meet federal rule if state license is waived States cannot impose their own laws on Medicare plans Language access, unfair claims practices, provider relationships, etc. All complaints must go through federal system CMS complaint tracking through Medicare Fraud and abuse contractor, West MEDIC

9 California Health Advocates (c) Federal Law Applies To all plan operations All relationships with providers All benefits and services All grievances and appeals All marketing of MA and Part D plans Plan marketing materials Plan marketing events Plan marketing activities All enrollment activities

10 California Health Advocates (c) State Law Applies To licensed agents selling Part D plans Marketing activities, but Not marketing materials approved by CMS Agents name on marketing materials Must include those things required under CA state law such as business names and other information Can’t be misleading Sales activities New sales and replacements Must be appropriate to needs of consumer Cannot be misleading Cannot misrepresent product Cannot be coercive

11 California Health Advocates (c) Marketing Activities: Federal Law Agents/brokers can not: Do unsolicited door-to-door marketing Say they are from Medicare or HICAP Offer money to join a plan Enroll someone in a plan without their permission Misrepresent a product someone is buying Use scare tactics

12 California Health Advocates (c) CA Statues Applying to Agents § 785 requires a duty of honesty, good faith, and fair dealing in the sale of insurance (65 and older) § requires a full and accurate written comparison with other coverage (65 and older) Requires explanation of relationship of proposed coverage with existing Medicare and Medi-Cal coverage

13 California Health Advocates (c) Statues……. § 780 prohibits misrepresentations § 781 prohibits twisting and high-pressure sales tactics Twisting is convincing someone to drop one policy in favor or another § 332 requires all parties to the contract to communicate all facts material to the contract which the other has no way to ascertain May impose a duty to divulge Current providers may not accept the plan being sold Drugs a consumer is taking may not be covered

14 California Health Advocates (c) HICAP Can Help! The Health Insurance Counseling and Advocacy Program (HICAP) for local appointments State funded, statewide program Free, individualized assistance with: Medicare and Medicare Advantage Part D choices and complaints Supplementing Medicare Long Term Care Insurance Claim problems

15 California Health Advocates (c) Contact Information California Health Advocates ■ Websites: (Professionals)www.cahealthadvocates (Consumers/General Public)www.calmedicare.org Health Insurance Counseling & Advocacy Program (HICAP) 1 (800)


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