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Copyright © Center for Medicare Advocacy, Inc. CENTER FOR MEDICARE ADVOCACY, INC. MEDICARE ADVANTAGE: 2010 AND BEYOND _____________ Vicki Gottlich, Esq. Families USA January 28, 2010
Copyright © Center for Medicare Advocacy, Inc. 2 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
Copyright © Center for Medicare Advocacy, Inc. 3 MARKETING ABUSES A Continuing Saga New requirements - 42 CFR But old problems continue New and devious methods using third parties The issue of political mailings
Copyright © Center for Medicare Advocacy, Inc. 4 PRIVATE FEE FOR SERVICE PLANS Will they continue? New network requirements 42 CFR stricter network requirements Some plan sponsors terminated PFFS plans most PFFS plans must have a provider network Will plans become PPOs? Changes to retiree PFFS plans
Copyright © Center for Medicare Advocacy, Inc. 5 SPECIAL NEEDS PLANS New eligibility criteria 42 CFR Enrollees must be a special needs person Including CMS approved categories of chronic conditions ID & notify enrollees who dont 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
Copyright © Center for Medicare Advocacy, Inc. 6 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
Copyright © Center for Medicare Advocacy, Inc. 7 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 MAOs SNP benefit package CMS Memo to Plans Jan. 2010
Copyright © Center for Medicare Advocacy, Inc. 8 SPECIAL NEEDS PLANS FOR DUAL ELIGIBLES Requirement for contract with State Medicaid agency 42 CFR – New D-SNPs 2011 – All D-SNPs must have contract Opportunity for advocacy with state
Copyright © Center for Medicare Advocacy, Inc. 9 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
Copyright © Center for Medicare Advocacy, Inc. 10 PLAN TERMINATIONS Plan termination issues Clarity and adequacy of notice Timing of SEP Prescription drug coverage Protections for duals/LIS –eligible individuals
Copyright © Center for Medicare Advocacy, Inc. 11 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
Copyright © Center for Medicare Advocacy, Inc. 12 RESOURCES Center for Medicare Advocacy, Inc. CT/(860) DC/ (202) Chiplin, Stein, et al, Medicare Handbook; Aspen Pub. Co. (2010) Centers for Medicare & Medicaid Services (CMS) & CMS Policy Manual can be found on
Copyright © Center for Medicare Advocacy, Inc. 13 CONCLUSION CENTER FOR MEDICARE ADVOCACY, INC. CT: (860) DC: (202) _______________
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Copyright © Center for Medicare Advocacy, Inc. IN THE TRENCHES: MAKING MEDICARE CHANGES WORK FOR BENEFICIARIES Families USA January.
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