1. Dual Eligibles and Medicare: Ongoing Issues California Medicare Coalition Webcast – April 9, 2008 Presented by David Lipschutz California Health Advocates This webcast is supported by The California Endowment

2. California Health Advocates (c) 2008 2 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. www.cahealthadvocates.org

3. California Health Advocates (c) 2008 3 Acknowledgments National Senior Citizens Law Center www.nsclc.org Center for Health Care Rights www.healthcarerights.org Health Assistance Partnership www.hapnetwork.org Also see: Center for Medicare Advocacy – www.medicareadvocacy.org www.medicareadvocacy.org Medicare Rights Center – www.medicarerights.orgwww.medicarerights.org

4. California Health Advocates (c) 2008 4 Outline Overview – Dual Eligibles and Medicare Part D Enrollment Issues Auto-Assignment and Benchmark Plans Reassignment Point of Sale (POS) Process Medicare Advantage & Dual Eligibles Marketing Misconduct Low Income Subsidy (LIS) Eligibility Best Available Evidence (BAE) Other Issues

5. California Health Advocates (c) 2008 5 Overview Part D benefit only available through private, commercial plans Stand-alone prescription drug plans (PDPs) Medicare Advantage-Prescription Drug Plans (MA-PDs) Individuals dually eligible for Medicare and Medi- Cal (Medicaid) must be enrolled in a Medicare Part D drug plan in order to obtain drug coverage Medi-Cal still covers many drugs excluded under Part D

6. California Health Advocates (c) 2008 6 Overview (cont’d) Medicare Modernization Act (MMA) created a Part D Low-Income Subsidy (“LIS” or “Extra Help”) available for qualifying individuals Helps pay for some Part D costs Some people automatically eligible for LIS Full Dual Eligibles, Medicare Savings Program Others must actively apply (through SSA)

7. California Health Advocates (c) 2008 7 Auto-Assignment LIS enrollees auto-assigned to a Part D plan unless they are already enrolled in one Auto-enrollment is random assignment into a standard plan with fully subsidized premium (“benchmark plan”) Problems with delays …

8. California Health Advocates (c) 2008 8 Benchmark Plans PDP qualifies as a benchmark plan only if it offers basic coverage w/ premiums at or below the regional benchmark level Full subsidy LIS enrollees can enroll in benchmark plans without paying any premium 2008 benchmark in CA = $19.80 (down from $21.03) 9 benchmark plans in CA – same # as 2007, but some different actors

9. California Health Advocates (c) 2008 9 Plan Reassignment ½ of the benchmark and other plans for which LIS enrollees paid no premium in 2007 (“de minimis” plans) are not benchmark or de minimis plans in 2008 De minimis plans – charge above benchmark but are still premium-free for LIS enrollees Many benchmark plans raised premiums so they are no longer benchmark plans in 2008 In CA, including UnitedHealth (AARP), Humana Std., - 2 biggest plans Approximately 500,000 duals in CA were reassigned

10. California Health Advocates (c) 2008 10 Plan Reassignment (cont’d) Some LIS enrollees reassigned, others not CMS reassigned people who remained in PDP into which CMS auto-assigned them If plan sponsor offers another benchmark plan for 2008, individual was reassigned to that plan Everyone else – random assignment Group that was NOT reassigned – “choosers” LIS enrollees who chose their own Part D plan instead of being auto-assigned Approx 97,000 in CA at end of 2007 Should have received a letter explaining that they have to pay portion of premiums unless they switched to a benchmark plan

11. California Health Advocates (c) 2008 11 Data Issues Several data systems must share Medicare and Medi-Cal information in order for a dual eligible to be effectively enrolled into a Part D plan and show LIS eligibility See NSCLC webcast “Behind the Scenes of Medicare Part D: Data Transfers and the Point of Sale Mechanism” System delays often result in gaps between eligibility for LIS and enrollment in Part D plans leading individuals to pay out of pocket (if they are able)

12. California Health Advocates (c) 2008 12 Point of Sale (POS) CMS Point of Sale (POS) Facilitated Enrollment Process (a.k.a. Wellpoint) for dual eligible beneficiaries who should have been automatically enrolled, but do not appear in a plan’s records Provides drug fill and assigns to a plan Pharmacist can choose whether or not to use POS process

13. California Health Advocates (c) 2008 13 Dual Eligibles & Medicare Advantage Plans Dual Eligibles can enroll in Medicare Advantage (MA) plans if they wish How much value does a Dual Eligible get by enrolling in a particular MA plan? Specific care coordination? Access to more (or fewer) providers? Easier – or more difficult – access to Medi-Cal benefits? Any benefits not already entitled to? If so, how much more, and is it worth it? More out-of-pocket expenses?

14. California Health Advocates (c) 2008 14 Duals and SNPs Special Needs Plans (SNPs) are Medicare Advantage plans designed to serve 1 of 3 types of “special needs individuals”: Dual Eligibles Institutionalized Individuals with severe or disabling chronic conditions SNPs can disproportionately enroll or limit enrollment to the designated population or even a subpopulation Many Dual Eligibles were “passively enrolled” Moratorium on SNPs – legislation passed at end of 2007 extends existing SNPs through December 2009, but freeze on any new SNPs in areas where not offered as of 1/1/08

15. California Health Advocates (c) 2008 15 Marketing Misconduct Ongoing egregious conduct by agents, driven partly by plan compensation CMS implemented some new marketing rules, but abuse is ongoing Duals and other LIS enrollees attractive targets because they can enroll year-round In addition to Dual Eligible SNPs, some other MA plans specifically target Dual Eligibles E.g., certain Private-Fee-for-Service (PFFS plans)

16. California Health Advocates (c) 2008 16 Marketing Misconduct (cont’d) Undoing the damage of marketing misconduct Prospective Disenrollment Duals have an ongoing Special Enrollment Period (SEP) right to change plans monthly Retroactive Disenrollment See, e.g., Health Assistance Partnership materials at www.hapnetwork.orgwww.hapnetwork.org

17. California Health Advocates (c) 2008 17 LIS Eligibility Individuals who are eligible for LIS must go through an annual process to determine continuing eligibility Redeeming by CMS LIS enrollees who appear in info sent by state to CMS between July and December will be re- deemed for following year (including SOC) In CA, 47,000+ not re-deemed for 2008 Redetermination by SSA Most LIS folks passively redetermined as eligible in 2008 without receiving any notice from SSA Active redetermination – certain people selected for review (e.g. subsidy changing events)

18. California Health Advocates (c) 2008 18 LIS – Best Available Evidence (BAE) CMS “Best Available Evidence” policy – process through which Dual Eligibles and other LIS enrollees can show evidence of their LIS subsidy status E.g. copy of Medi-Cal card, copy of state document (including print out of electronic system) that confirms active Medicaid status (see 6/27/07 CMS Memo) Ongoing problems using this system E.g. plan customer service reps unaware of and/or unwilling to use process

19. California Health Advocates (c) 2008 19 Recent Rules … Ongoing Special Enrollment Period (SEP) CMS created an ongoing SEP right for all LIS enrollees (only used to apply to Dual Eligibles and Medicare Savings Program) Waiver of Late Enrollment Penalty Individuals who qualify for LIS and enroll in a Part D plan by end of 2008 will be exempt from Part D late enrollment penalty CMS has extended policy from 2006 and 2007

20. California Health Advocates (c) 2008 20 Other Issues… State budget crisis and Medi-Cal cuts E.g. provider reimbursement cuts – 10% Proposal to have state stop paying Part B premiums for Duals with a SOC Ongoing 1-800-MEDICARE problems Language Access At 1-800-MC, say “I speak ____” See materials by NSCLC, NHeLP, others

21. California Health Advocates (c) 2008 21 Questions…? California Health Advocates ■ Sacramento Office – (916) 231-5110 5380 Elvas Avenue, Suite 104, Sacramento, CA 95819 ■ Los Angeles Office – (213) 381-3670 3435 Wilshire Blvd., Suite 2860, Los Angeles, CA 90010 www.cahealthadvocates.org Health Insurance Counseling & Advocacy Program (HICAP) 1 (800) 434 - 0222