Transcript California Medicare Coalition

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
Our Focus
California Health Advocates is dedicated to Medicare
beneficiary advocacy and education for Californians.
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Policy – Public policy research and recommendations for improved
rights and protections, partner with national Medicare organizations
based in Washington D.C.
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Training – Professionals and informal helpers, vibrant web
resources, newsletter and regional forums
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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
California Health Advocates (c) 2006
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Types of Medicare Plans
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Part D – stand alone prescription drug
plans (PDPs)
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Provide prescription drug benefit only
Medicare Advantage (MA) plans
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Offer all services covered under
Medicare Parts A and B
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Some may include Part D coverage
(called MA-PDs)
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Medicare Advantage Plans
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3 Types of MA plans:
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Coordinated Care Plans
• Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Special Needs Plans (SNPs)
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Private Fee-for-Service (PFFS) Plans
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Medicare Medical Savings Accounts (MSAs)
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Medicare Advantage and
Other Part D Coverage
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Individuals enrolled in an MA coordinated care
plan (HMO, PPO, SNP) cannot also be
enrolled in a PDP
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Even if MA plan does not provide Part D
coverage
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If PFFS plan does not offer Part D coverage,
enrollees can enroll in a PDP
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MSAs cannot offer Part D coverage
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So enrollees can also enroll in a PDP
Some retiree plans include Part D benefits and
retirees cannot have other Part D coverage
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Marketing of Medicare Plans
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Enormous increase in numbers and types of plans
being offered
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Many Part D sponsors offer multiple products
(HMO, PPO, PDP, PFFS, SPNP, Medigap)
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Many agents sell multiple products for the same
or different sponsors
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Informed decision making has become more
difficult for Medicare beneficiaries
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Lock-in rules mean limited opportunities to change
plans if mistakes are made
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Marketing …
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Multiple plan designs and variations are not
always understood by agents and beneficiaries
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Some MA rules, benefit designs not adequately
explained
• PPO deductibles
• Not all providers will accept PFFS plans
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Plans can pay higher commissions to agents for
certain products
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Agent are paid more for PFFS plans than a PDP
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Some plan sponsors convinced current PDP
enrollees to switch to their MA products
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Federal Law Preempts States
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All Medicare Advantage plans and free standing
Part D plans are regulated by federal law
State law preempted, except
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• 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.
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All complaints must go through federal system
• CMS complaint tracking through 1-800-Medicare
• Fraud and abuse contractor, West MEDIC
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Federal Law Applies
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To all plan operations
All relationships with providers
All benefits and services
All grievances and appeals
All marketing of MA and Part D plans
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Plan marketing materials
Plan marketing events
Plan marketing activities
All enrollment activities
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State Law Applies
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To licensed agents selling Part D plans
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Marketing activities, but
• Not marketing materials approved by CMS
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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
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Sales activities
• New sales and replacements
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Must be appropriate to needs of consumer
Cannot be misleading
Cannot misrepresent product
Cannot be coercive
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Marketing Activities:
Federal Law
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Agents/brokers can not:
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Do unsolicited door-to-door marketing
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Say they are from Medicare or HICAP
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Offer money to join a plan
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Enroll someone in a plan without their
permission
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Misrepresent a product someone is buying
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Use scare tactics
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CA Statues Applying to Agents
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§785 requires a duty of honesty, good
faith, and fair dealing in the sale of
insurance (65 and older)
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§786.5 requires a full and accurate
written comparison with other coverage
(65 and older)
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Requires explanation of relationship of
proposed coverage with existing
Medicare and Medi-Cal coverage
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Statues…….
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§780 prohibits misrepresentations
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§781 prohibits twisting and high-pressure sales
tactics
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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
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May impose a duty to divulge
• Current providers may not accept the plan being sold
• Drugs a consumer is taking may not be covered
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HICAP Can Help!
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The Health Insurance Counseling and
Advocacy Program (HICAP)
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1-800-434-0222 for local appointments
• State funded, statewide program
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Free, individualized assistance with:
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California Health Advocates (c) 2006
Medicare and Medicare Advantage
Part D choices and complaints
Supplementing Medicare
Long Term Care Insurance
Claim problems
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Contact Information
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California Health Advocates
■ Websites: www.cahealthadvocates (Professionals)
www.calmedicare.org (Consumers/General Public)
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Health Insurance Counseling &
Advocacy Program (HICAP)
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California Health Advocates (c) 2006
1 (800) 434 - 0222
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