Under the Medicare managed care option, the beneficiary has a right to
expect
that the basic health benefit package available under the traditional
fee-for-service program can be obtained from managed
care plans. The beneficiary has a right to know what benefits are
provided, any
applicable restrictions
or limitations, and which services are excluded. The beneficiary has a
right to
know if there are
premiums, deductions, copayments and to which services the copayments
apply.
In turn, the plan must either provide the services or arrange for the
beneficiary
to receive services
from a qualified provider. Beyond that, the delivery of selected care
and
services is directed by the
plan using proven medical practice techniques, acceptable regional and
community
norms or new
information about improved health care delivery methods. In some
instances plan
providers may
consult with other Medicare contractors to confirm local practices with
respect
to a particular
treatment modality.
The beneficiary has a right to expect that managed care plans will
provide
instructions on how the
beneficiary can obtain emergency and urgent health services on a
24-hour basis,
both in the plan's
service area and when the beneficiary is away from home.
The beneficiary has a right to expect managed care plan staff and
providers to
provide accurate
information about ways the beneficiary can address medical issues and
problems
with the plan. This
includes a description of the plan's internal complaint procedures as
well as the
Health Care Financing
Administration's (HCFA) required appeals and grievance processes.
The beneficiary has a right to expect managed care staff and providers
to provide
a full explanation
if and when the plan denies a service, fails to continue a service
which the
beneficiary believes is
required, or delays the provision of a service. Where appropriate or
when
requested by the
beneficiary, the service denial should be accompanied by information
necessary
for the enrollee to
pursue the appeals process.
The beneficiary has a right to expect that his or her care will be
appropriate
for his or her age, sex,
preventive and acute or chronic health care condition.
The beneficiary has a right to expect that plan providers will be able
to
communicate with the
beneficiary in his or her language and that quality care will be
provided in a
way that is culturally
sensitive.
The beneficiary has a right to expect that the managed care industry
and HCFA
will work
expeditiously to provide plan outcome data from patient encounters to
help all
beneficiaries make
better educated decisions about health care providers.
The beneficiary has a right to enjoy freedom from marketing enrollment
pressures
and the right to
disenroll from the plan.
And finally, the beneficiary has a right to expect staff at the plan
and at HCFA
to respond to all
inquiries promptly and courteously.
What is Medicare SELECT?
Medicare SELECT is private insurance that supplements traditional
Medicare
insurance coverage. Medicare SELECT is the same as standard Medigap
insurance in
nearly all respects. If you buy a
Medicare SELECT policy, you are buying one of the 10 standard
Medigap
plans. Medicare
SELECT is required to meet certain Federal standards and is regulated
by the
state insurance
commissioners.
The only difference between Medicare SELECT and standard Medigap
insurance is
that some
insurers have specific doctors and hospitals that you must use, except
in an
emergency, to receive full
benefits. Medicare SELECT policies generally have lower premiums in
comparison
to other Medigap
policies because of this requirement.
Isn't Medicare SELECT only available in 15 States?
This has changed. Congress originally designed Medicare SELECT as
an
experimental program and initially approved its availability in 15
states. Last
year Congress expanded the program to include
all 50 states and extended it for another three years. It will be up
for
reauthorization in 1998.
If the program is not continued after 1998, insurers are still required
to honor
all Medicare SELECT
policies in effect as of that date because they are guaranteed
renewable.
This means that you could keep your Medicare SELECT policy as long as
you wanted
it. You would also have the option to
purchase, without regard to the status of your health, any other
Medigap policy
that the insurance
company or HMO offers, if it issues Medigap insurance other than
Medicare SELECT.
To the extent
possible, the replacement policy would have to provide similar
benefits.
How does Medicare SELECT work?
Medicare SELECT policies generally include certain conditions that
you must
follow. If you follow these rules, Medicare will pay its share of the
approved
charges and the SELECT policy will pay or
provide full supplemental benefits. Under some Medicare SELECT
policies, payment
may be denied
or reduced if you go outside the network for non-emergency services.
(Network
restrictions do not
apply to emergency care.) However, if you decide to use a health care
provider
that is not in the
network, Medicare will continue to pay its share.
Medicare beneficiaries have the freedom to choose each time
health care
is needed, between the Medicare SELECT network or any health care
provider not in
the network. REMEMBER, choosing to receive care from a
Medicare SELECT
network is likely to cost less than choosing care from a non-SELECT
health care
provider. For Example:
(2) Two
months later, Ms. Smith receives similar care from Dr. Todd, who is not
a
Medicare SELECT physician. Dr. Todd's bill is $100. Medicare approves
the
charge and pays 80
percent (80), and Medicare SELECT does not contribute
to the
bill. Ms. Smith pays Dr. Todd $20.
How can individuals find out about Medicare SELECT policies?
Medicare SELECT policies can be sold by insurance companies and
HMOs
throughout the country. You can find out whether a Medicare SELECT is
available
in a particular area and who sells the
policies by contacting the State Department of Insurance.
NOTE: If a Medicare beneficiary already
has a
Medigap policy and decides to enroll in a managed care plan, the
beneficiary may
want to keep the Medigap policy for a short time until a
final decision is made to stay in the plan. It is recommended that
eventually
the Medigap
policy be canceled because some of the Medigap benefits are likely to
duplicate
the
managed care plan benefits. Beneficiaries should obtain assistance
from the
State
Insurance Counseling Service before making a final decision.
What is the Out-of-Network/Point-of-Service option?
The Out-of-Network or Point-of-Service option is a
new
managed care product available to Medicare enrollees of
Medicare-contracting
HMOs. Typically, the Out-of-Network/Point-of- Service (ON/POS)
option
will allow members of an HMO to receive certain services outside the
plan's
established provider network. The ON/POS option will usually
increase
the cost-sharing amount for potential members.
Who should consider the Out-of-Network/Point-of-Service option?
1. Any Medicare beneficiary who needs the
increased
flexibility to seek health care services outside of the HMO's provider
network.
2. Any Medicare beneficiary who may have been
reluctant to
enroll in an HMO because the individual was "locked-in" to
using the
HMO's network of providers.
Can each Medicare beneficiary choose the kind of services he/she
would like
to have under the Out-of-Network/Point-of-Service option?
No. Risk plans are responsible for designing the benefit. For
example,
plans may:
1. Determine what services will be offered.
2. Set annual cost limits on services
provided
through the benefit.
3. Design beneficiary cost-sharing provisions,
including
premiums, coinsurance, copayments and deductibles.
Beneficiaries who are interested in the ON/POS option
should get
copies of all benefit packages in the area. These should be compared
to
determine which set of benefits will best meet the needs of
the individual.
Who will monitor this new managed care product?
HCFA will monitor ON/POS benefits to (1) ensure that plans
continue
to make all Medicare-covered services available and accessible in the
plan's
established health care provider network, and (2) ensure
continued financial soundness.
HMOs that choose to offer an ON/POS benefit must provide
beneficiaries with clear and concise information about the product,
including
information about any costs associated with using the
benefit, restrictions on using the benefit and appeal rights. As with
other
marketing materials, HCFA
will review and approve informational materials on the out-of-network
benefit.
Are all Medicare-contracting managed care plans offering this
option?
No. Only the managed care plans that have
"risk-based"contracts that
choose to and receive approval from HCFA may offer an ON/POS
option.
Since "cost" HMOs allow members to go out of plan to receive routine
services,
these HMOs do not need to offer the ON/POS benefit.
Why is HCFA permitting these plans to offer a new benefit at this
time?
This product has been a very popular option within commercial HMOs
and a
number of such plans had requested direction from HCFA on how to
structure an
ON/POS benefit for Medicare enrollees. In addition, the
availability of this
new product will help Medicare beneficiaries achieve parity with
commercial enrollees by providing similar health care choices.
Managed care plan marketing can provide both an educational and
enjoyable
experience for
beneficiaries. Many managed care plans expand the traditional
marketing activity
to engage in a
concerted effort to match the beneficiary with the plan. This process
increases
the likelihood that
future enrollees will be well served and remain with the plan.
Some plans provide health care discussions for groups of individuals as
part of
the marketing strategy,
offer coffee and donuts, provide an opportunity for attendees to ask
questions,
or speak with some
current enrollees. This approach allows the plan to reach more than
one
individual at a time and
maximizes marketing staff effectiveness.
However, when marketing abuses occur, a beneficiary may be wrongly
pressured into
joining a
managed care plan. A guiding principal is that "not all Medicare
beneficiaries belong in managed care plans". The marketing
process should
include a determination of which individual is a good managed care
candidate and
which individual will be better served by the traditional Medicare
program.
How do marketing abuses occur? There are basically three reasons why
managed
care plans pursue
an overly aggressive marketing campaign to solicit enrollees:
1. A particular area
becomes
saturated with managed care plans and competition for enrollees assumes
an
increased level of intensity.
2. The general
requirement that
managed care plans enroll one individual at a time. The requirement
tends to
increase the importance of each beneficiary contact for the marketing
staff.
3. The managed care plan
may offer
incentives for its marketing personnel to enroll as many new members as
possible.
Competition can provide positive results for beneficiaries, often
driving down
premium prices and
reducing beneficiaries' out-of-pocket costs. Conversely, some
beneficiary
copayments may be
increased or associated with a greater number of services to offset
lower or
eliminated premiums.
INAPPROPRIATE SOLICITATIONS
The agency has occasionally become aware of instances in which plan
staff have
solicited individuals
for plan participation who may not fully understand the implications of
plan
enrollment or who may
be inappropriately encouraged to join a plan. Although such stories
are
primarily anecdotal, they are
troubling for the agency and may serve as the basis for further review
of the
plan's marketing
practices.
PROHIBITED MARKETING ACTIVITIES
The agency specifically prohibits marketing practices which either
mislead,
confuse or misrepresent
(See Part 2, Chapter 3, Marketing - Section 2211 of the Medicare
HMO/CMP
Manual).
The most appropriate way to determine which plan is best is for the
beneficiary
to engage in a
thorough comparison of ALL PLAN MATERIALS, PRICES AND SERVICES. Until
this
process is complete, the beneficiary should be encouraged "TO JUST
SAY
NO".
Two of the most frequently asked questions about managed care plan
payments
are:
.
How much does the government pay the HMO for my care?
.
How can the HMO make a profit if it does not charge a premium?
There is no simple answer to the first question. HCFA's payment to
each plan on
behalf of a
beneficiary will vary by geographic location, by plan, by inpatient
status and
whether the enrollee has
end stage renal disease or is a working aged individual. HCFA
calculates the
plan payment based on
what the agency would have paid for the individual if he or she had
received
services under the fee-
for-service program less five percent. The agency generally responds
to this
inquiry by providing a
listing of average county payments.
The second question is easier to explain but is often not believed by
the
inquirer. In some instances,
the payment that HCFA makes to the plan is sufficient to cover the
plan's cost of
providing health
care services to the Medicare beneficiary. In other situations, the
plan will
augment the HCFA per
member per month amount with copayments or coinsurance for certain
services, or a
deductible. This
combined amount is sufficient to cover the cost of providing health
care services
to the enrolled
beneficiary in lieu of a monthly premium.
If the plan's payment structure is not profitable, a premium may be
charged,
copayments increased
or applied to a greater number of services.
For Medicare covered services, an HMO is prohibited from charging a
Medicare
beneficiary more
than an amount specified by Medicare. Each year HCFA informs the HMO
of this
maximum amount
and the HMO must inform its Medicare enrollees.
The beneficiary is always responsible for payment of the Medicare Part
B premium
as a condition of
continuing eligibility for the managed care option. In most instances,
the Part
B premium is withheld
from the beneficiary's Social Security check.
Most surveys have found that Medicare beneficiaries are satisfied with
the health
care they receive
through managed care plans. However, if the beneficiary or potential
enrollee is
not familiar with
managed care plans, he or she needs to know how these plans operate.
HCFA
provides information
about managed care plans in several publications. These include:
Medicare and Managed Care Plans, Publication No. HCFA 02195
85 Commonly Asked Questions, HCFA Publication No. 02172
The Medicare Handbook, Publication No. HCFA 10050
Guide to Health Insurance for People with Medicare, Publication No.
HCFA
02110
Copies of these publications may be obtained by calling HCFA's Hotline
at
1-800-638-6833.
Making an Informed Decision
Before making a final decision on which plan to join, the beneficiary
should
follow these simple rules:
.
Read each plan's literature to see what kind of plan it is and what it
pays for.
.
Determine what plan services are provided at additional cost and how
much. All
preventive services should be identified as well as any limitations
associated
with visits or services. The
beneficiary should fully understand where to go for emergency, urgent
and routine
care.
.
If plan materials do not provide answers to all questions, the
beneficiary should
contact the plan for additional information. Beneficiaries should make
a note of
how plan staff respond to such
inquiries and use the information in evaluating the plan.
.
Beneficiaries should not hesitate to ask about plan doctors and how to
change
doctors if a satisfactory relationship cannot be established.
.
Beneficiaries should know how to use the plan's complaint system and
how appeals
and grievances are handled.
.
Beneficiaries should inquire among friends and relatives to determine
if any are
currently enrolled in managed care plans or have been enrolled in the
past.
Beneficiaries should ask about their
experience with the plan.
.
Beneficiaries should ask the plan representative if member satisfaction
surveys
are conducted and if the results are available for review.
.
Beneficiaries should not hesitate to contact HCFA Regional Offices to
determine
if a plan has failed to comply with HCFA regulations.
An increasing number of individuals are electing to enter retirement,
continuing
and life care
communities. These lifestyle housing changes have provided new
challenges for
managed care plans.
The result is that some of these residents are discovering that managed
care
plans will not permit the
enrollee to return to the community following an acute care episode.
In most
instances this problem
arises because the managed care plan does not have a contract with the
retirement, continuing or life
care community for post-acute, follow-up or rehabilitation care. In
the absence
of a contract with
the community, the plan refers the Medicare enrollee to its own
facility. In
some cases, the plan's
facility may be miles away from the retirement community, the
enrollee's friends
and relatives.
To minimize these problems, Medicare beneficiaries who are managed care
enrollees
should
determine if a contractual relationship exist between the plan and the
community
as part of the initial
decision-making process. In some instances the individual may find
that he or
she may return to the
community for follow-up care. In other instances the individual may
discover
that the plan will use
other facilities for post-acute care. In these situations, it may be
better for
the individual to disenroll
or not elect enrollment under the managed care plan. Electing the
traditional
fee-for-service program
may be the best option under these circumstances.
Legislation prohibits entities from selling health insurance to
beneficiaries
that would duplicate
coverage which the beneficiary already has under Medicare. Every
beneficiary who
joins a managed
care plan should review all policies to determine if he or she has
duplicate
insurance coverage.
Assistance in reviewing insurance policies may be obtained through
local Health
Insurance Counseling
Programs.
The agency provides additional advice for fee-for-service Medicare
beneficiaries
who enroll in
managed care plans and who have Medigap or supplemental coverage. The
agency
recommends that
the supplemental or Medigap policy be retained for a while until the
individual
is certain that he or
she will remain with the plan.
If the Medigap or supplemental coverage is dropped immediately, the
individual
may not be able to
obtain comprehensive coverage if he or she returns to the traditional
Medicare
program. A 6-month
waiting period may be applied before full coverage can be obtained.
Every Medicare beneficiary has the right to complain when he or she
feels that
his or her plan has failed to provide Medicare covered services, has
not
performed up to his or her expectations or has
failed to meet plan or HCFA requirements. There are three types of
procedures
available for
beneficiaries to use in resolving complaints. Each procedure covers
specific
types of complaints. It
is important to direct a complaint appropriately in order to get a
response as
soon as possible. The
procedures are:
1. The plan's internal
grievance
procedures.
2. The Peer Review
Organization
procedures.
3. The appeals
procedures.
Plan materials are required to explain all complaint procedures. These
materials
should include a
thorough explanation of the steps an enrollee should follow in
completing a
complaint procedure.
All managed care enrollees should receive a copy of this material from
the plan.
1. The Plan's Internal Grievance Procedures
Grievances to the plan may include:
+ questionable
enrollment
practices
+ long waiting periods
for
appointments
+ physician demeanor or
behavior
+ adequacy of
facilities
+ involuntary
disenrollment
issues
Beneficiaries may wish to share these
grievances with
HCFA Regional Office staff. This
information is useful in helping HCFA establish a pattern of behavior
by the
plan. The Regional
Office can also assist a beneficiary in resolving an issue through the
plan's
grievance process.
2. Peer Review Organizations (PROs)
Issues which may be referred to PROs
include:
+ quality of care
issues
+ early discharge from a
hospital
Under new regulations released November 21,
1994, an
enrollee can request an immediate PRO
review of an HMO/CMP's determination that an inpatient hospital stay is
no longer
necessary.
In this case, the beneficiary remains in the hospital and is not billed
for the
period of review which
is generally 24 hours.
3. Appeals Procedures
Appeals to the plan may include disputes
involving:
+ denial
of reimbursement for emergency or urgently needed services
+ denial
of reimbursement for other services which the beneficiary believes are
Medicare
covered and should have been furnished
+ denial
of requested services
The plan makes a written initial determination within 60 days once a
complaint is
submitted. If the
decision is not fully favorable for the beneficiary, he or she may
request a
reconsideration by the plan.
Plans must reconsider any initial determination if requested by the
enrollee.
If the plan upholds its initial determination, the plan must forward
the case to
the Network Design Group (NDG), a HCFA contractor, for reconsideration.
NDG
provides independent review activities
for HCFA. If NDG upholds the plan, the beneficiary can continue the
appeals
process by submitting
the complaint through the traditional Medicare program appeals
processes.
NDG also screens cases for potential quality of care issues and refers
these
cases to HCFA or the
appropriate PRO for follow up.
When necessary, complaints may be pursued on behalf of the beneficiary
by an
authorized
representative. Every Medicare beneficiary or his or her
representative should
be familiar with
appropriate appeals, complaints and grievance procedures and should use
these
when necessary. The
beneficiary may contact the nearest HCFA Regional Office for additional
assistance.
During 1993 and 1994, the highest number of cases appealed and
forwarded for
reconsideration involved:
o services provided by Non-plan
Practitioners
o services provided in Emergency
Rooms,
and
o services provided on an Inpatient
Hospital
basis. Of these cases:
Beneficiaries were almost twice as
likely as
managed care plans to be found responsible for costs associated with a
questionable use of Non-plan Practitioners.
Beneficiaries were nearly three times as
likely
as managed care plans to be found responsible for costs associated with
a
questionable use of Emergency Rooms.
Beneficiaries were less likely than
managed care
plans to be held responsible for costs associated with a questionable
use of
Inpatient Hospital services.
UPHELD FOR | UPHELD FOR |
PARTIALLY |
RETROACTIVELY |
|||||
---|---|---|---|---|---|---|---|---|
APPEALED CASE TYPE | PLAN | % | BENEFICIARY | % | UPHELD | % | DISENROLLED | % |
Non-plan Practitioner | 1028 | 28 | 570 | 27 | 93 | 24 | 238 | 43 |
Emergency Room | 999 | 27 | 373 | 18 | 23 | 6 | 21 | 4 |
Inpatient Hospital | 268 | 7 | 345 | 16 | 50 | 13 | 144 | 26 |
Nursing Home Care | 250 | 7 | 208 | 10 | 134 | 35 | 24 | 4 |
Clinic (Lab, X-ray) | 251 | 7 | 152 | 7 | 28 | 7 | 72 | 13 |
Ambulance | 266 | 7 | 139 | 7 | 5 | 1 | 2 | 0 |
DME/Medical Supplies | 322 | 9 | 138 | 7 | 16 | 4 | 13 | 2 |
Therapies | 79 | 2 | 53 | 3 | 14 | 4 | 7 | 1 |
Non-Medicare Benefit | 175 | 5 | 50 | 3 | 10 | 3 | 0 | 0 |
Home Health Care | 86 | 2 | 49 | 2 | 8 | 2 | 30 | 5 |
OPD Mental Health | 7 | 0 | 6 | 0 | 1 | 0 | 1 | 0 |
Hospice Care | 2 | 0 | 1 | 0 | 0 | 0 | 0 | 0 |
Total All Services | 3733 | 2084 | 382 | 552 |
Twelve percent of all reconsideration
case
decisions were partially favorable for the beneficiary.
Fourteen percent of all reconsideration
case
decisions resulted in the Medicare beneficiary being retroactively
disenrolled
from the plan.
What are the implications suggested by this data for Medicare
beneficiaries
enrolled in managed care plans?
1. Some beneficiaries may not belong in
managed care
plans. (See number of Medicare beneficiaries retroactively
disenrolled from
plans.)
2. Some beneficiaries may need a better
understanding of
what services are covered by managed care plans.
3. Some beneficiaries might not be contacting
the plan
early enough when out-of-network services are contemplated or
obtained.
4. Some beneficiaries may need to see
information in a
different format/style/size than is currently available from plans or
HCFA.
5. Some beneficiaries may not be receiving
sufficient
information from the practitioner about his/her condition to preclude
the use of
an inappropriate follow-up visit outside of the plan's network of
providers.
6. Some beneficiaries may need to consider the
purchase of
an Out-of-Network/Point-of-Service option.
7. Some beneficiaries are using services
appropriately and
are being improperly denied coverage/payment by otherwise responsible
plans.
The next section includes a sample of data from emergency room case
files in
instances where the
beneficiary has requested a reconsideration of an initial unfavorable
decision.
Our intent in providing
this data is to help interested individuals better understand which
areas are
most likely to cause
problems for managed care enrollees. It is our hope that beneficiaries
and those
who assist them will
familiarize themselves with plan coverage rules and restrictions
before
problems arise that might result in an appeal.
APPEALS/RECONSIDERATIONS FOR EMERGENCY CASES |
||
|
|
|
|
|
|
Chest pain | Beneficiary upheld | Beneficiary believed chest pain was a heart attack. |
Something stuck in throat | Plan upheld | Recurring problem and beneficiary had appt with plan on day of ER visit. |
Pain on right side and chest | Beneficiary upheld | Beneficiary fell and believed a rib was broken. |
Rash-allergic reaction ambulance for transportation | Plan upheld | Beneficiary experienced no shortness of breath, fever, chills, sore throat, earache, chest pain, nausea or vomiting. |
ER hospital bill for $500 | Plan upheld | New coverage material included notice about $500 annual deduction. Member acknowledged receipt of material. |
Knee pain | Plan upheld | Member fell in kitchen 5 days before ER visit. No evidence of distress or fracture. No evidence that condition deteriorated. |
Heel blisters Ambulance for transportation |
Plan upheld |
Services could have been provided by plan. |
Sickle cell crisis. Ten visits to non plan provider during 2 month period |
Dismissed | History of use of non plan services. Retroactive disenrollment by Regional Office of HCFA. |
Dizziness w/vomiting and headache | Beneficiary upheld | Member had elevated blood pressure, nausea, vomiting, & vertigo. |
Unable to sleep, choking sensation | Plan upheld | Dispute - member said plan physician authorized ER visit. Physician indicated instructions were to take benadryl and relax. Non emergency symptoms. |
Severe pain in left ankle. Possible fracture |
Beneficiary upheld | Previously injured ankle, hit with door. Plan failed to submit records to substantiate denial of emergency services. |
Swollen forehead and black eyes | Plan upheld | Member fell 6 days prior & received ER care. Member returned to ER for care of related symptoms which could have been provided by plan. |