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3 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Contnts LIST OF ACRONYMS... ii MESSAGE FROM THE MEDICARE BENEFICIARY OMBUDSMAN... iv MISSION, VISION, AND ORGANIZATION... vi EXECUTIVE SUMMARY... 1 Ky Accomplishmnts... 2 Aras for Improving Bnficiaris Exprincs with Mdicar... 3 CHANGING CHARACTERISTICS OF THE ELDERLY AND MEDICARE: IMPLICATIONS FOR THE OMO S MISSION... 5 Introduction... 6 Th Changing Charactristics of th Eldrly... 8 Implications for Mdicar and th Mission of th OMO HOW THE OMO MANAGES BENEFICIARY ISSUES AND COMPLAINTS Introduction Issus Managmnt Caswork Influncing Customr Srvic Partnrship Initiativs Comprhnsiv Studis Dvlopmnt Facilitation and Tracking of Rcommndations Implmntation Th Comptitiv Acquisition Ombudsman ISSUES AND RECOMMENDATIONS REGARDING BENEFICIARY CONCERNS Introduction Halth Savings Accounts and Informing Mdicar-Eligibl Individuals about Thir Covrag Choics Th Mdicar-Rlatd Information Nds of th Employr Community Information Nds of Nw Mdicar-Mdicaid Enrolls Othr Issus Addrssd by th OMO APPENDIX A: TRENDS IN MEDICARE BENEFICIARY CONTACTS... A-1 APPENDIX B: FY 2012 MEDICARE PARTS C AND D ONLINE COMPLAINT FORM DATA ANALYSIS...B-1 i

4 Offic of th Mdicar Ombudsman 2012 Rport to Congrss List of Acronyms Acronym CAO CBP CCIIO CFC CM CMS CO COB COBRA CSR CTM DMEPOS DMOA DoD DOE DORTA EGWP ESRD FFS FY GHP HDHP HHS HSA IRMAA IRS IVR MA MAC MAISTRO Trm Comptitiv Acquisition Ombudsman Comptitiv Bidding Program Cntr for Consumr Information and Insuranc Ovrsight Combind Fdral Campaign Cntr for Mdicar Cntrs for Mdicar & Mdicaid Srvics Cntral Offic Coordination of Bnfits Consolidatd Omnibus Budgt Rconciliation Act Customr Srvic Rprsntativ Complaint Tracking Modul Durabl Mdical Equipmnt, Prosthtics, Orthotics, and Supplis Division of Mdicar Ombudsman Assistanc Dat-of-dath/Dat-of-discharg Division of Ombudsman Excptions Division of Ombudsman Rsarch and Trnds Analysis Employr Group Waivr Plan End-Stag Rnal Disas F-for-Srvic Fiscal Yar Group Halth Plan High-Dductibl Halth Plan U.S. Dpartmnt of Halth & Human Srvics Halth Savings Account Incom-Rlatd Monthly Adjustmnt Amount Intrnal Rvnu Srvic Intractiv Voic Rspons Mdicar Advantag Mdicar Administrativ Contractor Mdicar Administrativ Issu Trackr and Rporting of Oprations (Systm) ii

5 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Acronym Trm MMA Mdicar Prscription Drug, Improvmnt, and Modrnization Act of 2003 MMCO Mdicar-Mdicaid Coordination Offic MSA Mdical Savings Account MSN Mdicar Summary Notic NF Nursing Facility NUBC National Uniform Billing Committ OA Offic of th Administrator OC Offic of Communications OFM Offic of Financial Managmnt OIS Offic of Information Srvics OMHA Offic of Mdicar Harings and Appals OMO Offic of th Mdicar Ombudsman QMB Qualifid Mdicar Bnficiary RDS Rtir Drug Subsidy RO Rgional Offic SEP Spcial Enrollmnt Priod SHIP Stat Halth Insuranc Assistanc Program SNF Skilld Nursing Facility SSA Social Scurity Administration SSDI Social Scurity Disability Insuranc SSI Supplmntal Scurity Insuranc iii

6 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Mssag from th Mdicar Bnficiary Ombudsman It is my plasur to prsnt th Offic of th Mdicar Ombudsman s (OMO s) 2012 annual rport to Congrss and to th Scrtary of th U.S. Dpartmnt of Halth & Human Srvics. This rport dscribs th OMO s 2012 activitis, systmic issus currntly affcting Mdicar bnficiaris, and th OMO s rcommndations for addrssing ths issus. Sinc th OMO s incption 8 yars ago, th typ of work it dos and its approach to fulfilling its mission hav volvd as th OMO draws on lssons larnd and adapts to th changing nds of Mdicar bnficiaris. For xampl, th compltion of comprhnsiv studis, which includ dtaild analyss of bnficiary issus and actionabl rcommndations, is now on of th OMO s cor activitis. Today, Mdicar bnficiaris hav accss to a varity of sourcs to answr thir qustions and addrss thir concrns. Som of ths sourcs hav sn a dclin in th numbr of inquiris, which suggsts that th quality of information providd and bnficiaris accss to this information may hav improvd. For xampl, th numbr of calls to MEDICARE was lowr in fiscal yar (FY) 2012 than in FY 2011, continuing th dclin that startd in FY In addition, th numbr of complaints rlatd to Part C and Part D, as capturd in Mdicar data systms, has dclind ach yar sinc FY Ths dclins in inquiris and complaints likly rflct svral factors. First, CMS has bcom a mor bnficiaryfocusd agncy that placs gratr mphasis on anticipating bnficiaris nds and concrns and on providing strong ovrsight of halth plans and othr contractd ntitis. Scond, th advocats and othr profssionals who intract dirctly with bnficiaris and work with th OMO hav improvd not only how thy communicat with bnficiaris but also how thy convy bnficiaris concrns to CMS staff, which hlps solv problms mor fficintly. Third, bnficiaris, thir family mmbrs, and thir cargivrs ar bttr abl to accss information bcaus of Wb-basd rsourcs. Fourth, CMS has improvd program oprations and ovrsight of th Part D program. Finally, th OMO continus to mak strids in improving th bnficiary xprinc with Mdicar as it lads th collaborativ procss of idntifying bnficiary issus, rsarching thm, and rcommnding solutions to CMS Ladrship. Ths positiv dvlopmnts hav nabld th OMO to incras its focus on idntifying th root causs of nw, complx issus; tracking ths issus; and, in many cass, guiding CMS componnts implmntation of th rcommndations mad by th OMO and prsntd in prior rports to Congrss. In addition to advocating for Mdicar bnficiaris in 2012, I had th opportunity to advocat on bhalf of many worthy nonprofit organizations as chairprson of th CMS Combind Fdral Campaign (CFC). Th CFC provids an opportunity for fdral mploys across th country to support thousands of organizations in thir local communitis, across th nation, and around th world. Th CMS Cntral Offic (CO) raisd $435,511 through th campaign in It iv

7 Offic of th Mdicar Ombudsman 2012 Rport to Congrss is indd a privilg to lad th ffort to showcas th spcial work of ths organizations as wll as th gnrosity of our fdral workforc. I am also privilgd to work with hundrds of talntd, hard-working individuals within th OMO and at its partnr organizations, including othr CMS CO componnts, Rgional Offics, Stat Halth Insuranc Assistanc Programs, and advocacy organizations. Evry day, ths ddicatd individuals ar activly ngagd in making Mdicar work bttr in ways big and small. On bhalf of th 50 million bnficiaris whos livs ar improvd through thir continual fforts, I thank thm. Danil J. Schrinr Mdicar Bnficiary Ombudsman v

8 Th Offic of th Mdicar Ombudsman provids dirct assistanc to bnficiaris with thir inquiris, complaints, grivancs, and appals. Mission, Vision, and Organization MISSION Th Offic of th Mdicar Ombudsman (OMO) provids dirct assistanc to bnficiaris with thir inquiris, complaints, grivancs, and appals. Th OMO srvs as a voic for bnficiaris by valuating policis and procdurs, idntifying systmic issus, making rcommndations to Congrss and th Scrtary of th U.S. Dpartmnt of Halth & Human Srvics, and working with partnrs to implmnt improvmnts to Mdicar. VISION Th OMO nsurs that Mdicar bnficiaris hav accss to th halth car and covrag to which thy ar ntitld. Whn issus aris, information and assistanc ar availabl for timly and appropriat rsolution. ORGANIZATION Th OMO is locatd within th Cntrs for Mdicar & Mdicaid Srvics (CMS) Offic of Public Engagmnt and has dirct accss to th CMS Administrator to rais bnficiary issus and concrns. To handl its rang of activitis, th OMO is organizd into thr divisions: th Division of Ombudsman Excptions (DOE), th Division of Mdicar Ombudsman Assistanc (DMOA), and th Division of Ombudsman Rsarch and Trnds Analysis. Both DOE and DMOA dirctly assist bnficiaris through caswork. Th Comptitiv Acquisition Ombudsman, also within th OMO, rsponds to inquiris and complaints from individuals and supplirs of durabl mdical quipmnt, prosthtics, orthotics, and supplis (DMEPOS) rlating to th application of th Mdicar DMEPOS Comptitiv Bidding Program. Th activitis of ach of th OMO s divisions ar discussd in mor dtail in this rport. vi

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10 Th bnficiary xprinc is volving, and th Offic of th Mdicar Ombudsman, as th primary advocat for Mdicar bnficiaris, is rsarching a varity of nw and improvd mchanisms to srv bnficiaris nds bttr. Excutiv Summary Mdicar srvs mor than 50 million bnficiaris through a varity of covrag options, including traditional Mdicar, Mdicar-contractd halth plans, and prscription drug plans. Th faturs of ths programs and plans and th information providd about thm to bnficiaris must volv as bnficiaris nds volv. Th Mdicar population has rcntly undrgon significant changs: th aging of th baby boomr gnration has ld to an incras in th numbr of bnficiaris who hav divrgnt dmographic profils bcaus of changing socioconomic factors. Today, many adults ar continuing to work byond ag 65 and may choos to continu rciving mployr-basd halth insuranc bnfits whil also nrolling in Mdicar. Participating in multipl programs rquirs bnficiaris to considr thir availabl options carfully so that thy can maximiz thir bnfits and avoid pnaltis. Additionally, an incrasing numbr of oldr Amricans ar bcoming ligibl for both Mdicar and Mdicaid, a halth bnfit program administrd undr a fdral-stat partnrship for low-incom prsons who mt crtain critria. Bcoming ligibl for both programs can crat complx issus for bnficiaris as th programs oftn offr diffrnt bnfits and srvics that may not b wll coordinatd. Thus, th bnficiary xprinc is volving, and th Offic of th Mdicar Ombudsman (OMO), as th primary advocat for Mdicar bnficiaris, is rsarching a varity of nw and improvd mchanisms to bttr srv bnficiaris nds. In doing so, th OMO has usd its position and rlationships, both within and outsid th Cntrs for Mdicar & Mdicaid Srvics (CMS), to protct th bst intrsts of Mdicar bnficiaris. This rport dscribs th OMO s fiscal yar (FY) 2012 activitis and informs Congrss and th Scrtary of th U.S. Dpartmnt of Halth & Human Srvics (HHS) of th OMO s fforts and its rcommndations for improving bnficiaris xprincs with Mdicar. 1

11 Offic of th Mdicar Ombudsman 2012 Rport to Congrss KEY ACCOMPLISHMENTS Th ky accomplishmnts of th OMO in 2012 ar highlightd in figur 1 and includ th following: Dirct srvic to bnficiaris: Th OMO s total caswork volum for FY 2012 was 26,400 cass. Of ths, th OMO providd dirct assistanc with mor than 13,500 contacts from bnficiaris, thir cargivrs, advocats, and congrssional offics. Th rmaining cass wr handld by CMS Rgional Offics (ROs). Caswork rspons tim: On avrag, th Division of th Mdicar Ombudsman Assistanc (DMOA) rspondd to 99.5 prcnt of inquiris within 30 businss days in This rspons rat marks a 6.5 prcnt incras abov th 2010 rat of 93 prcnt. National Caswork Calls and casworkr training: In January 2012, th OMO conductd a national casworkr training nds assssmnt survy to dvlop a robust training program rlatd to topics idntifid by RO and Cntral Offic (CO) casworkrs. Th OMO conductd 10 training sssions in FY 2012 via National Caswork Calls, classroom sssions, and wbinars, covring a varity of topics that rflctd th nds of casworkrs, as xprssd in th survy. Comprhnsiv studis: Continuing its fforts to conduct in-dpth rsarch on complx issus affcting Mdicar bnficiaris, th OMO compltd thr comprhnsiv studis in 2012 and bgan working with CMS componnts to mak changs basd on th findings from ths studis. FIGURE 1. MAJOR ACCOMPLISHMENTS IN FY

12 Offic of th Mdicar Ombudsman 2012 Rport to Congrss AREAS FOR IMPROVING BENEFICIARIES EXPERIENCES WITH MEDICARE In this 2012 Rport to Congrss, th OMO dtails thr comprhnsiv studis, dscribd blow, that rsultd in spcific rcommndations to CMS for improving Mdicar. HEALTH SAVINGS ACCOUNTS AND IMPLICATIONS FOR MEDICARE ENROLLMENT Halth Savings Accounts (HSAs), stablishd by th Mdicar Prscription Drug, Improvmnt, and Modrnization Act of 2003, ar accounts that individuals can us to pay for qualifid mdical xpnss, such as insuranc dductibls, copaymnts, or srvics not covrd by insuranc. To b ligibl to contribut tax-fr incom to an HSA, an individual must b nrolld in a high-dductibl halth plan (HDHP) and not b nrolld in Mdicar. Individuals who bcom ligibl for Mdicar du to ag and who rciv halth covrag undr an HSA HDHP bcaus thy ar activ workrs or spouss of activ workrs may fac complicatd dcisions. For xampl, if thy do not qualify for th low-incom subsidy and do not nroll in Part D prscription drug covrag whn thy first bcom ligibl for Mdicar but thn latr dcid to nroll, thy may incur a lat nrollmnt pnalty for as long as thy ar nrolld in th Mdicar drug plan. Th pnalty would apply unlss two rquirmnts ar mt: (1) thy had bn covrd undr a plan offring crditabl prscription drug covrag covrag that is at last as good as th standard Part D covrag, and (2) thy did not hav a brak in such covrag for 63 days or mor. Howvr, high dductibl plans ar at gratr risk of not mting th crditabl covrag rquirmnt. Th comprhnsiv study found that, although th lgislation govrning HSAs HDHPs and thir intraction with Mdicar is gnrally clar, activ w o rk rs d o no t fully undrstand th ff c t o f th at in t ra c tio n o n th ir n rol l m nt d c is ion s. Th crditabl cov ra g r q ui r m n t is a sourc of p a r tic u l a r con fu s ion, a s th ma in i n fo rma tio n al r s ou r c s o n H S A s a v a il a b l to b n fic iar is do not addrss this topic. Th c o mp rhnsiv study idntifid sv r al r c ommndation s, s u mma r iz d b lo w, f or imp r ov in g th i n fo r ma tio n al r sou r c s f or a c tiv workrs and f o r n s urin g that activ workrs ar mad awar of th nw rsourcs: Dvlop a nw HSA fact sht with input from th Intrnal Rvnu Srvic (IRS) and rfrnc it in othr information sourcs to aid bnficiaris in undrstanding th nuancs of thir nrollmnt dcisions, including th crditabl covrag rquirmnt for Part D. Train customr srvic rprsntativs (CSRs) at CMS, rqust that th IRS and th Social Scurity Administration train thir CSRs to promot th nw HSA fact sht, and ducat thm on th importanc of th crditabl covrag rquirmnt. Coordinat with th IRS to includ Mdicarrlvant information in th IRS s HSA-rlatd publication (969) and Wb pag. Provid information on HSAs HDHPs in rsourcs about nrollmnt dcisions to mployrs. MEDICARE INFORMATION NEEDS OF THE EMPLOYER COMMUNITY Employrs ar bcoming an incrasingly important information rsourc for individuals who ar ligibl for or alrady nrolld in Mdicar. Ths Mdicarligibl mploys and rtirs may hav qustions on such topics as ligibility, covrag options, prmium paymnts, and coordination of bnfits. Howvr, prvious OMO studis suggstd that Mdicar-rlatd rsourcs availabl to mployrs may b difficult to locat or incomplt. Additionally, mployrs thmslvs may not b awar of thir own rsponsibilitis rlating to businss intractions with Mdicar, such as rporting rlatd to coordination of 3

13 Offic of th Mdicar Ombudsman 2012 Rport to Congrss bnfits. Th comprhnsiv study found that, although many informational sourcs ar availabl to mployrs, no singl sit consolidats th rlvant rsourcs. Anothr finding was that mployrs rquir mor rsourcs and information about four major aras: Mdicar nrollmnt, coordination of bnfits, mployr-providd Mdicar-rlatd covrag (.g., mployr group waivr plans), and account-basd halth arrangmnts (.g., HSAs). In addition, mployrs ar lss familiar with th considrations associatd with popl who bcom ligibl for Mdicar bcaus thy hav disabilitis or nd-stag rnal disas than thy ar with th considrations associatd with aging into Mdicar. Th following spcific rcommndations ar includd in th study: Dvlop an Employr Community Portal on th CMS or Mdicar Wb sit. Dvlop nw informational rsourcs and augmnt currnt sourcs to fill information gaps. Us multipl mthods for raching out to mployrs and making thm awar of ths rsourcs. INFORMATION NEEDS FOR NEW MEDICARE-MEDICAID ENROLLEES Individuals who ar alrady nrolld in Mdicar and thn bcom ligibl for Mdicaid or vic vrsa oftn nd assistanc with undrstanding th ligibility rquirmnts and srvics associatd with ach program. In 2012, th OMO and th Mdicar-Mdicaid Coordination Offic workd collaborativly to study how to improv information that is mad availabl to nw Mdicar-Mdicaid nrolls. Th comprhnsiv study highlights th fact that th pathways that lad individuals to Mdicar-Mdicaid nrollmnt, th individuals charactristics, and th lvl of stat Mdicaid involvmnt combin to crat a complx situation for ths nrolls. Bcaus of this high lvl of complxity, svral information stratgis and mchanisms that ar customizd to th spcific charactristics of ths bnficiaris ar ndd. Th study provids rcommndations for assisting nrolls, profssionals who work with ths nrolls, and program administrators. For nw Mdicar-Mdicaid nrolls: Crat a sris of brif, targtd informational Wlcom Kits basd on th bnficiary s ligibility catgory and bnfits. Crat on-pagrs focusd on spcific topics rlvant to Mdicar-Mdicaid nrolls. Dvlop a Wb pag within Mdicar.gov dvotd to ths nrolls. For profssionals who assist ths nrolls: Dvlop a qury procss that halth profssionals and providrs can us to obtain information on whthr a Mdicar bnficiary is also ligibl for Mdicaid. Dvlop informational rsourcs, such as fact shts, to ducat thm about th intraction of Mdicar and Mdicaid bnfits/covrag. Dvlop tchnical assistanc prsntations that can b usd by profssionals in group sttings with Mdicar-Mdicaid nrolls. For program administrators: Assss th fasibility of dvloping Mdicar Summary Notics tailord to th information nds of Mdicar-Mdicaid nrolls who ar ligibl to hav thir Mdicar cost-sharing liability covrd by Mdicaid. Provid timly initiation of Mdicaid buy-in for Mdicar Part B prmiums and assss th fasibility of giving advanc notic to Mdicaid agncis rgarding currnt disabld Mdicaid bnficiaris rciving Supplmntal Scurity Incom and Social Scurity Disability Insuranc who ar nar th nd of thir 24-month waiting priod for Mdicar ligibility. 4

14 Svnty-six million baby boomrs ar poisd to chang th way oldr Amricans liv, much in th sam way that thy rdfind socital norms as thy cam of ag in th lat 1960s and 1970s. Changing Charactristics of th Eldrly and Mdicar: Implications for th OMO s Mission SECTION HIGHLIGHTS Th Mdicar bnficiary population is xpctd to grow rapidly in th nxt 20 yars as th baby boomr gnration ags. Compard to prvious gnrations of nw nrolls, today s nw Mdicar bnficiaris ar mor likly to nroll in Mdicar whil also rciving primary halth car bnfits through an mployr or othr privat or public sourcs. Enhancing communication with individuals approaching Mdicar ligibility will hlp smooth bnficiaris transitions into Mdicar and btwn Mdicar and othr programs. 5

15 Offic of th Mdicar Ombudsman 2012 Rport to Congrss INTRODUCTION Th Mdicar population incrasd by narly two million nrolls btwn 2011 and 2012, and is xpctd to continu to grow rapidly in th nxt 2 dcads, primarily bcaus of th aging baby boomr gnration. 1 Svnty-six million baby boomrs ar poisd to chang th way oldr Amricans liv, much in th sam way that thy rdfind socital norms as thy cam of ag in th lat 1960s and 1970s. 2 Compard to thir parnts and grandparnts, baby boomrs ar mor highly ducatd, likly to hav dualincom housholds, and lad activ lifstyls. 3 Howvr, thy ar also lss halthy than thir parnts. In a rcnt study using data from a national halth survy, rsarchrs compard halth status indicators of baby boomrs to thos of th prvious gnration at th sam ag and found that baby boomrs hav highr rats of hyprtnsion, hyprcholstrolmia, diabts, and obsity than th prvious gnration. 4 savings during th stock markt dclins of th past dcad and ar working longr to stabiliz thir financial futurs. Othrs may hav had childrn latr in lif and ar still supporting thm. Som may b working longr du to th incras in th Social Scurity ligibility ag, whil othrs may choos to work longr bcaus thy njoy doing so. Whatvr th rason, oldr working Amricans may choos to continu rciving som mployr-basd halth insuranc bnfits whil nrolld in Mdicar, a choic that rquirs bnficiaris to considr th availabl options carfully to nsur that thy maximiz thir bnfits and avoid pnaltis. Boomrs startd nrolling in Mdicar in 2011, whn th oldst of th gnration turnd 65. By 2040, narly 80 million boomrs will qualify for Mdicar, compard to today s total nrollmnt of 50.7 million. 5 Figur 2 illustrats th incras in Mdicar nrolls. Along with th xpctd incras in Mdicar nrollmnt attributabl to th baby boomrs, conomic conditions and social factors will continu to affct Mdicar nrollmnt in th coming yars. Many adults ar continuing to work byond ag 65 for a varity of rasons. Som of thm lost a portion of thir rtirmnt 1 Baby boomrs ar dfind as thos who wr born btwn 1946 and Dohm, A. (2000, July). Gauging th Labor Forc Effcts of Rtiring Baby-Boomrs. Monthly Labor Rviw: Grnblatt, A. (2007, Octobr 17). Aging Baby Boomrs: Will th Youth Gnration Rdfin Old Ag? CQ Rsarchr, 17: Ibid. 4 King, D.E., Mathson, E., Chirina, S., Shankar, A., and Broman-Fulks, J. (2013). Th Status of Baby Boomrs' Halth in th Unitd Stats: Th Halthist Gnration? JAMA Intrn Md: 173(5): U.S. Dpartmnt of Halth and Human Srvics Cntrs for Mdicar & Mdicaid Srvics Offic of Information Products and Data Analysis. (2012, Jun). CMS Pub. No Mdicar nrollmnt may also b affctd by an incrasing numbr of nrolls who bcom ligibl for both Mdicar and Mdicaid. As Mdicaid nrolls ntr Mdicar or as Mdicar bnficiaris ntr Mdicaid, thy will nd to navigat two complx programs and undrstand thir diffring bnfits. With limitd financial rsourcs and oftn with significant halth issus, ths nrolls may struggl to navigat th complxitis of bing nw Mdicar-Mdicaid nrolls. In 2012, th Offic of th Mdicar Ombudsman (OMO) undrtook thr comprhnsiv studis focusd on th issus and nds of Mdicar bnficiaris, with a particular focus on transition priods rlatd to bcoming ligibl for Mdicar and intractions of Mdicar with othr typs of covrag. 6

16 Offic of th Mdicar Ombudsman 2012 Rport to Congrss FIGURE 2. CURRENT AND PROJECTED NUMBER OF MEDICARE ENROLLEES, BY PART Summarizd latr in this sction and dscribd in mor dtail in th Issus and Rcommndations Rgarding Bnficiary Concrns sction of this rport, ths studis includ a focus on th dcisions that oldr working Amricans fac as thy nroll in Mdicar and th information nds of individuals nrolld in both Mdicar and Mdicaid, providing spcific rcommndations to smooth ths transitions. To provid a contxt for th OMO s work, this sction dscribs th Mdicar covrag options availabl to bnficiaris today. Following th covrag dscriptions is a dpiction of th changing dmographic profil of th Mdicar bnficiary population, a summary of th findings of th thr comprhnsiv studis, and a discussion of th implications of that changing profil for Mdicar. MEDICARE COVERAGE OPTIONS As th nation s largst, fully fundd halth bnfits program srving approximatly 50.7 million bnficiaris, Mdicar plays a vital rol in providing halth car srvics not only to individuals who ar 65 yars and oldr but also to individuals who ar undr ag 65 and hav disabilitis or nd-stag rnal disas. Mdicar offrs multipl covrag options to mt th varid nds of its bnficiaris. Most popl ags 65 or oldr ar ligibl for Part A for hospital insuranc and may choos to nroll in Part B for mdical insuranc or Part C (Mdicar Advantag [MA] Plans) for both hospital and mdical insuranc. Sinc 2006, bnficiaris hav also had th option of rciving prscription drug covrag through Part D, ithr 7

17 Offic of th Mdicar Ombudsman 2012 Rport to Congrss through a privat Prscription Drug Plan or through an MA Plan that includs prscription drug covrag. Parts C and D covrag ar providd through privat insuranc companis that contract with Mdicar. Currntly, th bulk of Mdicar bnficiaris ar nrolld in traditional Mdicar (Parts A and B), whil Part C (MA Plans) accounts for about 26 prcnt of th Mdicar population, or 13.5 million bnficiaris. 6 Enrollmnt in Part C has incrasd substantially in rcnt yars but is xpctd to dclin aftr 2013, both in numbr and as a prcntag of total bnficiaris. 7 If th availability of Part C plans bcoms mor limitd in 2014, bnficiaris currntly nrolld in a Part C plan may hav to switch to a diffrnt Part C plan or to traditional Mdicar. Th OMO will monitor ths changs and th inquiris that might rsult from thm to hlp bnficiaris through this transition. THE CHANGING CHARACTERISTICS OF THE ELDERLY Th 2010 Cnsus showd that th numbr of sniors popl ags 65 and oldr has grown not only in siz but also as a shar of th total U.S. population. In 2010, oldr Amricans rprsntd 13 prcnt of th U.S. population, compard to 12.4 prcnt in By 2050, th numbr of oldr Amricans is projctd to b doubl that of 2010, incrasing to 88.5 million and rprsnting 20.2 prcnt of th U.S. population Annual Rport of th Boards of Trusts of th Fdral Hospital Insuranc and Fdral Supplmntary Mdical Insuranc Trust Funds. (2012, April). Rtrivd Octobr 10, 2012, from 7 Ibid. 8 Th Oldr Population: Cnsus Brifs. (2011, Novmbr). U.S. Cnsus Burau. Rtrivd Octobr 10, 2012, from 9 Vincnt, G. K. and Vlkoff, V. A. (2010). THE NEXT FOUR DECADES, th Oldr Population in th Unitd Stats: 2010 to Currnt Population Rports, P , U.S. Cnsus Burau, Washington, DC. Rtrivd Octobr 12, 2012, from Incrasingly, oldr Amricans ar staying in th workforc longr. For thos 65 and oldr, th labor forc participation rat is projctd to almost doubl, from 11.8 prcnt in 1990 to 22.6 by 2020, as shown in figur Many socioconomic factors, dscribd abov, ar driving oldr Amricans dcisions to continu working byond th traditional rtirmnt ag. Incrasingly, oldr Amricans ar staying in th workforc longr. EMPLOYER-BASED HEALTH BENEFITS Oldr Amricans who ar still working must dcid whthr to continu rciving covrag through thir mployrs, to nroll in Mdicar, or to us som combination of privat halth car and Mdicar to mt thir nds. Halth Savings Accounts (HSAs) hav bcom a particularly popular componnt of privat halth insuranc policis. To b ligibl to contribut tax-fr incom to an HSA, an individual must b nrolld in a high-dductibl halth plan (HDHP) and not b nrolld in Mdicar. In January 2012, nrollmnt in HSAs incrasd to 13.5 million, th highst lvl sinc HSAs wr introducd in Th OMO compltd two comprhnsiv studis in 2012 that addrss th complxitis of th diffrnt covrag options availabl to oldr working Amricans and rtirs and provid rcommndations for hlping nw bnficiaris mak sound dcisions. 10 Employmnt projctions for civilian labor forc. Burau of Labor Statistics. Rtrivd Octobr 12, 2012, from 11 January 2012 Cnsus Shows 13.5 Million Popl Covrd by Halth Savings Account/High-Dductibl Halth Plans (HSA/HDHPs). (2012, May). Amrica s Halth Insuranc Plans, Cntr for Policy and Rsarch. Rtrivd Octobr 12, 2012, from 8

18 Offic of th Mdicar Ombudsman 2012 Rport to Congrss FIGURE 3. LABOR FORCE PARTICIPATION, BY AGE GROUP Th topic of th first study is th rlationship btwn HSAs and th dcision to nroll in Mdicar. For individuals who ar activ workrs or spouss of activ workrs, th dcision to nroll in Mdicar or rciv halth covrag undr an HSA HDHP is mor complicatd than dcisions rlatd to traditional mployr-basd insuranc covrag. Enrolls must considr many factors, such as th ffct on tax burdns, crditabl covrag rquirmnts, and lat nrollmnt pnaltis, bcaus a prson cannot b nrolld in Mdicar whil continuing to contribut to an HSA. Th OMO xamind th ffct of HSAs on Mdicar nrollmnt dcisions for Part A, Part B, and Part D covrag and dvlopd rcommndations for ducating nwly ligibl bnficiaris about th implications of thir dcisions. In th scond study, th OMO invstigatd ways in which mployrs can assist thir activ mploys and rtirs in dtrmining how and whn to nroll in Mdicar. Th study assssd Mdicar-rlatd rsourcs that ar currntly availabl to mployrs and th informational nds of th mployr community. It provids rcommndations for how CMS can nsur that mployrs ar awar of currnt and forthcoming rsourcs availabl to thm, thir mploys, and thir rtirs. MEDICARE-MEDICAID ENROLLEES Rprsnting prcnt of all Mdicar bnficiaris, about 10.2 million individuals rciv bnfits from both Mdicar and Mdicaid. 12 Givn thir halth 12 Data Analysis Brif: Mdicar-Mdicaid Dual Enrollmnt from 2006 through 2011 (2013, Fbruary). CMS Mdicar-Mdicaid 9

19 Offic of th Mdicar Ombudsman 2012 Rport to Congrss challngs and th complxitis of navigating two ntitlmnt programs that ar not intgratd, Mdicar-Mdicaid nrolls fac uniqu challngs in accssing th halth car thy nd. Navigating informational rsourcs and undrstanding th options offrd by Mdicar (a fdrally administratd program) and Mdicaid (a fdral-stat program) may com with a host of challngs, particularly for individuals with limitd cognitiv and physical functioning. Th CMS Mdicar-Mdicaid Coordination Offic (MMCO), cratd by th Affordabl Car Act, xists to nsur that Mdicar-Mdicaid nrolls hav full accss to samlss, high-quality halth car and to mak th systm as cost-ffctiv as possibl. Th MMCO works with Mdicaid and Mdicar across fdral agncis, stats, and stakholdrs to align and coordinat bnfits btwn th two programs ffctivly and fficintly. Thir halth issus ar oftn svr and complx, as thy may hav multipl chronic conditions accompanid by physical/cognitiv disabilitis and/or mntal halth issus. Ths individuals oftn bcom ligibl for both programs aftr having ndurd significant halth-rlatd pisods or changs in thir functional or cognitiv status, which rsultd in thir nding long-trm-car supports and srvics. Mdicar-Mdicaid nrolls ar mor likly to hav a Mdicar-qualifying disability: about 41.3 prcnt of Mdicar-Mdicaid nrolls hav a disability, whil about 12 prcnt of Mdicar-only bnficiaris hav a disability. 13 Although many ar 65 or oldr, approximatly 39 prcnt of Mdicar-Mdicaid bnficiaris ar undr ag 65 and disabld, which is thr tims th rat among all othr Mdicar bnficiaris. 14 Coordination Offic. Rtrivd March 21, 2013, from and-mdicaid-coordination/mdicar-mdicaid-coordination- Offic/Downloads/Dual_Enrollmnt_ _Final_Documnt.pdf. 13 Ibid. 14 Jacobson, G., Numan, T., and Damico, A. (2012). Issu Brif: Mdicar s Rol for Dual Eligibl Bnficiaris (Rport No ). Th OMO collaboratd with MMCO on a comprhnsiv study to idntify ky changs and challngs xprincd by individuals nwly nrolld in both programs, to assss rsourcs availabl to thm, and to rcommnd improvmnts rgarding informational rsourcs that can assist individuals as thy transition to nrollmnt in both programs. Th improvmnts rcommndd in th study focus on informational rsourcs for nrolls, thir familis, and program profssionals who intract with bnficiaris. Th study also rcommnds that program administrators assss th fasibility of dvloping procsss that would draw on information from CMS systms rgarding Mdicar and Mdicaid nrollmnt. IMPLICATIONS FOR MEDICARE AND THE MISSION OF THE OMO Th larg influx of nrolls into Mdicar ovr th nxt 2 dcads will likly affct CMS and th various othr ntitis that assist in administring Mdicar in two major ways. First, th larg numbr of nw bnficiaris will likly rsult in a highr volum of inquiris to th Mdicar call cntr and to th many othr ntitis that intract dirctly with bnficiaris. Kaisr Family Foundation. Rtrivd Dcmbr 12, 2012, from 10

20 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Ths ntitis will nd to b adquatly staffd with wll-traind rprsntativs to handl th largr numbr of inquiris mad by mor informd bnficiaris. Scond, nw nrolls ar likly to b in th workforc and, as a rsult, will hav othr (privat and public) sourcs of halth car that thy will continu to accss vn aftr nrolling in Mdicar. Program profssionals who intract dirctly with bnficiaris will nd to b quippd with th knowldg and informational rsourcs ncssary to ducat bnficiaris about th bnfits to which thy ar ntitld. Having highly traind program profssionals and appropriat ducational matrials will hlp nrolls rciv samlss, high-quality car and avoid pnaltis for not having nrolld in Mdicar at th right tim. As th Affordabl Car Act is fully implmntd, changs to xisting car dlivry options and th full implmntation of nw modls of car dlivry may crat a nd for nw or improvd ducational matrials for both bnficiaris and th profssionals who intract with thm. For xampl, th Mdicar halth and drug plans offrd may chang ach yar. This may rsult in qustions and concrns from bnficiaris rgarding nrollmnt options. Similarly, th growing numbr of Accountabl Car Organizations groups of halth car providrs who provid coordinatd car to patints to improv quality of car may rais qustions for bnficiaris unfamiliar with this halth car dlivry option. 11

21 Th OMO carris out its mission by providing dirct assistanc to bnficiaris with thir inquiris, grivancs, and complaints. How th OMO Manags Bnficiary Issus and Complaints SECTION HIGHLIGHTS Th Offic of th Mdicar Ombudsman (OMO) participats in svral cor activitis to manag and rspond to bnficiary inquiris and complaints as wll as to proactivly idntify bnficiary issus and solutions. In 2012, th OMO: Rlasd thr comprhnsiv studis on th following topics: th rlationship btwn Halth Savings Accounts and th Mdicar nrollmnt dcision, mployrs' Mdicar-rlatd information nds, and th informational nds of bnficiaris nwly ligibl for both Mdicar and Mdicaid. Bgan tracking all rcommndations it mad to th Cntrs for Mdicar & Mdicaid Srvics ovr its tnur and guiding agncy componnts in implmnting thos rcommndations dtrmind to b fasibl. Gaind fficincis in its cor functions, which has allowd for an xpansion of activitis, such as rcommndations implmntation tracking. Strngthnd its partnrship with th Offic of Mdicar Harings and Appals to hlp idntify mrging systmic issus facing Mdicar. 12

22 Offic of th Mdicar Ombudsman 2012 Rport to Congrss INTRODUCTION Th Offic of th Mdicar Ombudsman (OMO) carris out its mission in part by providing dirct assistanc to bnficiaris with thir inquiris, grivancs, and complaints. Through collaboration with othr Cntrs for Mdicar & Mdicaid Srvics (CMS) componnts, advocacy groups, and subjct-mattr xprts, th OMO is abl to idntify and addrss systmic issus that affct Mdicar bnficiaris. To nhanc its ability to carry out its mission, th OMO has stablishd a st of cor activitis, dscribd in figur 4. Th OMO will build on ths fforts during 2013, as it continually looks for ways to improv th ovrall bnficiary xprinc with Mdicar. Th following subsctions provid a mor dtaild ovrviw and spcific xampls of how th OMO assistd bnficiaris and thir cargivrs in Updats ar also providd on th work of th Offic of th Comptitiv Acquisition Ombudsman, which is locatd within th OMO. ISSUES MANAGEMENT nws publications, advocacy groups, and Mdicarncssary, solicits fdback from CMS subjct-mattr rlatd blogs and Wb sits. Th OMO also analyzs data from CMS inquiry and complaint tracking systms to idntify trnds that might indicat systmic problms across th diffrnt parts of Mdicar. Monthly Issus Managmnt mtings giv OMO ladrship and analysts th opportunity to discuss nwly idntifid concrns and to dvlop ffctiv stratgis for addrssing thm. For ach issu, th lad analyst prforms a root-caus analysis and, whn xprts. FIGURE 4. CORE ACTIVITY SUMMARY Th OMO uss its Issus Managmnt procss to valuat and addrss bnficiary issus that hav bn raisd by its xtrnal partnrs or intrnally through th xamination of inquiris and complaint (caswork) trnds. Th procss involvs: Prforming issus validation and tracking. Compiling rsarch on bnficiary issus. Facilitating intrnal Issus Managmnt mtings. Dvloping Quartrly Issus Rports. Issuing Bnficiary Contact Trnd Rports, which summariz bnficiary inquiris, complaints, and appals data from svral CMS sourcs (s Appndix A). To idntify bnficiary issus, th OMO mploys q u a l ita tiv m thods, s u c h as in v sti ga tin g is su s raisd b y b n f ic iar y ad voc at s, as w ll as q u an ti tat iv mthods, such as CMS data systm analysis. For xampl, th OMO conducts nvironmntal scans of 13

23 Offic of th Mdicar Ombudsman 2012 Rport to Congrss ESTABLISHING THE OFFICE OF THE MEDICARE OMBUDSMAN Sction 1808(c) of th Social Scurity Act, which was addd by sction 923 of th Mdicar Prscription Drug, Improvmnt, and Modrnization Act of 2003 (MMA), rquirs th Scrtary of th U.S. Dpartmnt of Halth & Human Srvics (HHS) to appoint a Mdicar Bnficiary Ombudsman. In stablishing th position and primary functions of th Mdicar Bnficiary Ombudsman, Congrss rcognizd th nd for an ntity that would srv as a rsourc for Mdicar bnficiaris. In March 2005, th Cntrs for Mdicar & Mdicaid Srvics appointd Danil J. Schrinr as th first Mdicar Bnficiary Ombudsman, giving him th rsponsibility of stablishing th Offic of th Mdicar Ombudsman (OMO) and fulfilling th provisions of sction 1808(c). Sction 1808(c) rquirs th OMO to assist Mdicar bnficiaris with thir complaints, grivancs, and rqusts for information as wll as with problms arising from disnrollmnt from Mdicar Advantag (MA) Plans. Th OMO is rquird to provid assistanc with th collction of rlvant information for appaling dcisions mad by a fiscal intrmdiary, carrirs, MA Plans, and th HHS Scrtary; its assistanc is also ncssary for prsnting information to bnficiaris concrning incom-rlatd prmium adjustmnts. Although th MMA allows th OMO to idntify issus and problms rlatd to paymnt or covrag policis, th law prohibits th OMO from srving as an advocat for any incras in paymnts or nw covrag of srvics. Th OMO must also work with halth insuranc counsling programs (.g., Stat Halth Insuranc Assistanc Programs), to th xtnt possibl, to hlp provid information to bnficiaris rgarding traditional Mdicar (i.., Parts A and B) and any changs to MA Plans. Lastly, th MMA rquirs th OMO to submit annual rports to Congrss and to th HHS Scrtary that dscrib its activitis and provid rcommndations for improving th administration of Mdicar. As th rsolution procss continus, implmntation stps (.g., dvloping nw ducational matrials or rvising th sarch function on Mdicar.gov) ar idntifid and rportd during Issus Managmnt mtings. Th issus that ntr th Issus Managmnt procss ar cntrally trackd and documntd, nabling a comprhnsiv viw of th ntir ffort for ach issu. Th information is usd to dvlop Quartrly Issus Rports, intrnal CMS documnts that highlight data and trnds, and provid a synopsis of th issus and of th OMO s actions and rcommndations to CMS for ach issu. Th rports ar prsntd to CMS Ladrship, including th Offic of th Administrator, and othr stakholdrs. CASEWORK Som bnficiaris nd hlp both obtaining and undrstanding information about th bnfits and srvics to which thy ar ntitld. OMO casworkrs provid dirct assistanc to bnficiaris on an individual basis by triaging and rsponding to inquiris and complaints in writing, via -mail, and ovr th phon. Th OMO s Division of Mdicar Ombudsman Assistanc (DMOA) and Division of Ombudsman Excptions (DOE) shar rsponsibility for handling a larg portion of inquiris and complaints rcivd through th CMS Cntral Offic (CO). In fiscal yar (FY) 2012, 99.5 prcnt of th inquiris snt to OMO staff wr handld in fwr than 30 days (th OMO s rspons tim rquirmnt), with an avrag rspons tim of 11 days. DMOA CASEWORK DMOA rcivd 26,400 inquiris in FY 2012, a dclin of two prcnt from FY Caswork staff dirctly rspondd to 13,515 inquiris from Octobr 2011 through Sptmbr 2012, a dclin of 11 prcnt from FY Th rmaining 12,885 cass wr rfrrd to th Rgional Offics (ROs). Figur 5 illustrats th volum of caswork compltd by DMOA and th numbr of cass rfrrd to th ROs. 14

24 Offic of th Mdicar Ombudsman 2012 Rport to Congrss FIGURE 5. DMOA/RO CASEWORK VOLUME, FY Figur 6 compars th top rasons for bnficiary contacts to DMOA in 2011 and In 2012, th top 10 rasons rmaind largly th sam as in Th highst numbr of contacts continud to b rlatd to prmiums, but svral catgoris xprincd dclins in th numbr of contacts. Contacts rlatd to coordination of bnfits xprincd th largst dcras, with 42 prcnt fwr inquiris in 2012 than Contacts rlatd to th low-incom subsidy program dcrasd by 15 prcnt. Ths dcrass could b partially du to improvmnts in bnficiary information, outrach, and ducation. In an ffort to mak information clarr and mor radily availabl, CMS has mad such improvmnts as adding clarifications to th Mdicar handbook, Mdicar and You, and launching a stramlind Wb sit. DOE CASEWORK DOE works primarily with bnficiary data systms to maintain th intgrity of Mdicar Parts A and B nrollmnt and prmium paymnt data. DOE also manags and nabls th rsolution of data discrpancis rlatd to: Mdicar nrollmnt Dirct prmium billing 15 Third-party prmium billing 16 MA and Part D data and transaction xcptions 15 Dirct prmium billing issus aris for bnficiaris who pay thir Part A and/or thir Part B prmiums dirctly rathr than through a Social Scurity chck withholding. 16 Third partis includ stats, privat ntitis, local govrnmnts, and th Offic of Prsonnl Managmnt. 15

25 Offic of th Mdicar Ombudsman 2012 Rport to Congrss FIGURE 6. COMPARISON OF FY 2011 AND FY 2012 BENEFICIARY CONTACTS TO DMOA Rason for contact Contacts, FY 2011 Contacts, FY 2012 Prcnt chang from FY 2011 to FY 2012 Prmiums 13,622 13,457-1% Mdicar ligibility/nrollmnt 1,880 1,706-9% Mdicar covrag 1,131 1,302 15% Coordination of bnfits 1, % Inquiris not Mdicar/Mdicaid spcific % Mdicar Advantag % Claims inquiris/complaints % Low-incom subsidy % Disnrollmnt/nrollmnt/withdrawal % Halth insuranc rplacmnt cards % Othr 5,534 5,865 6% Total 26,832 26,400-2% Additionally, DOE tracks trnds in bnficiary data systms and caswork through wkly and monthly rporting of ky issus. Of all th cass that DOE handld dirctly in 2012, it closd 33,292 dirct-billing cass (96 prcnt of th dirct billing casload) and 35,477 third-party cass (99 prcnt of th third-party billing casload). CUSTOMER SERVICE FEEDBACK SURVEY In 2012, th OMO conductd its third binnial Mdicar Ombudsman Customr Srvic Fdback Survy to assss whthr th OMO is mting th nds of bnficiaris and advocats. Th survy was snt to individuals who contactd th OMO for assistanc. It containd four closd qustions and on opn-ndd qustion that allowd th bnficiaris/rprsntativs to mak commnts or suggst ways to improv srvic. Th survy qustions sought bnficiary prspctivs on th timlinss, quality, clarity of rsponss, and bnficiaris ovrall satisfaction with th assistanc thy rcivd. Th rating scal rangd from on (strongly dissatisfid) to fiv (strongly satisfid). Also in 2012, th OMO maild 2,242 survys writtn in both English and Spanish to bnficiaris. Mor than 40 prcnt of th survys wr snt to bnficiaris with prmium-rlatd issus. Mor than 1,340 rsponss wr rcivd, a rspons rat of 60 prcnt. Th ovrall satisfaction rating rcordd by th 2012 survy was 4.5 out of a possibl 5.0 points, an incras of 0.5 points from Th two highst-ratd masurs wr clarity and quality, which ach had an ovrall avrag scor of 4.6. Th lowst-ratd masur was timlinss, which had an ovrall avrag scor of 4.0. Findings from th 2012 Customr Srvic Fdback Survy hav assistd th OMO in idntifying aras that could b improvd to mt th srvic and information nds of bnficiaris bttr. To improv ovrall rsponsivnss for complx cass, th OMO is contacting bnficiaris, through an intrim rspons lttr or phon call, whos inquiris will rquir mor 16

26 Offic of th Mdicar Ombudsman 2012 Rport to Congrss than 20 businss days to rsolv. This intrim rspons will confirm that a bnficiary s inquiry was rcivd and that th OMO is in th procss of rsolving th issu. Furthrmor, to rduc rspons tims, analysts ar snding bnficiaris -mail rsponss (whn applicabl) and following up with a hard copy of th rsponss for futur rfrnc. In addition, th survy indicatd that prmiums continu to caus confusion for bnficiaris. Th OMO is working to allviat bnficiary confusion through a rdsign of th Part B and Part D dirct prmium bills. INFLUENCING CUSTOMER SERVICE Th OMO ngags in and supports activitis to improv customr srvic. In particular, th OMO promots fforts to addrss bnficiary issus in a consistnt mannr through National Caswork Calls, facilitation of casworkr training, standard languag lttrs, and forign languag corrspondnc. NATIONAL CASEWORK CALLS AND TRAINING PROGRAMS Th OMO facilitats National Caswork Calls that includ staff from th CMS CO and its ROs. Ths calls communicat changs in policis, rgulations, or othr important programs that may affct bnficiaris and thir cargivrs. Th OMO also uss ths calls to conduct training sssions to improv th quality of customr srvic in inquiry and complaint managmnt. In January 2012, th OMO conductd a national nds assssmnt survy administrd to RO and CO casworkrs. Th rsults of th survy wr usd to dsign a training plan rlatd to topics idntifid by th casworkrs. Trains also includd rprsntativs from othr CMS componnts, including th Offic of Public Engagmnt, th Cntr for Mdicar (CM), and th Offic of Financial Managmnt (OFM). Th OMO conductd 10 training sssions in FY 2012 via National Caswork Calls, classroom sssions, and wbinars. CO and RO casworkrs participatd in th training sssions to gain th knowldg and skills ncssary to rsolv bnficiary inquiris fficintly and ffctivly. Th topics of ths calls includd th following: Rinstatmnt for good caus following non-paymnt of incom-rlatd monthly adjustmnt amount for Part D (IRMAA-D). As mandatd by th Affordabl Car Act, Part D nrolls with highr incoms ar rquird to pay an additional IRMAA to hlp fund th Mdicar Part D Trust Fund. If bnficiaris paying via dirct bill do not pay thir IRMAA-D on tim, thy will b disnrolld from thir Part D plan and could incur rnrollmnt pnaltis. CMS provids an opportunity for individuals to b rinstatd into thir Mdicar Part D plan in good caus situations. Th OMO dvlopd a caswork protocol to train staff from th Kansas City RO to us th Dirct Bill Systm to corrct IRMAA-D bnficiary rcords mting good caus rquirmnts. Th rsulting caswork-protocol training documnt was also usd to conduct a CMSwid training sssion for IRMAA-D and th Dirct Bill Systm during th Part C/D National Caswork Call. Mdicar dirct billing and prmium collction. Th OMO dvlopd a training modul for national-stat buy-in prmium billing and a complt dirct-bill-prmium- To rduc rspons tims, analysts ar snding bnficiaris -mail rsponss (whn applicabl) and following up with a hard copy of th rspons for futur rfrnc. 17

27 Offic of th Mdicar Ombudsman 2012 Rport to Congrss training packag in collaboration with OFM. Stat buy-in programs assist low-incom bnficiaris by allowing Mdicaid to pay for Mdicar prmiums. Third-party payr program/stat buy-in. For this training, a wbinar was usd, which allowd 187 popl to participat, including staff from th ROs/CO, stat Mdicaid agncis, and th Railroad Rtirmnt Board. Thirdparty payr rfrs to companis that bill Mdicar on bhalf of Mdicar providrs and supplirs. STANDARD LANGUAGE LETTERS To hlp nsur that CMS casworkrs consistntly and accuratly answr bnficiary inquiris about various Mdicar topics, th OMO has dvlopd standard languag lttrs. Ths lttrs us plain languag principls and rcommndations from th Mdicar Ton of Voic Workgroup to nsur uniformity and th appropriat dlivry of information. In FY 2012, th OMO dvlopd 34 nw standardlanguag lttrs as changs in program information occurrd, bringing th total numbr of standard languag lttrs to 543. For xampl, a nw lttr was dvlopd to rspond to approximatly 500 bnficiary rqusts for a varity of information about th $250 rbat chcks maild in 2010 and rissud in 2011 to bnficiaris who should hav rcivd th rbat but did not. FOREIGN LANGUAGE CORRESPONDENCE Along with providing consistnt rsponss to bnficiary inquiris via standard languag lttrs, th OMO also nds to nsur that it can rspond to inquiris in a varity of languags. In FY 2012, th OMO handld 1,052 forign languag inquiris. Corrspondnc in Spanish accountd for th gratst numbr of forign languag inquiris, with additional inquiris in Albanian, Chins, Frnch, Grk, Japans, Russian, Grman, Hmong, Italian, and Vitnams. Othr call topics includd coordination of bnfits, th Consolidatd Omnibus Budgt Rconciliation Act, Mdigap, Mdicar fraud, and covrag dtrminations. Post-sssion valuations showd that th wbinar training format was wll rcivd, th training sssions incrasd CO and RO casworkrs knowldg, and th training providd a vnu for mting agncy subjctmattr xprts. PARTNERSHIP INITIATIVES A larg part of th OMO s mission is to idntify bnficiary issus that ar systmic and to rcommnd potntial solutions to thos problms. To aid in this ffort, th OMO strngthnd its rlationships not just within th agncy but with advocacy groups and othr stakholdrs. 18

28 Offic of th Mdicar Ombudsman 2012 Rport to Congrss INTERNAL PARTNERSHIPS Throughout th past svral yars, th OMO has focusd on capacity building and collaboration with othr componnts and offics within CMS. Whn ncssary, th OMO facilitats fforts involving th compting intrsts of svral CMS intrnal groups that ar rsponsibl for th businss oprations of th agncy. Figur 7 provids som xampls of intrnal collaboration fforts in FY INTRA-AGENCY PARTNERSHIPS In 2012, OMO staff continud collaborating with th Social Scurity Administration (SSA), th Railroad Rtirmnt Board, th Offic of Prsonnl Managmnt, th Administration for Community Living/ Administration on Aging, th Small Businss Administration, th U.S. Dpartmnt of th Trasury, and th stats. Th OMO continus to b involvd in svral cross- and th Systms Managmnt Board, which manag all th major bnficiary systms. Ths workgroups dvlop bst pr actics to provid accurat and timly rsponss to agncy workgroups, such as th Enrollmnt Databas and SSA/CMS Chang Control Boards bnficiary inquiris and systm problms in collaboration with CMS systm/businss ownrs. In accordanc with Sction 923 of th Mdicar Modrnization Act, th OMO also works closly with FIGURE 7. OMO S INTERNAL CMS STRATEGIC RELATIONSHIPS Partnr Offic of th Administrator (OA) Rgional Offics (ROs) Cntr for Mdicar (CM) Offic of Communications (OC) Offic of Information Srvics (OIS) Offic of Financial Managmnt (OFM) Cntr for Consumr Information and Insuranc Ovrsight (CCIIO) Mdicar-Mdicaid Coordination Offic (MMCO) Offic of Mdicar Harings and Appals (OMHA) Cntr for Mdicar and Mdicaid Innovation (CMS Innovation Cntr) Stratgic Rlationship Th Offic of th Mdicar Ombudsman (OMO) lvats systmic issus to OA and obtains OA s support in addrssing ths issus. Th OMO collaborats with ROs to idntify and facilitat th rsolution of systmic issus rlatd to CMS procsss and to dvlop standard caswork procdurs. Th OMO also provids training to RO staff through national caswork calls and training programs. CM provids valuabl insight into issus rlatd to halth plan oprations, policis, and communications. CM collaborats with th OMO to assss and addrss issus rgarding traditional Mdicar (Parts A and B). Th OMO collaborats with OC to facilitat updats to xisting CMS publications and th dvlopmnt of nw publications, as ndd. Th OMO ngags with OIS componnts to idntify changs to CMS data systms that may affct Mdicar bnficiaris. Th OMO works with OFM to addrss paymnt, data, and policy issus, including Mdicar scondary-payr and third-party liability policis and practics and coordination of bnfits issus. Th OMO srvd on th CCIIO Exchang Complaints Procss Workgroup in support of th implmntation of th Affordabl Car Act. Th workgroup is stablishing a procss to handl th complaints and complx inquiris that ar xpctd onc th nw provisions of th Affordabl Car Act go into ffct in Th OMO collaborats with MMCO on issus affcting Mdicar-Mdicaid nrolls. In 2012, th OMO and MMCO collaboratd on th Information Nds of Nw Mdicar-Mdicaid Enroll comprhnsiv study. Th OMO and OMHA work togthr to idntify issus ncountrd by administrativ law judgs that th OMO can assist with by providing ducation and outrach matrials. Th OMO works with th CMS Innovation Cntr to idntify th potntial bnficiary implications of nw initiativs, such as th Mdicar-Mdicaid Financial Alignmnt Dmonstration and Pionr Accountabl Car Organizations. 19

29 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Stat Halth Insuranc Assistanc Programs (SHIPs), fdrally fundd stat programs that provid fr halth insuranc counsling to bnficiaris by tlphon and through fac-to-fac sssions. Spcifically, th OMO collaborats with SHIPs to idntify issus that affct Mdicar bnficiaris. At th sam tim, th OMO sks to undrstand th challngs SHIPs fac whn providing support to bnficiaris and thir cargivrs. As in prvious yars, th OMO attndd th annual national SHIP Dirctors Confrnc in 2012 and prsntd information about svral topics, including th following: How th OMO provids information and assistanc to Mdicar bnficiaris. How CMS provids support and tchnical assistanc to SHIPs. Currnt OMO initiativs, such as comprhnsiv studis. Plans and training for Durabl Mdical Equipmnt, Prosthtics, Orthotics, and Supplis (DMEPOS) Round Two Comptitiv Bidding. ADVOCACY PARTNERS In addition to working dirctly with thousands of Mdicar bnficiaris ach yar, th OMO also works in partnrship with advocacy organizations that hlp idntify a varity of othr important issus affcting Mdicar nrolls. Th OMO communicats with ths xtrnal partnrs via Mdicar Ombudsman partnr and bnficiary advocat mtings and national confrncs. Mdicar Ombudsman Partnr and Bnficiary Advocat Mtings Th purpos of th Mdicar Ombudsman partnr and bnficiary advocat mtings is twofold: thy srv as a forum for informing organizations about th OMO s fforts to addrss systmic bnficiary issus, and thy allow th OMO to larn about th bnficiary concrns ths organizations constitunts hav about Mdicar. Th OMO typically uss th first part of ths mtings to discuss updats on issus raisd during th prvious mting as wll as th status of its comprhnsiv studis. Th lattr half of th mtings is rsrvd for th advocacy groups to rais nw issus thy hav obsrvd in thir work with bnficiaris. In 2012, th OMO hld two partnr and bnficiary advocat mtings, which wr attndd by rprsntativs from th National Council on Aging, th Alzhimr s Association, Familis USA, th Lgal Aid Socity of th District of Columbia, th Mdicar Rights Cntr, Mdicar Accss for Patints Rx, Administration for Community Living/Administration on Aging, and various SHIP rprsntativs. Ky issus includd concrns about th Mdicar-Mdicaid Financial Alignmnt Dmonstration, 17 th MEDICARE rfrral procss, halth risk assssmnts administrd during th Annual Wllnss Visit, balanc billing outrach, and spcialty drug tirs. As appropriat, th OMO invstigats th issus raisd during ths mtings, shars thm at Issus Managmnt mtings, and prsnts concrns to CMS ladrs for valuation and possibl rsolution. For xampl, th proposd Financial Alignmnt Dmonstration has raisd bnficiary concrns about th larg scop of th dmonstration, th impact of passiv nrollmnt, and th nd for additional support srvics. Consquntly, th OMO mt with staff from th Mdicar-Mdicaid Coordination Offic and th Cntr for Mdicar and Mdicaid Innovation to undrstand th implications of th dmonstration bttr, so th OMO could addrss th concrns of partnr and advocacy groups. 17 Bginning in January 2013, CMS will implmnt a 3-yar, multistat dmonstration authorizd by th Affordabl Car Act to tst nw srvic dlivry and paymnt modls for popl dually ligibl for Mdicar and Mdicaid. Rtrivd Novmbr 30, 2012, from Mdicar-and-Mdicaid-Coordination/Mdicar-Mdicaid- Coordination-Offic/FinancialModlstoSupportStatsEffortsinCar Coordination.html. 20

30 Offic of th Mdicar Ombudsman 2012 Rport to Congrss National Confrncs Through confrnc attndanc, th OMO has th opportunity to larn firsthand which programmatic and systmic issus ar affcting th Mdicar population and to conduct providr, bnficiary, and cargivr outrach. In 2012, th OMO participatd in fiv xtrnal partnr confrncs: National SHIP Dirctors Confrnc Amrican Halth Lawyrs Association Confrnc Mdtrad Fall Confrnc Amrican Socity on Aging Confrnc Th National Association of Community Halth Cntr s Policy & Issus Forum thmslvs. Th following ar th most rcnt study topics, dscribd in dtail in th Issus and Rcommndations Rgarding Bnficiary Concrns sction of this rport: Halth Savings Accounts and how to inform Mdicar-ligibl individuals about thir covrag choics. Th Mdicar-rlatd information nds of th mployr community. Information nds of nw Mdicar-Mdicaid nrolls. INDUSTRY PARTNERS Th OMO collaborats with industry partnrs whn ncssary. For xampl, whn working on th comprhnsiv study of mployrs Mdicar information nds, th OMO intrviwd larg and small mployrs to gain an undrstanding of th impact Mdicar may hav on thir mploys and how thy accss Mdicar-rlatd information. Additionally, th OMO workd with many privat prmium payrs on issus rlatd to bnfit ntitlmnt and prmium billing. COMPREHENSIVE STUDIES DEVELOPMENT In 2012, th OMO compltd thr comprhnsiv studis, bringing th total numbr of comprhnsiv studis to 11 sinc this ffort was initiatd in Th OMO bgan conducting ths studis to assist in idntifying th root causs of bnficiary issus and to dvlop spcific, actionabl rcommndations for addrssing thm. Initially, issus slctd as th subjcts of comprhnsiv studis mrgd from th Issus Managmnt procss. Mor rcntly, nw issus hav bn idntifid from th comprhnsiv studis Using th findings from th rsarch in ths aras as a guid, th OMO has bn abl to dvlop spcific, actionabl short- and long-trm rcommndations that can b implmntd quickly and ffctivly. Th OMO prsnts ach study to CMS Ladrship. Figur 8 provids a tim lin for th 11 studis th OMO has compltd, information on th mthods usd to conduct th studis, and an illustration of how som studis hav ld to othrs. To gain a bttr undrstanding of bnficiary issus involving appals, th OMO rachd out to th Offic of Mdicar Harings and Appals. Discussions includd issus ncountrd by Administrativ Law Judgs that th OMO may provid assistanc with by working within th agncy to nhanc ducation and outrach to bnficiaris. As a rsult of ths discussions, th OMO will b conducting two comprhnsiv studis in FY

31 Offic of th Mdicar Ombudsman 2012 Rport to Congrss FIGURE 8. COMPREHENSIVE STUDY METHODOLOGY AND DEVELOPMENT 22

32 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Th first study will xamin bnficiary us of and financial liability for ambulanc srvics. Bnficiaris may bliv that crtain dnid ambulanc srvics wr rasonabl and ncssary and thus ligibl for th Social Scurity Act s bnficiary liability protctions. Howvr ths dnials ar, in fact, tchnical dnials and thus not ligibl for ths bnficiary protctions. Th scond study will xplor possibl nhancmnts to th OMO s rol in th Mdicar bnficiary appals procss, particularly in light of its statutory rsponsibility to assist bnficiaris with appals. Aftr ngaging with Offic of Mdicar Harings and Appals subjct-mattr xprts, th OMO study tam will conduct outrach to othr groups who likly hav xprinc assisting bnficiaris with Mdicar appals, including SHIPs, bnficiary advocacy organizations, CMS ROs, and OMO cas workrs. Additionally, in 2013, th OMO will xamin th customr srvic practics of Mdicar Parts C and D plans and idntify and rviw CMS rquirmnts and rlatd bnficiary fdback. FACILITATION AND TRACKING OF RECOMMENDATIONS IMPLEMENTATION With th dvlopmnt of comprhnsiv studis, th OMO has bn abl to mak mor spcific and bttr informd rcommndations to CMS. In 2012, th OMO also bgan facilitating and tracking th implmntation of its rcommndations. OMO staff compild and organizd narly 150 rcommndations that had bn dvlopd ovr th last 6 yars and prsntd to th agncy in annual rports to Congrss, intragncy CASE EXAMPLE: IMPROVING THE PARTS B AND D DIRECT BILL Th Offic of th Mdicar Ombudsman s (OMO s) facilitation of th rdsign of CMS-Form 500 is on xampl of its fforts to implmnt rcommndations. CMS-Form 500 is snt to bnficiaris who ar dirctly billd for thir Mdicar Part A and/or Part B prmiums and bnficiaris who ar billd for th Incom-Rlatd Mdicar Adjustmnt Amount (IRMAA) for thir Mdicar Part B and Part D prmiums. Bnficiaris who rciv CMS- Form 500 oftn hav difficulty undrstanding how th prmium amount du is calculatd, spcially whn prvious amounts du hav bn carrid forward. Th currnt form lacks a dtaild brakdown of prvious billing cycls of applid paymnts (i.., crdits), which somtims lads bnficiaris to bliv that CMS or th Social Scurity Administration (SSA) has mad a mistak in calculating th prmium amount du. Th OMO conductd a Part D IRMAA outrach ffort to contact bnficiaris in dangr of disnrollmnt du to nonpaymnt of Part D IRMAA prmiums. In collaboration with CMS Rgional Offic staff, th OMO analyzd CMS-Form 500 and rviwd th numbr of dirct bills issud to gain a bttr undrstanding of th numbr of bnficiaris who may xprinc issus. To rduc bnficiaris confusion about th prmium bill and significantly lowr disnrollmnt causd by a failur to pay Part D-IRMAA, th OMO rcommndd that CMS rdsign th form so that it would provid a mor dtaild brakdown of th amount du and would b writtn in plain languag. Not only is CMS-Form 500 confusing for bnficiaris, but rsponding to bnficiary qustions about th prmium bill crats a considrabl rsourc burdn and cost for CMS. A cost-bnfit analysis comparing th bnfits of laving th bill as is to th costs of committing rsourcs to improv th bill was prsntd to CMS Ladrship. Th OMO blivs that if CMS rdsignd th form, it would xprinc considrabl cost savings as a rsult of dcrasd prmium billing inquiris. As of th nd of FY 2012, th OMO was working with staff from th CMS Offic of Communications to dvlop and tst a mor bnficiary-frindly form. Following this, th OMO plans to collaborat with th Offic of Financial Managmnt to implmnt changs to th form. 23

33 Offic of th Mdicar Ombudsman 2012 Rport to Congrss mmos, and, most rcntly, comprhnsiv studis. Rcommndations rangd from updats to ky Mdicar publications to mor complx rvisions of Mdicar systms and procdurs. As part of th facilitation and tracking procss, OMO staff bgan working with CMS componnts to dtrmin whthr oldr rcommndations had or had not bn implmntd and why. For nwr rcommndations, th OMO is lvraging its intrnal partnrships to dtrmin th fasibility of th rcommndations and, in som cass, guiding th rcommndations through initial implmntation stps. Ths stps might includ schduling mtings to bring ky stakholdrs togthr or drafting languag for a form intndd for bnficiaris. (S th cas xampl on th Parts B and D dirct bill.) Th OMO staff is documnting its fforts for intrnal and xtrnal rporting purposs. To dat, narly 150 rcommndations hav bn suggstd to CMS, many of which hav bn prsntd in prvious rports to Congrss. About 30 prcnt hav bn addrssd, and an additional 20 prcnt ar progrssing. THE COMPETITIVE ACQUISITION OMBUDSMAN Sction 154 of th Mdicar Improvmnts for Patints and Providrs Act of 2008 rquirs th stablishmnt of a Comptitiv Acquisition Ombudsman (CAO) to rspond to complaints and inquiris mad by supplirs and individuals rlatd to th DMEPOS Comptitiv Bidding Program (CBP). In 2009, th Mdicar Bnficiary Ombudsman appointd a CAO within th OMO. In FY 2012, OMO staff supportd th CAO in dvloping a nw data managmnt stratgy with nw rporting and monitoring rquirmnts to provid fdback on th impact of th impnding scond-round xpansion of th DMEPOS CBP in Furthrmor, th CAO hld a supplir listning sssion in FY 2012 with DMEPOS-contractd and non-contractd supplirs to idntify significant issus affcting supplirs participating in th CBP. It also conductd dmographic studis utilizing Mdicar claims data in anticipation of th scond round of comptitiv bidding. 24

34 Th OMO compltd thr comprhnsiv studis to idntify th root causs of systmic issus and dvlop rcommndations to addrss thm to improv bnficiaris xprincs. Issus and Rcommndations Rgarding Bnficiary Concrns SECTION HIGHLIGHTS Individuals who ar nwly ligibl for Mdicar and ar covrd undr a Halth Savings Account fac complicatd Mdicar nrollmnt dcisions. Employrs ar an important sourc of information for both currnt workrs and rtirs ligibl for or alrady nrolld in Mdicar, but thy nd mor informational rsourcs to srv thir currnt and formr mploys bttr. Bnficiaris who hav just bcom Mdicar-Mdicaid nrolls (bnficiaris nrolld in both Mdicar and Mdicaid) fac challngs in undrstanding th ruls and rgulations associatd with both programs. 25

35 Offic of th Mdicar Ombudsman 2012 Rport to Congrss INTRODUCTION In fiscal yar (FY) 2012, th OMO compltd thr comprhnsiv studis to idntify th root causs of systmic issus and dvlop rcommndations to addrss thm to improv bnficiaris xprincs. Ths studis covrd (1) Mdicar nrollmnt dcisions rlatd to Halth Saving Accounts (HSAs), (2) th Mdicar-rlatd information nds of th mployr community, and (3) th information nds of nw Mdicar-Mdicaid nrolls. Information was compild through such mthods as data analysis, stakholdr intrviws, and nvironmntal scans. In addition, potntial topics for nw studis wr idntifid. This sction prsnts an analysis of ach study topic and th rcommndations mad to th Cntrs for Mdicar & Mdicaid Srvics (CMS) Ladrship during FY 2012, whn th studis wr compltd. Th procss of addrssing and implmnting th rcommndations has alrady bgun for som of th rcommndations prsntd in this sction. Updats on issus idntifid in past yars ar also prsntd. HEALTH SAVINGS ACCOUNTS AND INFORMING MEDICARE- ELIGIBLE INDIVIDUALS ABOUT THEIR COVERAGE CHOICES HSAs, stablishd by th Mdicar Prscription Drug, I mp rov m nt, and Mod r n iz a tion Ac t of , a r a ccou nts th a t in div idu al s c a n u s to p a y f o r qu a l if i d mdical xp n ss n ot cov rd b y insu r an c, su c h a s d ductibls, c o p aymnts, or srvics. To b ligibl to c on tr ib u t ta x - f r incom to a n H S A, a n in div idu al mu s t b n rol l d in a h ig h-d d u c tib l h alt h plan (HDHP) and not b n r olld in M dicar. A ky bnfit of having an HSA is that participants or thir mployrs can contribut prtax incom to th savings account. 18 In 2012, th annual HSA contribution limit for individuals with slf-only covrag was $3, 100 ($6,250 for family covrag), and individuals who wr at last 55 yars of ag but not yt nrolld in Mdicar wr abl to contribut an additional $1,000 annually. In addition, HSA funds accru as thy roll ovr yar to yar, and thy can arn intrst. Enrollmnt in HSAs HDHPs has grown xponntially in rcnt yars and is forcastd to continu growing. It is xpctd that som individuals with HSAs will continu working aftr bcoming Mdicar-ligibl. Additionally, nrollmnt in ths plans is projctd to grow, partly du to an incrasd dmand for low-cost halth insuranc plans as a rsult of th insuranc mandats in th Affordabl Car Act. Individuals who bcom ligibl for Mdicar du to ag, ar activ workrs or spouss of activ workrs, and rciv halth covrag undr an HSA HDHP nd to considr multipl factors whn making nrollmnt dcisions about Part A, Part B, and Part D covrag: (1) th implications of continuing to contribut to an HSA, (2) th possibility of having to pay a lat nrollmnt pnalty for Part D covrag if th individual dlays nrollmnt byond th initial nrollmnt priod without having crditabl covrag, and ( 3) potntial tax pnaltis if HSA contributions ar not stoppd up to 6 months bfor Mdicar nrollmnt, as Part A can b mad rtroactiv if nrollmnt is dlayd. 19 Mdicar Part A Enrollmnt: In gnral, bcaus most individuals ar ligibl for prmium-fr Part A covrag, activ workrs can nroll in Part A whil still rtaining thir mploymnt-rlatd covrag. Upon nrollmnt in Mdicar Part A, howvr, HSA HDHP 18 Any individual may contribut to a participant s HSA, although ths contributions ar subjct to applicabl taxs. 19 Th crditabl covrag standard rquirs that in ordr for a Part D ligibl individual to avoid th lat nrollmnt pnalty, his or hr othr prscription drug covrag must b xpctd to pay, on avrag, at last as much as Mdicar s standard prscription drug covrag. Although th law rquirs that plan sponsors provid crditabl covrag notification to nrolld individuals, ths notifications may not b prominntly displayd and may occur within th contxt of a largr xplanation of bnfits. 26

36 Offic of th Mdicar Ombudsman 2012 Rport to Congrss nrolls ar no longr prmittd to mak contributions to thir HSAs or rciv contributions from thir mployrs or othrs. As a rsult, Mdicarligibl individuals nrolld in HSAs HDHPs may want to dlay nrollmnt in Mdicar Part A, which can b don without incurring lat nrollmnt pnaltis. If a Part A ligibl individual chooss to dlay nrollmnt, th ffctiv dat of nrollmnt will b mad rtroactiv for up to 6 months from th actual nrollmnt dat. Consquntly, individuals dlaying nrollmnt may fac tax pnaltis if thy do not stop making HSA contributions in anticipation of thir rtroactiv Mdicar Part A nrollmnt dats. Mdicar Part B Enrollmnt: Bcaus nrollmnt in Part B involvs paying prmiums, activ workrs with mploymnt-rlatd halth insuranc, such as an HSA HDHP, ar mor likly to dfr Mdicar Part B nrollmnt. Ths individuals can nroll in Mdicar Part B latr during a spcial nrollmnt priod (SEP) and ar not subjct to lat nrollmnt pnaltis, providd thy can documnt having mployr-rlatd activ workr covrag from th dat of Mdicar ligibility. Mdicar Part D Enrollmnt: Individuals ar ligibl for Mdicar Part D covrag if thy ar ntitld to Part A or nrolld in Part B. As with Part B, thr is an SEP for individuals who withdraw from mploymntrlatd prscription drug covrag and nroll in Mdicar Part D. Individuals who dlay Mdicar Part D nrollmnt to rmain covrd by an HSA HDHP will b ligibl for an SEP whn withdrawing from HDHP prscription drug covrag. Howvr, to avoid lat nrollmnt pnaltis, th bnficiary s prscription drug covrag undr th HDHP must mt th crditabl covrag standard. This standard rquirs that th mployr-rlatd prscription drug covrag b actuarially quivalnt to or xcd standard Part D covrag. An individual may incur a lat nrollmnt pnalty if thr is a continuous priod of 63 days or mor aftr th nd of an individual's Part D initial nrollmnt priod during which th individual is ligibl for but dos not nroll in a Mdicar Part D plan and dos not hav any crditabl prscription drug covrag. As with Part B, th lat nrollmnt pnalty for th Part D prmium is applid for as long as th bnficiary is nrolld in Part D. All Mdicar-ligibl individuals with mploymnt-rlatd prscription drug covrag nd to b mad awar of th Part D crditabl covrag rquirmnt. Activ workrs who ar HSA HDHP nrolls ar at particular risk of lacking crditabl covrag as a rsult of th high-dductibl bnfit dsign. Th HSA balanc or currnt-yar contributions ar not includd in th crditabl covrag calculations. 20 Spcial considrations apply to all nrollmnt dcisions whn a prson has rachd Mdicar ligibility but his or hr spous has not. In addition, spcial considrations apply to all nrollmnt dcisions whn a prson has rachd Mdicar ligibility but his or hr spous has not. In particular, two factors should b takn into account: Th HSA cannot b usd to covr Mdicar prmiums for dpndnts or spouss if th HSA account holdr is not Mdicar ligibl. Evn though th Mdicar-nrolld spous can no longr contribut to th HSA, th HSAnrolld spous can continu to us HSA funds to pay for th Mdicar-nrolld spous s ligibl mdical xpnss. If th HSA account holdr is Mdicar ligibl but th spous is not, thn th account holdr may want to continu working and maintaining mployr-providd halth covrag for his or hr spous. 20 CMS has issud guidanc rgarding why HSAs ar not considrd in th calculation of crditabl covrag. Som of th rasons includ that HSAs do not qualify as group halth plans undr th Employ Rtirmnt Incom Scurity Act and that both th mployr and individual may contribut to th plan, so it is not asy to distinguish btwn ths sourcs of funding. 27

37 Offic of th Mdicar Ombudsman 2012 Rport to Congrss FINDINGS To undrstand th implications of dlaying Mdicar nrollmnt for HSA HDHP nrolls, th OMO rviwd policy background matrials (statutory and rgulatory provisions, tax cods, and lgislation that govrns HSAs HDHPs and thir ffct on Mdicar nrollmnt) and data from th HSA markt. Th OMO also conductd intrviws with stakholdrs and sarchd for availabl guidanc for Mdicar-ligibl HSA holdrs (or thir dpndnts). Four main findings mrgd from this rsarch: Th lgislation is gnrally clar on th us of HSAs and thir intraction with Mdicar. Howvr, th fact that Part B and Part D hav similar ligibility ruls for SEPs but diffrnt lat nrollmnt pnalty ruls can confus activ workrs approaching th Mdicar ligibility ag. Individuals ar having difficulty undrstanding th crditabl covrag rquirmnt for Mdicar Part D. Morovr, dtrmining whthr mployr-sponsord prscription drug covrag is crditabl from an actuarial point of viw may b difficult for a layprson. Th information on whthr th covrag is crditabl also may not b radily apparnt in halth plan matrials. Individuals trying to dtrmin whthr thir covrag is crditabl may think that thir HSA balancs and currnt-yar contributions ar includd in th calculations and that thir bnfits ar actuarially gratr than thy ar. Th primary CMS bnficiary rsourcs Mdicar.gov and Mdicar & You provid no information about HSAs. In addition, th non- CMS sourcs that addrss HSAs and th Mdicar nrollmnt dcision do not dirctly addrss th issu of crditabl covrag for prscription drug insuranc plans with HSAs. Bcaus HSAs hav tax implications, th Intrnal Rvnu Srvic (IRS) has a fact sht on HSAs that includs ruls concrning Mdicar nrollmnt. 21 Som advocacy groups, such as th Mdicar Rights Cntr, hav producd informativ onlin rsourcs rlating to HSAs and Mdicar. 22 RECOMMENDATIONS To addrss th nd for mor accssibl rsourcs that provid a thorough xplanation of HSA HDHP implications for Mdicar nrollmnt dcisions, th OMO rcommnds that diffrnt typs of information and training b dvlopd for bnficiaris, customr srvic profssionals, and mployrs. For bnficiaris: Dvlop a fact sht on HSAs. Rfrnc HSAs and th fact sht in CMS primary bnficiary rsourcs: Mdicar and You and Mdicar.gov. Coordinat with th IRS to includ Mdicarrlvant information in th IRS HSA publication (969) and on th IRS HSA Wb pag. 21 Halth Savings Accounts and Othr Tax-Favord Halth Plans. Rtrivd Novmbr 30, 2012, from 22 Halth Savings Accounts (HSAs) and Mdicar. Rtrivd Fbruary 24, 2012, from topic=counslor&pag =script&slid_id=

38 Offic of th Mdicar Ombudsman 2012 Rport to Congrss For customr srvic profssionals: Train MEDICARE customr srvic rprsntativs (CSRs) on th nw HSA fact sht, crditabl covrag, and th implications of crditabl covrag for nrollmnt dcisions. Rqust that th IRS and th Social Scurity Administration (SSA) train thir CSRs rgarding HSAs and Mdicar nrollmnt dcisions and that thy promot th nw HSA fact sht. For mployrs: Provid information about HSAs HDHPs and th crditabl covrag rquirmnt to mployrs. THE MEDICARE-RELATED INFORMATION NEEDS OF THE EMPLOYER COMMUNITY Employrs ar bcoming an incrasingly important information rsourc for individuals who ar ligibl for or alrady nrolld in Mdicar. Employrs may b approachd by thir Mdicar-ligibl mploys or rtirs with Mdicar-rlatd qustions on such topics as ligibility, covrag options, prmium paymnts, and coordination of bnfits. Additionally, mploys may xprss confusion about th chang in th Social Scurity rtirmnt ag and Mdicar ligibility. Thus, mployrs nd to hav th rsourcs ncssary to rspond to ths individuals Mdicar information nds and b awar of thir own rsponsibilitis rlatd to businss intractions with Mdicar. Until rcntly, Mdicar ligibility and Social Scurity rtirmnt wr synchronizd at ag 65. Howvr, in 2009, th Social Scurity rtirmnt ag incrasd to 66 and will vntually incras to 67, whil th Mdicar ligibility ag rmains 65. As a rsult, issus rlatd to mploys bing ligibl for Mdicar and covrd by mployr-rlatd halth insuranc may aris mor frquntly as mor mploys dlay rtirmnt past ag 65. Employs may not know whthr to nroll in Mdicar Part B or Mdicar Part D if thy alrady hav covrag through thir mployrs plans. Th ky finding is that, vn though numrous rsourcs ar availabl to th mployr community, no singl sourc consolidats all th rlvant rsourcs. In addition, coordination-of-bnfits (COB) ruls dpnd on th siz of th mployr and th rason for th individual s Mdicar ligibility (ag, disability, or nd-stag rnal disas [ESRD]). Ths COB ruls dirctly influnc an individual s dcision to nroll in Mdicar. As a rsult, th mployr s guidanc dpnds on th particular charactristics of th mployr and th Mdicar-ligibl mploy. FINDINGS To dtrmin th Mdicar-rlatd information nds of mployrs, th OMO conductd intrviws with stakholdrs, including mployrs and ntitis that advis mployrs on halth bnfits. In addition, th OMO undrtook a rviw of availabl guidanc for mployrs and idntifid gaps in th information. Th ky finding is that, vn though numrous rsourcs ar availabl to th mployr community, no singl sourc consolidats all th rlvant rsourcs. In addition, th study rvald that mployrs ar lss familiar with th issus associatd with individuals with disabilitis or ESRD than with thos associatd with bnficiaris who ag into Mdicar. Som mployrs hav turnd to bnfit consulting firms to assist thir mploys. 29

39 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Th study idntifid four major aras about which mployrs rquir mor rsourcs and information: Mdicar nrollmnt. Each of th Mdicar parts (Parts A, B, C, and D) involvs diffrnt nrollmnt considrations, such as ligibility and prmium paymnts, which may add to th complxity of nrollmnt dcisions. Topics of particular importanc includ: o Qualification for a Spcial Enrollmnt Priod. Distinctions btwn SEPs for Part B and Part D may caus mployr and mploy confusion rgarding ligibility rquirmnts and th duration of th SEP. In addition, stakholdrs rportd misundrstanding th rlationship btwn SEPs and lat nrollmnt pnaltis assssd on Mdicar prmiums. Also, stakholdrs notd confusion about th distinction btwn Consolidatd Omnibus Budgt Rconciliation Act (COBRA) covrag and group halth plan (GHP) covrag. For Mdicar purposs, COBRA is not considrd mployr-sponsord halth insuranc, and individuals who wait until aftr COBRA covrag nds may miss thir SEP. o Confusion causd by th diffrncs btwn Part B and Part D rquirmnts for avoiding lat nrollmnt pnaltis. In gnral, an individual will not incur a Part B lat nrollmnt pnalty if h or sh has GHP covrag basd on currnt mploymnt through his or hr own or spous s mployr. Part D has an additional rquirmnt that th covrag must b crditabl that is, th covrag must b at last as good as that providd by Mdicar Part D. Coordination of bnfits. COB applis to situations in which th individual has mor than on sourc of halth car covrag, and it dtrmins th ordr of paymnt for th diffrnt halth car payrs. COB ruls vary basd on th rason for ligibility (ag, disability, ESRD) and ar furthr complicatd whn an individual is covrd undr a spous s GHP. Additionally, mployrs must fulfill COB rporting rquirmnts to avoid potntial financial and lgal pnaltis. Employr-providd Mdicar-rlatd covrag. Employrs can provid covrag to Mdicar bnficiaris via svral options, including th Rtir Drug Subsidy (RDS) and Employr Group Waivr Plans (EGWPs). Th RDS is a subsidy from CMS to mployrs for prscription drug covrag for rtirs and thir dpndnts. EGWPs ar mployrspcific Mdicar Advantag plans that may provid halth and/or prscription drug covrag. Account-basd halth arrangmnts. Svral account-basd halth arrangmnts ar availabl to individuals, ach with diffrnt ruls for contributions, nrollmnt, and whthr thy mt th Part D crditabl covrag rquirmnt. Ths arrangmnts includ: o HSAs o Halth Rimbursmnt Arrangmnts o Flxibl Savings Arrangmnts o Archr Mdical Savings Accounts (MSAs) o Mdicar MSAs RECOMMENDATIONS Th OMO dvlopd thr rcommndations rgarding improvd information and rsourcs for th mployr community: Crat an Employr Community Portal locatd on CMS.gov or Mdicar.gov through which mployrs and othr rlvant stakholdrs can radily locat rsourcs that will hlp thm assist Mdicar-ligibl and Mdicar-nrolld individuals. 30

40 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Dvlop additional mployr rsourcs to fill idntifid gaps. Ths could includ a fact sht that compars Part B and Part D rquirmnts rgarding SEPs and lat nrollmnt pnaltis, an mployr-spcific Mdicar nrollmnt publication, and a rcordd wbinar spcifically on COB considrations for disabld and ESRD bnficiaris. Employ a multimthod approach to mployr outrach and communication. INFORMATION NEEDS OF NEW MEDICARE-MEDICAID ENROLLEES Th Affordabl Car Act, nactd in 2010, stablishd th Mdicar-Mdicaid Coordination Offic (MMCO) to nsur that Mdicar-Mdicaid nrolls hav full accss to samlss, high-quality halth car and to mak th systm as cost-ffctiv as possibl. In 2012, th OMO and MMCO workd collaborativly to study how to mak maningful improvmnts to information that is mad availabl to individuals nwly nrolld in both programs. Th study idntifis aras for improving th currnt stat of information through thr stratgis: idntifying th ky changs affcting individuals transitioning from Mdicaid or Mdicar as thir only covrag to ligibility for both programs, conducting stakholdr intrviws/focus groups, and prforming an nvironmntal scan of information for nw Mdicar-Mdicaid nrolls. From ths findings, information gaps wr idntifid, and rcommndations for improvd communication wr dvlopd. Mdicaid involvmnt offr a pictur of a complx population, as sn in figur 9. Bnficiaris incom and halth-status charactristics can b vry diffrnt, dpnding upon how an individual bcoms ligibl for both programs. Mdicar-Mdicaid nrolls always hav accss to Mdicar bnfits. Howvr, bing a Mdicar- Mdicaid nroll dos not ncssarily man that an individual has accss to all Mdicaid bnfits ( such as long-trm nursing hom srvics and nonmrgncy transportation). For xampl, Mdicar-Mdicaid nrolls who ar Qualifid Mdicar Bnficiaris- Only ( QMBs-Only) rciv assistanc with Mdicar prmiums and Mdicar cost-sharing. Howvr, a QMB- natur of stat assistanc falls into on of thr forms of Only is not ligibl to rciv Mdicaid bnfits. Th bnfits: Mdicaid-covrd bnfits Stat Mdicaid assistanc with Mdicar costsharing Stat Mdicaid assistanc with Mdicar prmiums Mdicar-Mdicaid nrolls rciv diffrnt combinations of ths forms of bnfits dpnding upon thir incom/ligibility group and th stat in which thy liv. Mdicar-Mdicaid nrolls is a trm that ncompasss divrgnt substs of individuals, making a on-siz-fits-all information stratgy impractical. Bnficiaris pathways to Mdicar-Mdicaid nrollmnt, thir charactristics, and th lvl of stat 31

41 Offic of th Mdicar Ombudsman 2012 Rport to Congrss FIGURE 9. PATHWAYS AND CHARACTERISTICS OF MEDICARE-MEDICAID ENROLLEES FINDINGS Stakholdr intrviws rvald that th information currntly availabl to nw Mdicar-Mdicaid nrolls can b complx, lngthy, and oftn in a format that is hard to undrstand. In addition, th information is oftn not spcific nough to th bnficiaris situations, as Mdicar-Mdicaid nrolls circumstancs can b highly complx. Stakholdrs also indicatd that many Mdicar- Mdicaid nrolls ar unawar of thir ligibility status for both programs and oftn lack a full undrstanding of th bnfits and srvics to which thy ar ntitld. It was suggstd that individualizd counsling may b ndd to assist ths bnficiaris. Th information gathrd from stakholdrs was catgorizd into ths aras of concrn: Accss to bnfits and srvics. Th issu stakholdrs raisd with th gratst frquncy was th importanc of nw nrolls undrstanding how to accss thir bnfits and srvics. Such issus as how to gt prscription drugs and how to accss providrs, including spcialists, wr frquntly mntiond. Assistanc in figuring out which providrs can b sn and who will provid srvics undr which plan was anothr significant nd xprssd by nw nrolls. Nw nrolls ar oftn concrnd about whthr thy can continu sing thir xisting doctors, particularly thir spcialists. Eligibility ruls and procsss. Stakholdrs idntifid th nd for information about Mdicaid ligibility ruls and th rdtrmination procss with th scond highst frquncy. Many calld this an ara of 32

42 Offic of th Mdicar Ombudsman 2012 Rport to Congrss urgnt concrn, bcaus bnficiaris could los Mdicaid covrag if thy fail to undrstand th rquirmnt. Anothr concrn mntiond was th dlay in data xchang rlatd to stat Mdicar prmium buy-in for individuals who bcom ligibl for Mdicar upon complting th 24-month waiting priod aftr rciving Social Scurity Disability Insuranc (SSDI) bnfits. Som intrviws notd that it can tak months bfor th stat assums paymnt of th Part B prmium, during which tim th prmium is withhld from th bnficiary s Social Scurity chck. This can caus financial hardship for many bnficiaris. Covrd bnfits and srvics. Bnficiaris who hav bn in on program and nwly nroll into th othr nd to undrstand th bnfits and srvics to which thy ar ntitld. Many nrolls assum that vrything thy nd will b covrd, but this is not always th cas, bcaus Mdicaid covrag diffrs dpnding on th stat in which th bnficiary rsids. Spcifically, stakholdrs mntiond confusion and concrn among nw nrolls about which typs of long-trm srvics and supports ar covrd, whthr and how mntal halth srvics and psychiatric drugs ar covrd, th typs of dntal and vision bnfits includd, and which kinds of durabl mdical quipmnt ar covrd. What ach program covrs. Bnficiaris may know that thy ar ntitld to crtain bnfits, but thy frquntly do not undrstand which program will covr thir ndd srvics. Two issus compound this problm: (1) Many nw nrolls cannot idntify which programs thy ar in, and (2) som providrs and profssionals do not always know what ach program covrs. In addition, having multipl insuranc cards is a sourc of confusion for nw nrolls and thir familis. Sorting out which program pays for what is notably difficult whn bnficiaris ar rciving skilld nursing facility (SNF) car. Many stakholdrs obsrvd that th transition from th Mdicar SNF bnfit to Mdicaid long-trm-car covrag is an ara of grat confusion and misundrstanding. Out-of-pockt costs. Stakholdrs rportd rciving many qustions from nw nrolls about thir prmiums and copays/cost-sharing rsponsibilitis. Th biggst aras of confusion ar rlatd to Mdicar Part D and managdcar programs. Bcaus th Mdicar-Mdicaid population is prdominatly low-incom and oftn has a fixd incom, this is an issu of concrn and consqunc to individuals. In addition, som stakholdrs discussd th problm of providrs balanc billing (wrongly attmpting to bill bnficiaris to fill gaps lft by what Mdicar or Mdicaid dos not covr), an issu about which th OMO providd guidanc in FY Bnficiaris who hav bn in on program and nwly nroll into th othr nd to undrstand th bnfits and srvics to which thy ar ntitld. Undrstanding choics and rights. Many nw nrolls ar surprisd by having to mak choics btwn typs of plans and do not fl quippd to mak informd dcisions. Furthrmor, stakholdrs frquntly xprssd concrn that bnficiaris, spcially thos who ar oldr and thos with gratr lvls of disability, do not undrstand thir rights and ntitlmnts. Appals and grivancs wr also raisd as anothr ara of concrn. How and whom to ask for information and hlp. It was commonly notd that ths bnficiaris frquntly hav difficulty undrstanding writtn documnts. 33

43 Offic of th Mdicar Ombudsman 2012 Rport to Congrss CHANGES EXPERIENCED BY BENEFICIARIES: AREAS OF HIGH IMPACT Whn bcoming nwly ligibl for both Mdicar and Mdicaid, bnficiaris xprinc significant changs in th following aras: Numbr of insuranc cards. Bnficiaris who transition from Mdicaid-only to Mdicar-Mdicaid shift from having a singl insuranc card to having thr insuranc cards. Eligibility rdtrminations. Bnficiaris who wr initially Mdicar-only and ar accustomd to having a singl ligibility dtrmination at th start of that covrag shift to rcurring Mdicaid dtrminations that ar prformd at last annually and somtims as frquntly as quartrly. Prscription drugs. Bnficiaris who wr initially Mdicaid-only must mov to th Mdicar Part D program and plans and larn a nw systm for obtaining prscription drug s. Long-trm car. Mdicar-only bnficiaris who xprinc a srious halth car vnt may los thir ability to car for thmslvs and pay thir Mdicar xpnss. Thy may bcom ligibl for Mdicaid- covrd bnfits and rciv covrag for th costly long-trm srvics and supports not covrd undr th Mdicar program. Providr slction. Whthr a Mdicar-only or a Mdicaid-only nroll initially, a Mdicar-Mdicaid nroll with full Mdicaid bnfits must b sur that his or hr providr accpts both Mdicar and Mdicaid, bcaus Mdicar now pays first, and Mdicaid covrs th cost-sharing xpnss. Stakholdrs rcommndd that writtn matrials clarly and prominntly indicat who should b calld for hlp intrprting th information providd, who to ask about th bnfits and srvics covrd, and who to call if bnficiaris ncountr any problms accssing bnfits. Managd car. Nw nrolls in managdcar programs frquntly hav qustions about which srvics ar covrd, how to accss providrs, and th procss for idntifying and sing spcialists. If thy hav a choic btwn traditional srvics and managd car or a choic among managd- car providrs, thy nd additional information and assistanc with making ths dcisions. Anothr issu raisd in this catgory was th confusion that popl xprinc whn thy go from bing nrolld in a Mdicaid managd-car program to bing ligibl for Mdicar. In addition to ths ight aras, stakholdrs also idntifid issus rgarding th contnt, prsntation, and dlivry of information. Th most common thm to mrg was that most information providd to nw nrolls is in a writtn form that is too complx to undrstand. Stakholdrs rportd that writtn matrials do not match th litracy lvl, cognitiv and physical capacity, or prfrrd communication styl of th intndd audinc. In addition, stakholdrs dscribd th particular challngs facd by popl who spak English as a scond languag, popl with dmntia, and popl with intllctual disabilitis whn trying to undrstand th matrials. Lastly, stakholdrs agrd that nrolls rciv too much writtn information and that th matrials ar too lngthy. Consquntly, nrolls do not know what information is important, which rsults in nrolls not rading or discarding important matrial. 34

44 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Th Financial Alignmnt Dmonstration, aimd at intgrating primary, acut, bhavioral halth, prscription drug, and long trm srvics and supports for Mdicar-Mdicaid nrolls, may addrss som of ths issus facing this population. ENVIRONMENTAL SCAN OF ONLINE RESOURCES An nvironmntal scan was conductd to aid in idntifying aras for improving th currnt stat of information for nw Mdicar-Mdicaid n rolls. To complt th nvironmntal scan, th following Intrnt rsourcs wr assssd: th CMS Wb sit; Mdicar.gov; Wb-basd rsourcs from ach of th 50 stats and th District of Columbia; and national consumr advocacy and foundation organization rsourcs. also fw information rsourcs about Mdicar summary notics/xplanation of bnfits for bnficiaris whos ligibility pathway is from Mdicaid to Mdicar. Th nvironmntal scan uncovrd a rang of common styls of information sourcs, from shortr frquntly askd qustions or fact shts to longr handbooks. Although handbook rsourcs wr oftn mor comprhnsiv, ky informant intrviws notd that lngthy documnts, such as handbooks, can b ovrwhlming. Intrviws consistntly rportd that shortr, on-pag targtd topic rsourcs wr mor hlpful. Th scan did find that numrous rsourcs limitd information to on or two topics. But from th prspctiv of introducing nw nrolls to bing ligibl for both programs, thr is a gap in th provision of concis xplanatory rsourcs that ar focusd on a limitd numbr of ky topics for ths individuals. RECOMMENDATIONS Th rcommndations rsulting from this study ar catgorizd into thr groups: (1) thos for improving communication with nrolls and thir familis, (2) thos for assisting profssionals who work with ths bnficiaris, and (3) thos rlatd to program administration. For nrolls and thir familis: Th nvironmntal scan found that th topics of halth insuranc cards a n d M dicaid ligibility r dt r min a ti on s, w hic h w r n ot d b y th s tak h o ldr s as c o n fus in g ar as f o r n w M dicar- Mdicaid nroll s, w r i na d q u at ly d alt with in th r s ou rcs idntifid through th sca n. A ddit ion a l ly, an o th r ar a i d n ti f i d b y i n t rviw s as p arti c u lar ly confus in g f o r b n f ic ia r i s a n d th ir fa mil i s was Md icar c o v rag of SNFs vrsus Mdicaid covrag of n u r s in g f ac il iti s ( N F s). R so u rc s t hat addrss M d i car S NF c o v r ag o r M d ic ai d NF c ov r ag w r idntifid, b ut no rsourcs on th tr ans iti on b tw n ths programs covrag wr locatd. Thr wr Crat brif, targtd wlcom kits for nw Mdicar-Mdicaid bnficiaris basd on ligibility catgoris and bnfits. It is rcommndd that thr basic wlcom kit tmplats b cratd to targt th diffrnt ligibility groups basd on th natur of th bnfits thy rciv. Produc a st of targtd on-pagrs to addrss ky topic aras rlvant to Mdicar- Mdicaid bnficiaris. Th OMO idntifid a short list of topics that wr frquntly mntiond in stakholdr intrviws as mriting xplanation to bnficiaris nwly ligibl for both programs. 35

45 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Dvlop a Wb pag ddicatd to Mdicar- Mdicaid nrolls that can b accssd from th Mdicar.gov hom pag. 23 For profssionals working with Mdicar-Mdicaid nrolls: Dvlop a singl-qury procss that halth profssionals and institutional providrs can us to obtain information that indicats whthr a Mdicar bnficiary is also potntially ligibl for Mdicaid. Produc a st of topic-spcific on-pagrs on th intraction of Mdicar and Mdicaid for profssionals and providrs. Dvlop tchnical assistanc prsntations to bnfit counslors and othr profssionals that can b usd in group sttings with Mdicar- Mdicaid nrolls. For program administrators: Dvlop Mdicar Summary Notics (MSNs) tailord spcifically to Mdicar-Mdicaid bnficiaris, if fasibl. Bcaus of th claims crossovr procss that xists btwn th two programs, it is possibl that CMS claims data 23 Contnt is availabl on Mdicar.gov for Mdicar-Mdicaid individuals. Subsqunt discussions within CMS indicat that providing accss from th Mdicaid.gov hom pag would also b dsirabl. systms could support a MSN dsignd for Mdicar-Mdicaid nrolls who ar ligibl to hav thir cost-sharing liability covrd by Mdicaid. If spcific MSNs could b dsignd for ths catgoris of Mdicar-Mdicaid nrolls, it would hlp addrss th issu of providr balanc billing and bnficiary confusion rgarding MSNs. Provid a timly procss for th initiation of Mdicaid buy-in for Mdicar Part B prmiums (if fasibl) and giv advanc notic 24 to stat Mdicaid agncis rgarding disabld individuals rciving Supplmntal Scurity Insuranc (SSI) and SSDI who ar nar th nd of thir 24-month waiting priod for Mdicar ligibility. Bcaus of data-xchang dlays in som stats, som nw Mdicar-Mdicaid nrolls whos ligibility for Mdicar is basd on disability xprinc dlays in Mdicaid s assumption of Mdicar Part B prmium paymnts. For ths bnficiaris, th Part B prmium is takn out of thir Social Scurity chcks until th data xchang taks plac, causing financial hardship pnding systm updats. Bcaus ths bnficiaris hav both SSI and SSDI, SSA could idntify ths individuals and provid CMS with an advanc notic idntifying SSI/SSDI individuals with impnding Mdicar ligibility, which CMS could thn shar with stat Mdicaid agncis. Howvr, this would rquir spcial arrangmnts with SSA. Consquntly, th OMO rcommnds that CMS xamin th fasibility of providing advanc notic to stats of SSI/SSDI bnficiaris bcoming ligibl for Mdicar so that th stats can initiat th stat buy-in procss of Mdicar Part B prmiums at th start of Mdicar ligibility. 24 Subsqunt discussions within CMS indicat that advanc notic is alrady providd to th stats for Part D. Thrfor, CMS guidanc to th stats on how to us this information for Part B would b bnficial. 36

46 Offic of th Mdicar Ombudsman 2012 Rport to Congrss OTHER ISSUES ADDRESSED BY THE OMO Anothr notabl issu that th OMO xamind in FY 2012 was th rronous us of th dat-of-dath cod. In 2011, th OMO idntifid a systm coding issu affcting bnficiaris. Upon discharging patints from inpatint sttings, providrs must ntr on th mdical claim a patint discharg status cod: a two-digit cod that idntifis whr th patint is going at th conclusion of his or hr hospital stay. Th cods for dat-of-dath and dat-of-discharg wr suscptibl to input rrors, bcaus thy ar rfrrd to by th sam acronym DoD and thir numrical cods wr asily transposd. Th Division of Ombudsman Excptions (DOE) and CMS Rgional Offics rvald that a numbr of dat-ofdath discharg-cod rrors had occurrd in th Mdicar Bnficiary Databas, causing bnficiaris to b incorrctly markd as dcasd. Each yar, ths coding rrors caus svral hundrd Mdicar bnficiaris to tmporarily los primary and scondary covrag for months until th mistak is rsolvd. Ths rrors also ti up significant amounts of CMS caswork rsourcs and affct othr individuals and halth plans nationwid, as ths cods ar uniform across payrs. DOE took th lad in xploring options for addrssing th issu of discharg-cod rrors. In working with othr CMS componnts, including th Cntr for Mdicar and th Offic of Information Systms (OIS), th OMO hlpd fram th issu and idntify and facilitat th implmntation of a solution. Th OIS rcommndd to th National Uniform Billing Committ (NUBC), which has jurisdiction ovr patint discharg cods, that th dat-of-dath discharg cod b changd. Th OIS and th NUBC rachd an agrmnt to chang th dat-of-dath cod to a nw occurrnc for all claim typs (i.., lctronic, papr, and dirct data ntry) on which th cod can b ntrd, ffctiv Octobr Th OIS agrd to add an xtra layr of systm validation that rquirs ntring th spcific dat of dath whnvr th datof-dath cod is usd. 37

47 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Appndix A: Trnds in Mdicar Bnficiary Contacts Th OMO rviws and analyzs data from a varity of systms to assist in idntifying trnds in bnficiary concrns. Ths systms wr dsignd around businss nds and oprating purposs and track workloads, such as th numbr of contacts and broad rasons for bnficiary contact. Bcaus of th aggrgat natur of ths data, thy ar not usd to idntify th xact root causs of bnficiary issus or to assss th ffctivnss of OMO or CMS fforts to mitigat or addrss issus. Th OMO ngags in a wid rang of activitis, such as th caswork and xtrnal partnrships dscribd throughout th 2012 Rport to Congrss, to idntify systmic bnficiary issus and dvlop rcommndations for addrssing thm. CONTACTS RECEIVED THROUGH MEDICARE To find answrs to thir Mdicar bnfit inquiris, bnficiaris, thir familis, and othr mmbrs of th public most oftn contact th MEDICARE hlplin first. Whn popl call MEDICARE, thy first rciv assistanc from an automatd intractiv voic rspons (IVR) systm. If th IVR systm cannot addrss th callr s inquiry or if th callr rqusts to spak with a prson, th IVR systm transfrs th call to a customr srvic rprsntativ (CSR). To provid assistanc with bnficiary inquiris, CSRs accss dfind scripts basd on kywords rlatd to th callr s issu. FIGURE A-1. TOTAL NUMBER OF CONTACTS RECEIVED BY MEDICARE: FY , PER THOUSAND BENEFICIARIES Th total volum of calls to MEDICARE pr 1,000 bnficiaris has dcrasd vry yar sinc 2006, th yar Part D was implmntd. This trnd likly rflcts both th maturation of th Part D program and th growing availability and us of onlin rsourcs to addrss bnficiary qustions, among othr factors. A-1

48 Offic of th Mdicar Ombudsman 2012 Rport to Congrss FIGURE A-2. COMPARISON OF MEDICARE SCRIPT HITS IN 2011 AND 2012, BASED ON THE TOP 10 SCRIPT HITS IN 2012 Consistnt with prior yars, CSRs accssd scripts on Part B covrd/noncovrd srvics mor than any othr issu in Btwn 2011 and 2012, rductions in script hits wr sn in six of th top 10 catgoris. Of th four catgoris that incrasd, th largst prcnt chang was in th top two catgoris: rplacmnt Mdicar card and ntitlmnt lttr (11 prcnt) and Part B covrd/noncovrd srvics (7 prcnt). FIGURE A-3. MAP OF MEDICARE CONTACTS PER THOUSAND BENEFICIARIES, BY REGION: FY 2012 Th numbr of contacts to MEDICARE varid considrably across CMS rgions, with as fw as 96 calls pr 1,000 bnficiaris in th San Francisco Rgional Offic (RO) stats to 1,631 calls pr 1,000 bnficiaris in th Sattl RO stats. A-2

49 Offic of th Mdicar Ombudsman 2012 Rport to Congrss COMPLAINTS RELATED TO MEDICARE PARTS A AND B Th Mdicar Administrativ Issu Trackr and Rporting of Oprations Systm (MAISTRO) is usd to collct and rport complaints and inquiris rlatd to f-for-srvic Mdicar (that is, Mdicar Parts A and B) that com dirctly to and ar managd by CMS staff. FIGURE A-4. TOP 10 REASONS FOR BENEFICIARY INQUIRY RECORDED IN MAISTRO: FY 2011 AND FY 2012 Although svn of th top 10 catgoris showd rductions btwn 2011 and 2012, th top two catgoris (prmium and spcial initiativs/othr) incrasd by 43 and 22 prcnt, rspctivly. Th catgory of program intgrity, for which th numbr of contacts mor than doubld from 300 to 739, was among th thr catgoris that incrasd. COMPLAINTS RELATED TO MEDICARE PARTS C AND D Th Complaint Tracking Modul (CTM) rgistrs and catgorizs complaints rlatd to Mdicar Parts C and D that ar loggd by MEDICARE and CMS staff. FIGURE A-5. CTM S TOP 10 REASONS FOR PART C AND PART D CONTACT: FY 2011 AND FY 2012 Across both Parts C and D, th top complaints concrnd issus rlatd to nrollmnt and disnrollmnt. Across catgoris in 2012, th numbr of complaints was similar to or lowr than th numbr in Two nw catgoris paymnt/claims and quitabl rlif/good caus rqusts wr addd in A-3

50 Offic of th Mdicar Ombudsman 2012 Rport to Congrss CONTACTS TO STATE HEALTH INSURANCE ASSISTANCE PROGRAMS In addition to contacting MEDICARE and th CMS Cntral Offic and ROs, Mdicar bnficiaris and thir familis can sk assistanc from Stat Halth Insuranc Assistanc Programs (SHIPs). SHIPs offr counsling and assistanc to Mdicar bnficiaris on a wid rang of Mdicar, Mdicaid, and Mdigap issus. FIGURE A-6. REASONS FOR BENEFICIARY CONTACT OF SHIPS: FY 201 Rsponding to mor than 9.6 million rasons for contacts in 2012, SHIPs rmaind an important rsourc for Mdicar bnficiaris and thir cargivrs. Topics rlatd to Part D rprsntd th most frqunt rason for contact in A-4

51 Offic of th Mdicar Ombudsman 2012 Rport to Congrss Appndix B: FY 2012 Mdicar Part C and D Onlin Complaint Form Data Analysis BACKGROUND Parts 417, 422, and th 423 of Titl 42 of th Cod of Fdral Rgulations nact rvisions of th Mdicar Advantag (MA) Program (Part C) and Prscription Drug Bnfit Program (Part D). Spcifically, this lgislation implmnts provisions outlind in th Patint Protction and Affordabl Car Act and th Halth Car and Education Rconciliation Act of 2010 (collctivly rfrrd to as th Affordabl Car Act [ACA]) and maks othr changs basd on th Cntrs for Mdicar & Mdicaid Srvics (CMS ) xprinc with administring Parts C and D. Th rvisions also clarify various program participation rquirmnts, mak changs to strngthn bnficiary protctions, rmov consistntly poor prforming halth plans, and mak othr clarifications and tchnical changs. As rquird undr sction 3311 of ACA, CMS implmntd an lctronic complaint form. Th Cntr for Mdicar at CMS workd closly with othr CMS staff to dvlop a tchnical approach to implmnting th complaint form that usd xisting infrastructur and rquird minimal changs to businss procsss. For xampl, to nsur consistncy with xisting businss procsss, a subst of data lmnts to b includd in th form was slctd from th agncy s xisting mchanism for collcting Mdicar Parts C and D complaints: th Mdicar Complaint Tracking Modul (CTM). Th CTM is a tool that allows complaints to b rcordd and systmatically analyzd and aggrgatd, providing an arly indication of nw or mrgnt policy issus that may hav an impact on halth plan oprations and rquir immdiat rsolution. To nsur usr accssibility, th onlin complaint form was placd in thr locations by CMS: (1) on th hompag, (2) on th Mdicar Plan Findr hompag, and (3) on th Offic of th Mdicar Ombudsman hompag. As outlind in sction 3311 of ACA, ffctiv January 1, 2012, MA organizations and prscription drug plan (PDP) sponsors ar rquird to display this lctronic complaint form prominntly on thir wbsits. In a Novmbr 10, 2011 Halth Plan Managmnt Systm mmoranda, CMS providd guidanc instructing MA organizations and Part D sponsors on how to comply with this rquirmnt. COMPLAINT PROCESS Whil th numbr of complaints fild with CMS and th tim ndd to rsolv ths complaints hav diminishd as th Part D program has maturd, complaint data indicat that thr is still opportunity for improvmnt. CMS rquirs that plan sponsors provid information about whthr thy notifid bnficiaris about th status and rsolution of thir complaints. This allows CMS to dtrmin if sponsors ar closing complaints in a timly mannr. CMS routinly monitors th status of complaints and works with plan sponsors who fail to comply with rquirmnts for th complaints procss, illustratd in figur B-1. Sinc th rlas of th onlin complaint form in Dcmbr 2010, customr srvic rprsntativs (CSRs) at MEDICARE hav bn th first to rviw onlin complaints and ar rsponsibl for dtrmining if a submission is an inquiry or a tru complaint. Tru complaints ar assignd a catgory and B-1

52 Offic of th Mdicar Ombudsman 2012 Rport to Congrss FIGURE B-1. COMPLAINT TRACKING MODULE (CTM) PART D COMPLAINT PROCESS th data ar loadd into CTM for caswork and rsolution (figur B-1). Part A and Part B f-forsrvic (FFS) inquiris ar also handld by MEDICARE Customr Srvic Rprsntativs (CSRs). CSRs hav accss to FFS claims systms and ar abl to rspond to a majority of inquiris rlatd to Part A and Part B. Th call cntr scalats inquiris that MEDICARE is not contractually abl to handl (i.. appals dtrminations, chck rissus, claims adjustmnts, Mdicar Scondary Payr paymnt issus, tc.) to th appropriat Mdicar Administrativ Contractor (MAC). Lss than 2 prcnt of th total MEDICARE call volum is routd to MACs. DATA ANALYSIS AND RESULTS In fiscal yar 2012, a total of 2,514 complaints wr rcivd via th onlin complaint form, a 32 prcnt incras from th prvious yar whn 1,722 onlin complaints wr submittd. Considring that th onlin complaint form is widly accssibl to all Mdicar providrs, bnficiaris, and thir cargivrs, various typs of inquiris and complaints ar rcivd. Of th 2,514 total onlin submissions rcivd, 862 (34 prcnt) wr rlatd to Parts A or B, and 479 (19 prcnt) wr rlatd to Parts C or D. Th rmaining 47 prcnt fll into th B-2

53 Offic of th Mdicar Ombudsman 2012 Rport to Congrss gnral catgory, which includs complaints rlatd to partnr rfrrals, coordination of bnfits, and gnral information about Mdicar. Figur B-2 provids th numbr and prcntag of ovrall CTM and onlin form complaints by catgory. Of th 479 complaints rlatd to Parts C and D that wr submittd via th onlin form, 421 wr dtrmind to b tru complaints and wr, consquntly, rsolvd by a CSR at th call cntr and ntrd into CTM. Figur B-3 shows th numbr of complaints submittd via th onlin form by month and FIGURE B-2. ONLINE COMPLAINTS ENTERED INTO THE CTM: FY 2012 Complaint catgory Acquiring Mdicaid ligibility information CTM complaints Prcnt of ovrall CTM complaints Onlin form complaints Prcnt of ovrall onlin complaints % % Bnfits/accss 7, % % Confidntiality/privacy % % Contractor/partnr prformanc 1, % % Covrag gap discount program % % Customr srvic 4, % % Enrollmnt/disnrollmnt 29, % % Equitabl rlif/good caus rqusts 8, % % Excptions/appals/grivancs 2, % % Markting 10, % % Paymnt/claims 4, % % Plan administration 2, % % Pricing/prmium/co-insuranc 19, % % Program intgrity issus/potntial fraud, wast, or abus % % Grand total 92, % % FIGURE B-3. COMPLAINT CATEGORIES IN CTM: FY 2012 B-3

54 Offic of th Mdicar Ombudsman 2012 Rport to Congrss yar. Approximatly 26 prcnt of th onlin complaints rcordd in CTM wr rlatd to problms with customr srvic, 22 prcnt wr rlatd to pricing issus such as co-pays and co-insuranc, and about 18 prcnt wr rlatd to bnficiaris xprincing problms whn trying to fil an appal/grivanc or rqusting a plan xcption. Th rmaining 34 prcnt of th CTM complaints that cam in via th onlin form wr sprad among th rmaining complaint catgoris. Th top thr catgoris of complaints rcivd dirctly by MEDICARE wr rlatd to nrollmnt/disnrollmnt, pricing, and markting. Figur B-4 compars th top thr complaints by MEDICARE to thos rcivd via th onlin form. In addition to complaint catgoris, th CTM also contains information about th issu lvl of complaints (immdiat nd, urgnt, routin), and th dats on which complaints wr fild and rsolvd. Th majority of onlin complaints wr not rlatd to bnficiaris at risk of running out of thir mdication and wr, thrfor, considrd routin. Basd on initial rviw, CMS implmntation of an onlin complaint form nhancd complaint rsolution for bnficiaris and CMS partnrs by improving th consistncy, rliability, and usfulnss of complaint information FIGURE B-4. TOP THREE COMPLAINTS BY DATA SOURCE: FY 2012 B-4

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