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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... 10 HOW THE OMO MANAGES BENEFICIARY ISSUES AND COMPLAINTS... 12 Introduction... 13 Issus Managmnt... 13 Caswork... 14 Influncing Customr Srvic... 17 Partnrship Initiativs... 18 Comprhnsiv Studis Dvlopmnt... 21 Facilitation and Tracking of Rcommndations Implmntation... 23 Th Comptitiv Acquisition Ombudsman... 24 ISSUES AND RECOMMENDATIONS REGARDING BENEFICIARY CONCERNS... 25 Introduction... 26 Halth Savings Accounts and Informing Mdicar-Eligibl Individuals about Thir Covrag Choics... 26 Th Mdicar-Rlatd Information Nds of th Employr Community... 29 Information Nds of Nw Mdicar-Mdicaid Enrolls... 31 Othr Issus Addrssd by th OMO... 37 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
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
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
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 1-800- MEDICARE was lowr in fiscal yar (FY) 2012 than in FY 2011, continuing th dclin that startd in FY 2007. 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 2007. 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 2012. It iv
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
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
Offic of th Mdicar Ombudsman 2012 Rport to Congrss vii
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
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 2012. 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 2012 2
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
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
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
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 1964. Dohm, A. (2000, July). Gauging th Labor Forc Effcts of Rtiring Baby-Boomrs. Monthly Labor Rviw: 17 24. 2 Grnblatt, A. (2007, Octobr 17). Aging Baby Boomrs: Will th Youth Gnration Rdfin Old Ag? CQ Rsarchr, 17: 865 888. 3 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):385 386. 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. 03504. 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
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
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 2000. 8 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. 9 6 2012 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 https://www.cms.gov/rportstrustfunds/downloads/tr2012.pdf. 7 Ibid. 8 Th Oldr Population: 2010. 2010 Cnsus Brifs. (2011, Novmbr). U.S. Cnsus Burau. Rtrivd Octobr 10, 2012, from http://www.cnsus.gov/prod/cn2010/brifs/c2010br-09.pdf. 9 Vincnt, G. K. and Vlkoff, V. A. (2010). THE NEXT FOUR DECADES, th Oldr Population in th Unitd Stats: 2010 to 2050. Currnt Population Rports, P25-1138, U.S. Cnsus Burau, Washington, DC. Rtrivd Octobr 12, 2012, from http://www.cnsus.gov/prod/2010pubs/p25-1138.pdf. 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 3. 10 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 2004. 11 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 http://www.bls.gov/mp/hom.htm#labtabls. 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 http://www.ahip.org/ahiprsarch/. 8
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 19. 7 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
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 https://www.cms.gov/mdicar-mdicaid-coordination/mdicar- and-mdicaid-coordination/mdicar-mdicaid-coordination- Offic/Downloads/Dual_Enrollmnt_2006-2011_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. 8138-02). 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 http://www.kff.org/mdicar/upload/8138-02.pdf. 10
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