The Medicare-Medicaid Coordination Office has issued guidance inviting states to issue proposals for integrating Medicare and Medicaid services. Some of these proposals intend to use passive enrollment (also known as “opt-out”) processes. Passive enrollment auto-enrolls individuals into a new health care plan unless the individual takes some action to stop the auto-enroll. Past passive enrollment schemes have led to individuals having their coverage changed without their knowledge and/or ending up in an insurance that does not cover their long-standing providers and treatments. In addition to being dangerous policy, passive enrollment for individuals who are dually eligible may also violate Medicaid law (see Social Security Act § 1932(a)92)(B)). Unfortunately, MMCO has indicated some willingness to allow states to implement passive enrollment systems.
- NHeLP has developed some model “hold harmless passive enrollment” standards as suggested minimum beneficiary protections in passive enrollment systems. Many of these standards may also be useful for other voluntary or mandatory enrollment efforts. We encourage advocates to pursue these standards in their state and federal advocacy. The standards are available at: http://www.healthlaw.org/images/stories/2012_04_NHeLP_Hold_Harmless_Passive_Enrollment.pdf
Additional Ideas for Specific Protections include:
- Minimum requirements for beneficiary notices across system (timing, content)
- State and CMS have to work together to come up with content that explains enrollment rights and plan options
- Notices prior to enrollment:
- Initial notice 90 days in advance of enrollment effective date
- Additional notices at 60 and 30 days
- Notice must explain difference between passive enrollment into demo and auto-enrollment into Part D and interaction between the two
- Different for people already receiving Part D v. those who are newly dually eligible
- Notice must contain information about right to opt-out
- Content and tone of notices should encourage active choosing, with clear directions on how to review options and specific information on how to access choice counselors.
- Notice must explain care continuity rights.
- CMS and states need to figure out how the notice interacts with Medicare ANOC and EOC rules:
- Do you get an ANOC and EOC for current plan? Default plan? What if facing a Part D reassignment?
- Notices after enrollment take effect:
- Notice of right to change plans or go back to FFS and how to exercise that right.
- Notice of care continuity rights.
- Sent 1-3 months after enrollment.
- Phone calls:
- From an independent enrollment broker.
- Before the notice is sent informing them an important notice is coming.
- After the notice is sent to follow-up and offer assistance.
- If phone call identifies a need for language assistance, a follow-up call should be initiated with interpreter services.
- All notices must prominently indicate that they are available in alternate formats (e.g., Braille, large font, CD, audio, etc.), languages, and simplified language (and possible intersection among these needs), AND these must actually be readily available at the point enrollment begins.
- An independent enrollment broker should process enrollments, with initial and ongoing staff training specific to the duals implementation projects and the interaction of Medicaid and Medicare enrollment integration.
- Sufficiently funded, independent choice counselors must be available with expertise in Medicaid, Medicare, managed care, behavioral health and long term services and supports; and existing CBOs with connections to the aging and disability community must be integrated into the effort. Special attention should be paid to CBOs that can respond to cultural and linguistic needs.
- Funding for these groups must not be tied to decisions by beneficiaries to enroll in the demo.
- Plans and providers should not be the leading agencies in enrollment. They have incentives to enroll people in particular plans that may not be the best fit. Marketing should remain restricted. If passive enrollment, plans should receive no new flexibility for selling potential enrollees.
- The initial and ongoing enrollment process must include a process for preliminarily identifying PACE-eligible individuals and, if the beneficiary is interested, referring a beneficiary to a PACE program for further information and evaluation.
- Funding for education of beneficiaries, CBOs and providers about enrollment and transition process must be adequate to support one-on-one counseling. States are claiming big savings, they should invest some of those in a successful transition.
- Information about integrated plans must be available to enrollment brokers and CBOs no later than September 1 (consistent with current Medicare system).
- Training of enrollment brokers, beneficiaries, CBOs and providers must begin no later than August 1.
- There must be clear delineation of who holds the enrollment record (plan, state, Medicare) and there must be a process for updating instantly all computer systems. A process for resolving discrepancies between systems must be designed that gets the beneficiary what they need at the point of service.
- Notices should be developed with stakeholder input and should be tested on focus groups before being sent to ensure that duals understand them.
- If passive enrollment:
- Enrollment should happen in a phased manner, with consideration given to the capacity of the model to assess and develop new care plans – for example, enrolling individuals by birth month or enrolling beneficiaries without LTSS needs first. The Part D model of massive enrollment shifts on the same day should be avoided.
- The process should not be random. Assignment should be based on the least disruption to the existing provider network of the beneficiary.
- There must be a process for ensuring that individuals who opt out of the integrated model will still be enrolled in a Part D plan and that LiNET will recognize and respect the opt out; and a notice that sufficiently explains the difference between passive enrollment into the integrated entity and auto-enrollment into a Part D plan.
- There must be clear delineation of what role 1-800-Medicare and non-demo plans will have in an opt-out scenario. Will an individual be able to opt-out of the demo by joining another plan? 1-800-Medicare CSRs, whatever their role, need training on how to deal with calls from individuals who are eligible for demonstrations.
- Non-demo plans need clear rules on what marketing they may or may not undertake with respect to demo-eligible duals.
- No lock-in. People passively enrolled must have the ability to change plans or leave the demo at any time. It is not until they are in a plan that they will understand if it is a good fit.
- An independent, funded ombudsman is needed to monitor enrollment process, assist individuals facing problems and identify systemic problems that need to be addressed.
- A care continuity process must preserve access to current providers and services.
- For providers,
- This should last for 12 months (CA SPD process) or for 6 months from the first doctor visit.
- Payment must be at least what it was in FFS.
- The state or Medicare should make the payment during the continuity period. When payments are made by the plans, many providers refuse.
- Plan should be required to reach out to beneficiaries’ current providers to try to bring them in.
- For services:
- Services should continue until alternative service is identified and in place. Part D has some good language. Illinois has proposed that all prior approvals for drugs, therapies or other services existing in Medicare or Medicaid at the time of enrollment will be honored for 90 days post enrollment and will not be terminated at the end of 90 days without advance notice to the enrollee and transition to other services, if needed.
- If an appeal is filed, services should continue during appeal even if authorization period ends. Individuals should not face possible recoupment if an appeal is denied. This protection should apply to both Medicare and Medicaid services.
- The state, at the start of the enrollment process, should identify very high risk individuals (on constant oxygen, dialysis, in the middle of cancer treatment, etc.) based on Medicaid and Medicare data and establish very high touch protocols and oversight to ensure that they are properly counseled about enrollment and that their transitions run smoothly (see Oregon proposal).