Survey: Few seniors aware of new Medicare options
Survey: Few seniors aware of new Medicare options
A July survey of Medicare-eligible seniors by DiMark, a New York City health care marketing firm, found that only about one-third of survey respondents were aware of the Medicare +Choice program enacted by Congress. (See related stories on pp. 121-125 for more details of the program.) Of those with some awareness of the program, just 5% indicated they would "definitely or probably" enroll in or switch to a Medicare+Choice plan.
Even those who had some familiarity with Medicare+Choice had little specific knowledge of such key parts of the program as available plan options or its open enrollment concept, the study found.
Other survey findings showed:
- Seniors appear to trust doctors and senior organizations most for providing information about the new program. Of the top four sources, respondents said they would prefer to receive information from doctors (23%) and senior organizations (22%), followed by the government (16%) and insurance companies (13%).
- When asked for their feelings about Medicare+Choice, the most common reaction was negative. Almost half (47%) of the respondents gave a negative answer; about one out of five (22%) had a positive reaction; 18% were neutral; and 13% were unsure.
- Participation by insurance providers and health care carriers will influence enrollment in Medicare+Choice. Asked how they would react if their carrier or provider was not on the list distributed by the federal government, nearly half (44%) said they would not consider the program; 8% said they would consider the program; 17% said they were neutral; and 31% didn't know or couldn't say how they would react.
Tucked away in the details of HCFA's proposed Medicare+Choice rule are an assortment of provisions dealing with rights and responsibilities for providers choosing to participate in the new program.
Leading Medicare lawyer Wendy Krasner, JD, of McDermott, Will and Emery in Washington, DC, provides the following analysis of these provider-sensitive sections for Physician's Payment Update readers.
Overall, many of the provisions contained in HCFA's proposed rule, like the consumer protection standards backed by the White House, "appear to exceed the statutory requirements of the Balanced Budget Act," says Krasner.
Taken all together, the net effect is "a significant increase in the nature and scope of the requirements on organizations wanting to particpate in the Medicare+Choice program" over current Medicare risk guidelines, says Krasner.
Key Medicare+Choice revisions critical to physicians include:
1. Physician participation must meet clearly defined requirements and rejection procedures. Medicare+Choice organizations must establish reasonable procedures for physician participation in the plan, notes Krasner. For instance, physicians must be made aware of the plan's requirements for participation in the provider network, must receive written notice if they are not chosen for the network, and must receive the opportunity to appeal nonparticipation decisions.
These rules not only apply to physicians, but all other practitioners who might be included in a plan. These include podiatrists, optometrists, chiropractors, psychologists, dentists, physician assistants, physical or occupational therapists, speech and language pathologists, audiologists, nurse practitioners, clinic nurses, midwife specialists, certified nurse anesthetists, certified nurse midwives, and licensed certified social workers.
"HCFA also has adopted a very broad definition of what procedures might affect provider participation in the plan or network," says Krasner.
Advance notice of rule changes required
Specifically, providers must receive written advance notice before implementation of any material changes in plan rules that affect the direct delivery of services by a health professional to a Medicare beneficiary, including: payment, utilization review, quality improvement programs, credentialing, data reporting, or confidentiality guidelines.
2. The regulations allow subcontracting. The regulations permit Medicare+Choice organizations and providers to enter into global risk agreements. However, there must be provider protections for both direct contracting physicians and other health care professionals, plus protections for any subcontracted physicians. "This means that providers within subnetworks, such as an IPA, also must receive all the HCFA-required information, including the opportunity to appeal," Krasner says.
3. Physician communication with enrollees is protected. Medicare+Choice organizations cannot interfere with the medical advice a health care professional gives to an enrollee who is his or her patient. HCFA, however, is silent about what providers can tell patients who ask what plan they should enroll in, other than permitting physicians to disclose what Medicare+Choice organization they may be affiliated with.
"Since HCFA has actively discouraged overt marketing by physicians, and is concerned about inappropriate steerage based on knowledge of a beneficiary's health status or the physician's financial interest, HCFA will issue further instructions clarifying provider marketing activities," says Krasner. Until then, the best advice is - if asked - only tell patients which plan you are with.
4. Current physician incentive plan regulations are incorporated into the new Part C Medicare options. The good news: Unlike the original proposal, Medicare+Choice physicians will not have to provide related information about their capitation arrangements.
5. Payment for services provided by non- contract providers reverts to fee-for-service rates. Any health care providers who furnish services to Medicare+Choice beneficiaries without first having a contract with that plan must accept as payment in full what they would have collected if the beneficiary was enrolled in fee-for-service Medicare.
6. Plans must pay 95% of clean provider claims within 30 days of receipt. Interest penalties are tacked on to any clean claim not paid within the 30-day time frame. If plans do not comply with this stipulation, HCFA may pay providers what they are owed directly, and may deduct from the plan's reimbursement the direct payment plus its cost of making these payments.
7. Medicare-specific provider networks are allowed. Under current HCFA rules, a Medicare risk network must be a subset of the contractor's commercial network. However, HCFA also recognizes that provider-sponsored organizations and other possible new entrants to Medicare+Choice contracting may not have a commercial network in place.
"While the new rules do not specifically address whether Medicare-only networks will be permissible for organizations that have commercial networks, nothing appears to preclude Medicare-only networks, assuming, of course, that they meet the access and other standards," says Krasner.
8. Physician referrals for Medicare+Choice patients are not subject to normal Stark rules. Under Stark rules, the prohibition on referrals to a health care entity the physician or an immediate family member has a financial interest in does not apply to services furnished by Medicare risk contractors and federally qualified HMOs.
Despite the fact that the Medicare+Choice program replaces the Medicare risk contracting program, Congress failed to revise the Stark regulations to include an exception for services provided under Medicare+Choice coordinated care plans. HCFA, however, corrects this oversight in its proposed rule, Krasner says.
9. HCFA distinguishes between a Medicare +Choice "organization" and a Medicare+Choice "plan."
Specifically, a Medicare+Choice organization is the entity that contracts with HCFA to offer a managed Medicare plan. The group must be organized and licensed under state law as a risk-bearing entity (with the exception of provider-sponsored organizations [PSOs] receiving federal waivers) that is certified by HCFA as meeting the contract requirements. One organization may offer several plans.
The Medicare+Choice plan, meanwhile, consists of the specific health benefits, terms of coverage, and pricing structure being offered to beneficiaries. Requirements for service areas, benefit packages, uniform premium requirements, and adjusted community rate filings also apply only at the plan level.
HCFA notes that, with the exception of federally waived PSOs, organizational and operational distinctions among HMOs, PSOs, PPOs, and other managed care plans are not relevant for purposes of applying for a Medicare+Choice contract.
Plan must operate within scope of license
As long as an entity is licensed as a risk-bearing entity (as defined in its state), it does not have to be specifically licensed as an HMO, PSO, or PPO to apply for a Medicare risk contract, Krasner says.
However, applicants do have to be able to prove to HCFA that the type of Medicare+ Choice plan(s) that it intends to provide is within the scope of its state license, she says. As such, "HCFA is effectively deferring to states what types of entities constitute licensed risk-bearing entities eligible for the Medicare+Choice program and what types of Medicare+Choice plans they may offer," says Krasner.
This may be good news for some PSO applicants, because it could provide the kind of flexibility non-HMO entities like risk-bearing PPOs may need to qualify to offer a coordinated managed care plan, according to Krasner.
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