For Professionals: CMC

CMC Statewide Tele-conference Meeting

February 14, 2007

Download the MP3 recording of this telephone call ~ 12.9MB

Agenda

1. Welcome!
2. Special Presentation: After the Gold Rush: The Marketing of Medicare Advantage and Part D Plans —  Medicare Advantage, Private Fee for Service Plans: addressing marketing abuses; David Lipschutz, Staff Attorney, California Health Advocates.
   Private Fee for Service Plans from a Physician’s Perspective —  Dr. Steven Una, Internist (Infectious Disease); Don Waters, Assistant Executive Director; Alameda-Contra Costa Medical Association
3. CMC Updates
   • CMS
   • Medicare Part D & Low-Income Advocacy
   • Social Security (representative invited)
   • What’s happening in your area?
4. CMC Announcements:
   • Upcoming Regional Forums:
     • March 6: Bakersfield
     • March 20: Monterey
     • April 24: Riverside
     • May 8: San Francisco
     • June 13: Redding, Shasta County (would take the place of the regular NorCal CMC meeting…)
5. Next CMC Meeting Dates:
   • April 4, 2007 CMC Los Angeles
   • April 11, 2007 CMC Sacramento

Presentation Outline:

The Marketing of Medicare Advantage and Part D Plans

David Lipschutz, Staff Attorney, California Health Advocates

I. Marketing Overview

• California Health Advocates/Medicare Rights Center Report: “After the Gold Rush: The Marketing of Medicare Advantage and Part D Plans” (January 2007)
• Number of factors converge to make informed decision making/choice more difficult for Medicare beneficiaries
• Great increase in numbers and types of plans being offered, with limited oversight of marketing
  • Many sponsors offering multiple products (PDP, PFFS, Medigap, etc.)
• Many agents selling multiple products
• Lock-in rules mean limited opportunities to change plans
• Multiple plans/variations not always understood by agents and beneficiaries
• Some MA rules, benefit designs not adequately explained (e.g. PFFS rules, PPO deductibles, etc.)
• Plans can pay higher commissions to agents for MA enrollments vs. PDP enrollments
• Some plan sponsors actively seek to convince current PDP enrollees to switch to same sponsor’s MA products
• “enroll and migrate” strategy
• agents using lists of PDP enrollees to market MA products

II. Case Study: Private Fee-for-Service (PFFS) Plans

• PFFS plans do not limit enrollees to a network of doctors or hospitals; enrollees can go to any Medicare provider as long as provider is willing to accept the PFFS plan’s fees and terms
• When a PFFS enrollee obtains services from a provider, for those services a provider is classified into one of 3 provider types:
  • Direct-contracting – provider has a direct, signed contract with plan
• Deemed-contracting – provider is “deemed” as contracting with plan
• Non-contracting – provider does not have a direct contract and is not deemed
• Deemed-contracting – provider is “deemed” as contracted if:
• Provider is aware in advance of furnishing services that individual is in the PFFS plan;
• Provider has reasonable access to the plan’s terms and conditions of participation;
• If plan makes this information available through postal service, e-mail, FAX, telephone or website
• The service provided is covered by the plan
• Deeming rules — patient and episode specific (doctor can pick and choose)
• Some providers are unwilling to treat PFFS enrollees

III. Examples of Marketing Misconduct

• Dual eligibles being targeted for plans that may be inappropriate for them
• Agents aggressively selling PFFS plans
• Some using fraudulent tactics

IV. Recommendations/Conclusion

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