Senior Medicare Patrol in Tribal Communities

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Senior Medicare Patrol in Tribal Communities
Presentation by Wendell Holt, SMP Director Great
Lakes Inter-Tribal Council
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What is SMP?

• The SMP Project is a cooperative agreement
  between GLITC the Administration on Aging
• Focus is on the prevention of health care fraud

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Why Does MEDICARE and the Administration on Aging
fund this project
Last Year Medicare Lost
16 Billion!
What did the Tribes- IHS lose?
?????
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Health Care Fraud costs - EVERYONE!
Individuals Lost
US Lost
80-100 Billion
10 Billion
Medicare Lost
IHS Loss
16 Billion
?
That's a chunk of change!
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Health Care Fraud costs - Tribes!
Financial Abuse
Elder Abuse
A concern!
Growing!
in Indian Country
Tribal/IHS Loss
Ability to fund other services?
Priority?
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• Goals of Project

• Recruit volunteers to educate, reach out
  reporting health Care Fraud that may be occurring
  in Tribal Communities or urban facilities
• Meet the unique needs of each Tribal community
• Protect, Detect, Report Health Care fraud for
  Medicare, Medicaid, IHS
• Share with other Tribes

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New National look! (logo) New message
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Create local recognitions! message
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STAR Program2006/2008 direction

• Focus on protecting Contract Health Dollars
• Understand who is billing your tribe and did they
  provide the service they billed for?
• Partner with Statewide SMP program (CWAG) for
  complaint reporting Medicare Part D Watch
• Expanding to Minnesota Board on Aging and four
  bands of the Minnesota Chippewa Tribe

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Build a Network!
What Tribal members can you do to help?

• Be a STAR volunteer!
• Save Tribal Assets and Resources by reaching
  out to Elders and sharing!.

• Expand and encourage Medicare and Medicaid
  Services to Tribes
• Identify FRAUD, WASTE, ERROR OR ABUSE by
  referring questions and complaints to GLITC STAR
  program at 1-800-427-7207

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Build a Network!

• Build a tribal support system for Elders, the
  disabled, and the medically needy!
• Share information
• Partner with other organizations

Indian Law Office
Statewide SMP
Veterans Service Office
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Build a Network!
Collaboration and Centers of Influence!

Tribal Aging/Elders Network

• Tribal Elder Benefits Specialists, Senior Health
  Insurance Programs (SHIP)
• Nutrition Sites (Title III Title VI)
• Caregiver Programs
• Foster Grand Parents
• Senior Companions
• Senior Employment (Title V)

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Build a Network!
Collaboration and Centers of Influence!

Disability Network

• Vocational Rehabilitation for Native Americans
  VRNA
• Disability Benefits Specialist (county based)
• Disability Navigators
• Independent Living Centers

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Build a Network!
Collaboration and Centers of Influence!

Health Care Network

• Indians Health Services, Tribal Clinics (638),
  Urban Health Facilities (I/T/U)

• Direct Services
• Contract Care
• Community Health Services
• Medicaid Eligibility Outreach Specialists

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Build a Network!
Collaboration and Centers of Influence!

Other Tribal Departments

• Tribal Health Plans
• Family Services
• Social Service
• Economic Support
• Income Maintenance

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Build a Network!
Collaboration and Centers of Influence!

Inter-Tribal Organizations

• Wisconsin Tribal Health Directors Assoc.
• Wisconsin Tribal Elder/Aging Directors
  Assoc.
• Tribal Elder Organization

• NICOA
• Elder Associations (GLNAEA)

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Types of STAR Programs

• How Volunteers can identify Fraud, Waste, Error
  and Abuse
• Initial Refresher Courses on
• Basics of Medicare, Medicaid, IHS
• How to read Medicare Summary Notices
• Scooter Scams
• Elder Abuse
• Identity Theft
• Medicare Part D

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Saving Tribal Assets Resources
Medicare Part A Hospital Part B Dr.
/Surgical Part D - Drugs
IHS Direct Care Contract Care (Fed. Per
cap. Spending 1,650)
Age 65 or Disabled
Low Income
Tribal Member
Medicaid SeniorCare Community Options
Tribal Enterprises
Fed per cap spending for other prog. 3,600
Veterans Facilities
Employment Or Other Insurance
Veterans Benefits
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MEDICARE Fund Disbursement
PART A TRUST FUND Payroll Deductions/Earnings
tax Part A premiums of voluntary enrollees
PART B TRUST FUND Monthly premiums from
enrollees Federal general revenues (taxes)
CARRIERS WPS - Madison
INTERMEDIARIES United Gov. Services Milwaukee.
BENEFICIARIES (Tribal Member)
PROVIDERS (Often will be local Hospitals
Contracted by CHS)
PROVIDERS (Often will be IHS Clinic)
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Medicare A thru D!

• Medicare,
• Part A Hospital
• Part B Doctor or Clinic
• Part C Medicare Health Plans
• Part D Prescriptions Drugs

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Tribal Member choices under MEDICARE
Part A - Hospital Part B Drs/Clinics Part C HMO/PPOs Medicare Health Plans Part D Prescription Drugs
AUTOMATIC when you become eligible for Medicare at age 65, ESRD, or Disabled (SSDI) An additional option MUST SIGN UP TO GET BENEFIT Private Plan alternative to Traditional Medicare An alternative choice if available in your area New Benefit starting in Jan. 2006 Many Plans (PDPs) to choose from Medicare Health Plans C may include drug coverage
Part A can be purchased if a person is over 65, but otherwise not eligible for Part A. (410.00 in 2007) Requires payment of a monthly premium 93.50 in 2007 May have limitation as to who and where you can get services Requires payment of monthly Part B premium Voluntary Benefit except for Medicaid eligible (Duel Eligible) New Drug plan premium vary by plan chosen
Plan has deductibles, co-ins and co-pays Saves Money for Contract Health Care Plan has deductible 131, co-insurance and co-pays All tribal clinics are approved and can be reimbursed Additional out of pocket cost vary plan to plan Tribal clinics may be included Plans must meet minimum standards of benefits Infamous Donut Hole 3,051 between 2,400 and 5,451
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Medicaid MA FORWARD CARD

• Special type of sub-program
• Medicare Premium Assistance - pays for Part B
• QMB or SLMB
• Elderly, Blind or Disabled
• Community Options Waivers options for staying
  home Family Care expansion for Long Term Care
• Medicaid Purchase Program disabled who work
  (VRNA)
• SeniorCare Drugs (Future?)
• Family Benefits
• Aid to families with Dep. Children
• BadgerCare Health Insurance for those under 19
• Healthy Start Prenatal Care
• Medicaid Extension Return to Work

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INDIAN HEALTH SERVICE

• Federal legal responsibility for providing
  services to American Indians Not benefits
• Funding is not going up fast enough to cover cost
  of service or benefits
• Tribes are having to pick up the difference.
• Commitment to serve all members regardless of
  ability to pay.
• Indian descent and residency requirements.

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INDIAN HEALTH SERVICES

• DIRECT CARE
• Funding priority process
• Most are rural and lacking in facilities
  provider support
• Limited Hospital availability
• CONTRACT HEALTH SERVICES
• IHS or 638 tribal contract with non-IHS
  facilities and provider
• Contract typically are limited to local areas
• Referral process often needed to control cost
  for tribes on priority.

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Why do you rob banks?Because thats where the
money is!

• Medicare Prescription Drug Program
• 29 million people
• 700 billion in first decade

Famous Bank Robber Slick Willie Sutton
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General Examples of FRAUD

• Billing for services not provided
• Billing for services not ordered by a doctor
• Non-covered services billed as covered services
• Deliberate billing for the same thing twice
• Billing for gang visits or wave therapy
• Use of another persons Medicare card to obtain
  medical care/payment
• Kickbacks

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Medicaid Prohibitions

• MEDICAID PROVIDERS ARE PROHIBITED FROM
• Charging for covered services except for
  co-payments
• Charging to verify eligibility for Medicaid
• Charging for the difference between billed and
  paid amounts.
• Charging for billing errors or missed
  appointments
• Automatically waiving co-payments
• Billing Medicaid recipients instead of program
• Demanding money up-front prior to providing
  service!

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Lesson Learned

• Adapt to unique tribes needs!
• 500 Tribes
• Disparity of wealth affects how health care
  is delivered and who to contact to volunteer and
  give the message
• Tribal residency and benefits follow members
  and cross Reservation, State, County, USA,
  Canadian Mexican boarders

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Lessons Learned

• Audience communication is often thoughtful,
  reserved, and subtle
• Listen as much as share
• Effective form of communication through story
  -telling
• Ask open-ended questions and allow adequate time
  to respond
• Little emphasis placed on strict timeframes
• Collaboration and Networking is the key

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Barriers

• Broken promises in Health Care
• Treaties promised Health Care
• Health Care Service through Indian Health
  Services is very under-funded
• Health care Services vary by community Priority
  issues
• Confusion and Bureaucracy
• To many programs and initials!
• I dont know who to talk to?
• I just want my tribe to take care of me!

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What has Worked?

• Recognition of circles (no beginning and no end)
• Importance of color, numbers, and ties to the
  creator and mother earth.
• Importance of identifying influential tribal
  members/leaders and centers of influence

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Cherish the Elders!

• 1st Grandfathers Teachings

• WISDOM
• To Cherish knowledge is to know wisdom
• Use the wisdom of elders, tribal leadership, and
  spiritual leaders

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Tribal Collaboration

• WI Tribal Elder Directors Association is the
  program Advisory Board
• Advisory board has identified Elder issues and
  working with State on
• Tribal Area Agency on Aging and or Aging and
  Disability Resource Centers (ADRC)
• Impact of Long Term Care Reform on Tribes
• State Consultation process

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What can you do to help?

• Be a STAR Volunteer!
• Save Tribal Assets and Resources by reaching
  out to Elders and sharing!.

• Expand and encourage Medicare and Medicaid
  Services to Tribes
• Identify FRAUD, WASTE, ERROR OR ABUSE by
  referring questions and complaints to GLITC STAR

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Dont be reeled in by promises of Free goods or
services

• Remember If it sounds to good to be true
• it probably is!

MiiGwetch! Thank you