Best Practices in Consumer Protections

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Best Practices in Consumer Protections

• September 26, 2006
• Charles J. Milligan, Jr.
• Executive Director

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Preview

• Federal mandates
• Selected best practices from CMS
• Selected best practices from other states

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Federal Mandates
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Plans Have Requirements to Provide Information to
Members

• Plans must provide members with timely
  information (in a member handbook) about the plan
  that is understandable in English and prevalent
  non-English languages.
• Plans must include information about the covered
  benefits, cost sharing (if any), service areas,
  providers, member rights and responsibilities,
  grievance procedures, and emergency procedures,
  among many other items.

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Plan-Initiated Disenrollment Is Generally Barred

• A plan may not disenroll a member because of an
  adverse change in her/his health status,
  utilization of health services, diminished mental
  capacity, or uncooperative or disruptive behavior
  stemming from her or his special needs.
• The only exception where the plan demonstrates
  that the members behavior has become an
  impediment to the plans ability to provide
  services to the member or other individuals.

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Member-Initiated Disenrollment Must Be Allowed

• In Medicaid managed care, there must be an open
  enrollment period without cause during the 90
  days following initial enrollment, and every 12
  months thereafter.
• Various for cause reasons also must be
  available to disenroll at other times, such as
  providers that do not (for religious or moral
  reasons) offer needed services not all related
  services are available in the plans network or
  the plan lacks providers experienced with the
  individuals health care needs.
• Dual eligible individuals may disenroll from
  Medicare Advantage plans without cause at any
  time.

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Liability for Certain Payments Barred

• Plans only may charge copayments and other forms
  of cost sharing under the terms of the states
  waiver and/or state plan
• Plans are prohibited from charging members for
  any debts in the event of the plans insolvency,
  plan-covered services provided to the member
  which are outside the covered benefits, or for
  authorized services outside the plans network.

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Requirement to Use An External Quality Review
Organization

• States are required to contract with an External
  Quality Review Organization (EQRO), whose job it
  is to conduct quality reviews including plan
  performance in consumer protection areas with
  respect to access, consumer satisfaction,
  performance measures related to health status,
  and others as specified in the waiver and
  contract.

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Member Bill of Rights

• Each member has the right to
• Receive needed information about the program
• Be treated with respect, dignity and privacy
• Receive information about available treatment
  options and alternatives
• Participate in decisions regarding her or his
  health care, including the right to refuse
  treatment
• Be free from restraints and seclusion

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Member Bill of Rights (cont)

• Request and receive a copy of her or his medical
  records and to amend and correct the records
• Be furnished health care services which the plan
  has been contracted to provide
• Exercise her or his rights, the exercise of which
  does not affect how the plan treats the person.
• In addition, the plan must adhere to all other
  Federal and State laws (e.g., Civil Rights Act,
  American with Disabilities Act, Rehabilitation
  Act, etc.)

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Other Member Rights

• Other consumer protections are achieved through
  access standards, care coordination requirements,
  quality management programs, and detailed
  grievance and appeals procedures, among others
• In addition, each plan must adhere to all other
  federal and state laws (e.g., Civil Rights Act,
  American with Disabilities Act, and the
  Rehabilitation Act)

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Selected Best Practices from CMS
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How to Guides to Align Rules Between Medicare
and Medicaid

• CMS has developed how to guides to align
  Medicare and Medicaid program rules in three
  areas for dual eligibles
• Marketing
• Enrollment
• Grievance and appeals

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Other CMS Initiatives for Dual Eligibles

• Subsetting of dual eligibles permitted for
  Medicare Advantage Special Needs Plans (SNPs) to
  align with state initiatives
• CMS has worked with CHCS to develop a model
  three-way agreement to formalize the relationship
  among SNPs, the state and CMS to for voluntary
  programs.

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Selected Best Practices from Other States
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Survey of State Best Practices

• Our Center staff explored how other states that
  currently operate Medicaid managed long-term care
  programs address consumer protection issues.

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Surveyed States

• We communicated with the following states
• Wisconsin (Family Care and Partnership)
• Texas
• New York
• Minnesota
• Massachusetts
• Florida
• Arizona
• Washington State

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Survey Questions

• We asked the following questions
• What areas of the federal regulations do you
  consider consumer protection provisions, e.g.
  member rights, payment liability, access, etc.?
• Within those areas, do you require additional
  protections beyond those required under 42 CFR
  Part 438?
• If you require additional protections, are they
  specific to populations, e.g. aging and disabled,
  etc.?

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Survey Questions (cont)

• Do your state licensing requirements for Medicaid
  managed care organizations embody any additional
  protections?
• If your managed long-term care program includes
  plans that are also approved as Medicare
  Advantage Special Needs Plans, what steps have
  you and the plans taken to create a seamless
  system of consumer protection requirements and
  processes for consumers and providers?

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Wisconsin Family Care Program

• Care management organization (CMO) governing
  boards must include 25 percent older persons or
  persons with physical or developmental
  disabilities or their representatives.
• CMOs must employ a member rights specialist
  and/or a member advocate (Ombudsperson function),
  who reports directly to top management.

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Wisconsin Family Care Program (cont)

• Members must be actively involved in their
  care-planning process so their plans reflect
  their views and preferences
• Any negative appeal or grievance decision made by
  the CMO must be reported to the State for review,
  which may result in an external review and
  reconsideration

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Wisconsin Family Care Program (cont)

• Members may use the States complaint, appeals
  or grievances process instead of the CMOs.
• CMOs must inform members about how to use the
  States fair hearing process
• Members have the right to representation at any
  step in the complaint, appeal or grievance
  process

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Wisconsin Family Care Program (cont)

• CMOs member handbooks must include information
  about independent advocacy organizations and
  services
• Active member participation is encouraged by
  offering members the opportunity to self-direct
  their support services

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Wisconsin Partnership Program

• Wisconsin requires managed care organizations
  (MCO) to provide the same protections noted above
  in the Wisconsin Family Care Program.
• Also, Wisconsin has a contract with EDS to
  provide ombudsperson services to MCO members in
  the Partnership Program (as well as the Program
  for All Inclusive Care for the Elderly PACE
  program).

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Minnesota

• Minnesota state law, as opposed to the Minnesota
  Senior Health Options (MSHO) and the Minnesota
  Disabled Health Options (MnDHO) programs,
  heightens some protections (e.g., timelines for
  MCO responses to coverage decisions, complaints,
  grievances, etc.) beyond federal Medicaid
  requirements.

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Minnesota (cont)

• The State operates a managed care ombudsperson
  program for MSHO and MnDHO, and each county has
  an advocate ombudsperson to aid members.
• All nine Medicaid MSHO plans are also Medicare
  Advantage Special Needs Plans (MA/SNP) and
  members have the same protections in both
  programs.

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Massachusetts

• Massachusetts Senior Care Organization (SCO)
  program utilizes all Medicaid managed care
  requirements as the foundation for consumer
  protections.
• SCO also supports a 1-800 customer service line
  which goes directly to the Medicaid agencys SCO
  administrative unit to handle any problems
  consumers may encounter, including consumer
  protections.

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Massachusetts (cont)

• Consumers and/or representatives participate in
  care planning and affirmatively sign-off on
  personalized plans of care
• Consumers are represented on governing and
  advisory boards.
• Massachusetts conducts consumer satisfaction
  surveys to determine performance improvement
  needs

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Washington State

• The State requires a signed agreement with the
  member before the plan can bill the member for
  non-covered services.
• All members are defined to have special needs
  that require supplemental accommodations under
  state law, which, for example, gives members
  extra time to turn in paperwork
• Plan employees who work with members are
  mandatory reporters under state law -- for
  abuse situations -- and they are instructed to
  use the Adult Protective Services system as needed

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Best Practices in Consumer Protections in Managed
Long- Term Care

• Members have the right to self-direct their
  community-based supports and services (but
  members do not purchase those services directly)
• The Office of the Insurance Commissioner requires
  tighter timeframes for managed long-term care
  plans for handling of grievances and
  authorizations, resulting in faster response
  times.

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Questions

• Charles Milligan
• Executive Director, UMBC/CHPDM
• 410.455.6274
• cmilligan_at_chpdm.umbc.edu
• www.chpdm.org